A Summer Health Program for African-American High School Students in Baltimore, Maryland: Community Partnership for Integrative Health

Abstract

Context:

Physical inactivity, poor nutrition, and chronic stress threaten the health of African-American youth in urban environments. Conditions often worsen in summer with diminished access to healthy foods and safe venues for physical activity.

Objective:

A public–private partnership was formed to develop and evaluate an integrative health intervention entitled “Mission Thrive Summer” (MTS).

Methods:

The MTS setting was an urban farm and adjacent school in a low-income community in Baltimore, Maryland. The intervention included farming, nutrition education, cooking, physical activity, yoga, mindfulness, and employment. Mixed-methods outcomes evaluation was conducted. Quantitative measures included accelerometry and self-reported health behaviors, using the Child and Adolescent Mindfulness Measure, Perceived Stress Scale, Physical Activity Questionnaire for Adolescents (PAQA), CDC Youth Risk Behavior Survey, and Block Kids Food Screener (BKFS). Outcomes were compared pre- and post-intervention using paired t-tests. Qualitative evaluation was based on participant and parent interviews.

Participants:

In total, 36 African-American 9th- and 10th-grade students joined MTS (17 in 2013, 26 in 2014, and 7 participating both years).

Results:

In total, 88% of participants completed MTS. Accelerometry revealed that participants took 7158 steps and burned 544 calories per day during MTS. Participants experienced statistically significant improvements in self-reported physical activity (PAQA) and dietary habits (BKFS). Surveys did not detect changes in stress or mindfulness (P > .05). Qualitative data demonstrated new knowledge and skills, increased self-efficacy, health behavior change, and program enjoyment.

Conclusions:

MTS was feasible among African-American high school students in Baltimore. Mixed-methods outcomes evaluation provided preliminary evidence of health behavior change during the summer and at follow-up.

INTRODUCTION

Physical inactivity, poor nutrition, and a range of health risk behaviors continue to contribute to high levels of obesity and present urgent threats to the wellbeing of youth in the United States. Data from the Youth Risk Behavior Surveillance (YRBS) of the U.S. Centers for Disease Control and Prevention (CDC) reveal worsening trends in youth health behaviors.¹ Among high school students, the years 1999–2013 saw substantial increases in both overweight (rising from 14.1% to 16.6%) and obesity (from 10.6% to 13.7%).¹ Poor nutritional status is reflected in 2013 data showing that 6.6% of high school students reported eating no vegetables and only 28.4% ate vegetables two or more times per day.¹ By contrast, the U.S. Department of Agriculture (USDA) recommends that youth ages 14–18 consume 2½ to 3 cups of vegetables per day.² Many American high school students are also physically inactive. According to 2013 YRBS data, 15.2% reported engaging in no vigorous physical activity for at least 60 min in the previous seven days, whereas federal guidelines for children and adolescents recommend 60 min or more of physical activity per day.^1,3

Youth in low-income urban environments may experience even greater health risks. For instance, among public school students in Baltimore, Maryland, 84% qualify for free or reduced-price school meals.⁴ YRBS 2013 data revealed that among Baltimore high school students, 18.4% were overweight and 17% were obese; 13.5% ate no vegetables and only 21.9% ate vegetables two or more times per day; and 28.9% engaged in no vigorous physical activity for at least 60 min in the previous seven days.¹

In response to these pressing concerns, both the Institute of Medicine (IOM) and the Centers for Disease Control and Prevention (CDC) issued documents in 2014 calling for robust collaboration between public health and public education sectors.^5,6 The ultimate goal of this call to action was to create and deliver comprehensive, effective health programs for youth. The CDC initiative, called “Whole School, Whole Community, Whole Child,” advocates an integrative, whole-person approach to health promotion including the following components: health education; nutrition; physical activity; health services; mental, behavioral, and social–emotional health; school employee wellness; school environmental health; and family and community engagement.⁶ Integrating these components broadly into public education would mean a significant expansion of health-related educational content and could yield important benefits for youth.

Summer Health Risks

School-focused programming may lapse during the summer, however, when youth are out of school. This three-month period presents its own health risks, especially for youth from low-income families. An important summer health risk is poor nutrition. The Food Research and Action Center found that in July 2014, only 16.2% of low-income students who are eligible for free and reduced-price meals (breakfast and lunch) during the school year received meals through the USDA Summer Nutrition Programs, which are designed to pick up where school-year nutrition leaves off.⁷ This gap in receiving healthy meals provided by the USDA during the summer months exacerbates the public health problem of “food deserts,” areas in which access to healthy food is limited. Baltimore is a city that suffers from a preponderance of neighborhoods that are considered food deserts, as was confirmed in the 2015 Baltimore Food Environment Map.⁸

Socioeconomic factors are also evident in data on summer activity and weight gain. In a parent survey, urban, low-income, and minority families acknowledged difficulty finding and affording summer activity programs.⁹ A systematic review of studies of summer weight gain found that racial or ethnic minorities who were less able to afford summer camps and other activities were at increased risk of weight gain.¹⁰ A national sample of 1766 adolescents was studied to determine whether summer care arrangements were related to risk of obesity in the following school year. The greatest obesity risk was identified for youth who were cared for by a parent during the summer and not participating in organized activities. Conversely, the lowest obesity risk was found among youth whose regular summer care involved organized activities.¹¹

In addition to decreasing obesity risk, participation in organized summer activities has further importance in maintaining and improving youth physical fitness, which carries the potential for long-term health benefits. Physical activity, when maintained from adolescence into young adulthood and middle age, has been shown to significantly lower the risk of cardiovascular disease and support mental health.^12,13 Even one summer away from a school-based physical fitness curriculum has been shown to erase previous improvements in cardiovascular fitness, fasting insulin levels, and body composition.¹⁴

Community Safety

Maintaining physical activity through the summer may be a challenge for urban youth from low-income families, not only because of a lack of accessible programs, but also because the environment itself may not be conducive to physical activity. Inner-city neighborhoods may experience crime and present safety hazards, conditions that do not support outdoor physical activity.¹⁵ In a study of low-income African-American adults in New Orleans, Louisiana, participants who saw their inner-city neighborhood as safe were significandy more likely to meet federal guidelines for physical activity than were those who did not view their surroundings as safe.^3,16 High school students also express safety concerns. In 2013, 13.5% of Baltimore City high school students (versus 7.1% nationally) reported staying home from school at least one day in the previous month because they felt they would be unsafe on their way to, from, or at school.¹ In the summer, with greater unscheduled time, some may feel increasingly at risk in their environments and remain inactive at home, while others may put themselves at risk by going out. Unsupervised time with peers may yield to antisocial behavior or even criminal offending, as youth violence rises during summer months.¹⁷

It is also necessary to acknowledge the extraordinary physical and emotional risks faced by youth in times of social unrest and violence, such as what occurred in Baltimore in the spring of 2015, following the death of a 25-year-old African-American man in police custody.¹⁸ Many Baltimore youth took part in the days of peaceful protest or the riots that ensued as the city dealt with distress, disruption, and a declared state of emergency. Crime data from before and after these events fuel the perception that Baltimore is an increasingly unsafe city.¹⁹ For Baltimore’s youth, these circumstances add further complexity to the task of becoming a healthy adult in an environment with long-standing socioeconomic challenges.

To effectively address integrative, whole-person health, existing organizational silos must give way to new community partnerships.⁵ Beginning in 2012, several Baltimore-based organizations brought their diverse capacities together to design, implement, and evaluate a multi-faceted, experiential summer program for urban high school students. The partners induded two nonprofit organizations, the Institute for Integrative Health, which engages in interdisciplinary collaborations for health innovation and promotion²⁰; and Real Food Farm, a project of Civic Works, devoted to job training, skills development, and community service.²¹ Two public sector partners were YouthWorks, a summer youth employment program of the Baltimore City Mayor’s Office of Employment Development,²² and as an academic research partner, the University of Maryland School of Medidne²³ This cross-sector, multidisdplinary partnership brought together a range of resources needed to address summer risks for African-American high school students in Baltimore, Maryland, in a program called “Mission Thrive Summer” (MTS).²⁴

METHODS

“Mission Thrive Summer” Program Overview

The component of the Institute for Integrative Health focused on community health is called “Mission Thrive.” Its purpose is to develop, implement, assess, and disseminate experiential programs that teach healthy life skills, with particular attention to high school students. For example, Mission Thrive collaborated with researchers from the University of Maryland School of Medidne to create and evaluate “Spice MyPlate,” a novel nutrition education curriculum for teaching students how to use spices and herbs to make healthy foods more appealing. The Spice MyPlate intervention was shown to improve diet quality and attitudes toward healthy eating in a controlled trial in Baltimore high schools.²⁰ This evidence-based curriculum was integrated into the MTS program, which itself was created in response to an identified need for healthy youth devdopment programming in Baltimore for the months when school is out of session.

MTS Program Design Assumptions

The design of the MTS program emerged from several evidence-based assumptions:(1) Adolescent health promotion cannot be adequately addressed in clinical settings alone.²¹ (2) Integrative health engages the whole person across the lifespan –mind, body, community, and natural environment.²² (3) Youth are not problems to be fixed, but whole persons in the process of becoming. Health behavior change typically takes place in stages, over time. Increasing health awareness, new learning, and the intention to change are followed by significant new, health-focused actions, with a gradual development of self-confidence and self-efficacy.²³

(1) Adolescent health promotion cannot be adequately addressed in clinical settings alone.²¹ A 2009 National Research Council study of adolescent health services in the United States identified adolescence as a critical time for addressing health issues that have both immediate and long-term effects on wellbeing. Eloquently subtitled “Missing Opportunities,” the study found that health services are not set up to be accessible and acceptable to this age group.²¹ To address the disconnection between health services and populations, the Healthy People 2020 federal initiative has set a goal to improve the availability and quality of health programming in schools, communities, and worksites, and to encourage programs that combine multiple settings at once for greater impact.²⁴ Accordingly, the MTS program was located on an urban farm in Baltimore, adjacent to two public high schools, and situated between neighborhoods with high rates of unemployment and family poverty.²⁵ The farm setting is also a worksite, which permitted a program design in which youth could perform paid work, while being physically active and learning about sustainable farming, environmental concerns, and the food system.

(2) Integrative health engages the whole person across the lifespan–mind, body, community, and natural environmen.²² Personal health is supported by clinical care, but is affected daily by behaviors such as eating, exercising, and sleeping, as well as myriad factors including stress management, genetics, socioeconomic status, social and cultural values, economic conditions, and physical environments. In 2014, the CDC and the nonprofit ASCD (formerly the Association for Supervision and Curriculum Development) launched an initiative, called “Whole School, Whole Community, Whole Child,” as a model for collaborative, school-based integrative health promotion.^22,26 However, the school year is only 9 months long, while health is a concern for all 12 months. Therefore, MTS was designed to integrate multiple evidence-informed experiences that support development of healthy attitudes, behaviors, and norms. These included farming²⁷ and field trips to natural environments²⁸; nutrition education, cooking, and eating together as a group^20,29; physical activity, including fitness activities, sports, and games^30,31; and yoga as a physical and stress management practice.³² A leadership skills component addressed appropriate workplace behavior and teamwork, and included elements of public speaking and financial literacy. Youth actively planned and carried out community health education.

(3) Health behavior change takes place in stages, over time. According to the Transtheoretical Model of Health Behavior Change (TTM), the process of change may begin with avoidance or a lack of information (precontemplation stage), moves toward increasing awareness of a personal health issue (contemplation stage), and is followed by the intention to shift behavior (preparation stage). New learning leads to significant new behaviors (action stage), with gradually developing self-confidence and self-efficacy (maintenance stage).²³ A range of processes may support health behavior change, including health education, the presence of positive role models, learning healthy substitutes for unhealthy choices, self-reevaluation, and, particularly in minority health promotion, social liberation and empowerment.²³

The MTS program was designed to provide youth with an integrative health education in the context of environment and community. MTS strategy engaged youth directly in healthy self-care practices and life skills under the guidance of positive role models, with the goal of motivating long-term healthy behaviors. Four core values were consistently articulated: (1) the readiness to try new things (“trying it on”), (2) healthy choices, (3) accountability, and (4) teamwork.

Community Partnership

Though the Institute for Integrative Health and Real Food Farm are organizations with disparate expertise and goals, they formed an effective partnership based on coherent values: sustainable agriculture is consistent with healthy nutrition and whole-person health. Real Food Farm is a 6-acre farm within the city of Baltimore. Adjacent to two public high schools, Real Food Farm offers a range of educational, volunteer, and employment opportunities to students and the community, and delivers sustainably grown produce to surrounding low-income neighborhoods.

Two further partnerships were fundamental. An alliance with the Baltimore City Mayor’s Office of Employment Development allowed MTS to become part of the city’s YouthWorks program, which provides teens with minimum wage ($7.25 per hour) for summer work. This partnership positioned MTS for a clear emphasis on workplace skills and values. Finally, a continuing collaboration with the University of Maryland School of Medicine provided essential research expertise for MTS program evaluation.

Recruiting MTS Participants

Potential MTS participants were African-American 9th- and 10th-grade students and were recruited through fliers distributed in Baltimore public high schools. The program admission procedure included an application, essay, teacher recommendation, parent or guardian permission, and a physical examination. Group interviews were conducted on the farm and included a farm-related activity. Students could choose either to be paid an hourly wage through YouthWorks, or to count their work toward the state high school graduation requirement of 75 h of volunteer service. A large majority chose to receive the hourly wage ($7.25), which required a separate application and interview with Baltimore YouthWorks staff.

MTS Program Staff

Onsite staff included two full-time program leaders, one each from the Institute for Integrative Health and Real Food Farm; one full-time and two part-time assistants; a certified personal exercise trainer (2–4 hours per week); a yoga and mindfulness instructor (2–3 hours per week); and four full-time “crew leaders.” In Year I, the crew leaders were 11th- or 12th-grade students with experience in either farming or cooking. While this leadership experience was thought to be of benefit to the crew leaders themselves as their first responsible paid positions, it became evident that crew leaders of this age were not sufficiently effective in leading youth only about two years younger. In Year II, AmeriCorps volunteers, college or graduate students between the ages of 19 and 25, were engaged as crew leaders and were more successful as leaders. In both years, prior to the start of MTS, all crew leaders received training in forming, nutrition, and cooking. In Year II, training in cultural awareness and mind–body skills (e.g., self-awareness, mindfulness, and journaling) was added, and training time was substantially increased, from 8 h in Year I to 55 h in Year II. All staff met for 60–90 min at the end of each day of MTS for debriefing and planning.

Program Design and Instructional Strategies

The program day began with breakfast at 8:30 a.m. and ended at 3:00 p.m. Each of four crew leaders had his or her own consistent “crew” of four to six participants. Each crew had two mornings per week of farm education and farm work, and two mornings of nutrition education and cooking. The crews who cooked also prepared lunch for the entire group, who all sat down to eat together. The rest of the day included physical activity, yoga and mindfulness, and leadership components. An optional field trip (e.g., hiking, canoeing, swimming, and volleyball) took place each Friday. The schedule is shown in Figure 1.

Figure 1.

Mission Thrive Summer—weekly schedule.

The farming curriculum was based on publications of The Food Project, a nonprofit organization that engages youth in sustainable farming in Massachusetts.^33–35 Content included environmental and agricultural topics such as ecosystems and watershed, sustainable food production methods, composting, and the roles of insects. Larger questions of social, cultural, and economic influences on food availability and choice were discussed as affecting the health of individuals. Much of the learning was direedy experiential: planting, mulching, watering, weeding, and harvesting (Figures 2 and 3). Some farm produce went toward the cooking component of the program, and participants often took vegetables home.

Figure 2.

Participants tend crops in “hoop houses” and open fields.

Figure 3.

Youth work in crews to carry out farm tasks such as mulching.

The nutrition and cooking curriculum was based on the USDA MyPlate guidelines, which present the use of food groups to guide planning of balanced meals.³⁶ The Spice MyPlate curriculum was used to teach ways in which spices and herbs can make healthy foods more appealing and encourage their consumption.²⁰ Each nutrition lesson was presented together with appropriate ingredients and recipes, so that hands-on experience became a way to bridge the science, culinary practice, and sensory outcomes (Figure 4).

Figure 4.

Participants leam to make appealing, healthy meals using produce from the farm.

The curriculum stressed skills of immediate importance, such as the safe use of knives, and also addressed longer-term skills, such as how to incorporate more healthy foods into an established diet, how to shop for healthy foods in a grocery store, and how to interpret nutrition labels.

Physical activity sessions presented basic exercise science through fitness activities (resistance exercise, bodyweight exercises, plyometrics, etc.), sports (soccer, basketball, etc.), games (capture the flag, etc.), and various forms of dance. Yoga sessions included asanas, breath work, and meditation, presented in a context of stress reduction and self-calming.

The leadership component focused on personal and job skills development, including elements of financial literacy and public speaking. Working daily as part of a crew was presented as an opportunity to strengthen skills of cooperation and teamwork. Participants received regular performance feedback.

The sixth week of the program culminated in two events to which families and the Baltimore community were invited: a cooking competition among the four crews, and a “Health Expo,” produced by the youth, advertised to the public, and held at a nearby community center. For the cooking competition, each crew chose a nutritionally balanced dish and prepared it under the observation of a panel of community judges, such as local chefs, farmers, and school administrators. Each crew then presented its completed dish to the judges, describing the recipe, mode of preparation, and nutritional value. The judges chose the winning dish based on visual presentation, recipe presentation, teamwork, creativity, and taste.

For the Health Expo, youth worked in pairs to choose and research a topic (e.g., physical fitness, culinary knife skills, making healthy smoothies and snacks, or calculating the sugar content of sodas). They then created educational materials and a learning experience or game for attendees, who were community members of all ages. Over the course of MTS Years I and II, the Health Expo drew a total of 215 visitors from the Baltimore community.

Outcomes Evaluation

All MTS program participants also participated in the pilot outcomes evaluation of the program. The Institutional Review Board of the University of Maryland School of Medicine approved the outcomes evaluation protocol. Prior to the beginning of the program in both Years I and II, at least one parent or legal guardian of each participant came to Real Food Farm for a site tour, program discussion, and explanation of informed consent. Written informed consent from parents or guardians and written assent from all participating students were obtained at that time.

Quantitative Measures.

Accelerometry was performed to measure mean caloric expenditure and steps taken during each day of the MTS program. Participants wore ActiGraph accelerometers during program hours. ActiGraph accelerometers are commonly used in research, including research in adolescents, and are considered a “gold standard” of physical activity assessment.³⁷ While changes in weight were not an IRB-approved outcome, weight was measured at baseline via an electronic scale at the site of the MTS program in order to allow for the calculation of caloric expenditure by the accelerometry software.

In addition to the objective outcomes data provided by the accelerometers, a variety of previously validated questionnaires assessing various dimensions of health and wellbeing were administered to MTS participants. A concerted effort was made to choose age- and literacy-appropriate questionnaires whenever possible. Questionnaires were administered at the start of the MTS program (“baseline”), at the conclusion of the MTS program (“end of program”), and two (Year I) and eight (Year II) weeks after the conclusion of the MTS program (“follow-up”). The follow-up questionnaires were used to evaluate whether any changes noted during the program would persist into the following school year.

Questionnaires administered during Years I and II of MTS included the Child and Adolescent Mindfulness Measure,³⁸ Perceived Stress Scale,³⁹ and the Physical Activity Questionnaire for Adolescents.⁴⁰ Also used in Year I was the CDC Youth Risk Behavior Survey (YRBS) – Fruit and Vegetable Questions.⁴¹ The Child and Adolescent Mindfulness Measure contains 10 items that assess general mindfulness characteristics, including lack of awareness of ongoing activity and judgmental responses to thoughts and feelings. The version of the Perceived Stress Scale utilized in this outcomes evaluation also containedlO items and has been used in a wide variety of populations and settings to capture the subjective experience of stress. The Physical Activity Questionnaire for Adolescents contains nine items that assess general levels of physical activity for high schools students of approximately 14–19 years of age. The YRBS – Fruit and Vegetable Questions contained seven self-reported items that are part of a national high school-based survey that measures the risk of unhealthy dietary intake, inadequate physical activity, and other health behaviors. In Year II, however, because of the relatively limited scope of this survey compared to the substantial nutrition and healthy cooking emphasis of the MTS program, the YRBS Fruit and Vegetable Questions were replaced with the more comprehensive Block Kids Food Screener (BKFS) food frequency questionnaire that captured a much more expansive set of food choices.⁴² The BKFS contains 41 items and has been validated to accurately evaluate dietary intake of nutrients and food groups in youth 10–17 years of age. The BKFS asks the subject to reflect on the frequency and quantity of foods and beverages consumed during the previous week.

Statistical Analysis.

Descriptive statistics (means, frequencies, ranges, etc.) were performed to characterize the MTS program population at baseline. Shapiro-Wilk test of normality was conducted for all study outcomes. Comparisons in program outcomes from baseline to end of program and from baseline to follow-up were conducted utilizing paired t-tests. Statistical significance was defined as two-tailed p ≤ 0.05 and all analyses were performed using SAS (version 9.3, SAS Institute Inc., Cary, NC).

Qualitative Data Collection.

Participant and parent responses to Years I and II of MTS were gathered at several points. After Year I, at two-week follow-up, participants were interviewed individually as to what they had learned from the program and what, if any, ongoing effects they had experienced. Responses were transcribed concurrently. At the beginning of Year II, in June 2014, Year I participants who had chosen to return to MTS took part in a focus group to discuss: (1) why they had chosen to come back; (2) what they had liked most and least in Year I; (3) what, if any, personal changes they had experienced as a result of Year I; and (4) what their goals were for Year II. Responses were recorded and transcribed.

After Year II, at eight-week follow-up, participants were individually interviewed regarding: (1) their expectations of the program versus their experience; (2) the “good parts” and the challenges of the program; (3) what they had learned about the four core program values: “trying it on,” healthy choices, accountability, and teamwork; and (4) what, if any, personal change participants had noticed in themselves. Most responses were recorded and transcribed; some were transcribed concurrently.

At the close of Years I and II, parents and guardians who attended the final cooking competition at the farm were invited to be interviewed regarding their own and their child’s experiences of the program. Responses were transcribed concurrently.

All transcripts were read at least three times by two of the authors (B.P. and B.B.) and coded with reference to program components (yoga, mindfulness, farming, nutrition, cooking, physical activity, leadership, and field trips) and four core values (“try it on,” healthy choices, accountability, and teamwork). Emergent themes were noted and coded (e.g., self-awareness, self-efficacy, fun). Responses were further examined with regard to the stages and processes of the Transtheoretical Model (TTM) in order to assess participant progress toward longer-term positive health behaviors. TTM stages of change regarding youth diet and physical activity have been validated with reference to CDC YRBS questions.^41,43

RESULTS

In Year I (summer 2013), 17 students enrolled in MTS from four public high schools in Baltimore. Fifteen participants (88.2%) completed the program (one left for behavioral reasons, one for family reasons). Of the 15 students who completed the program, the mean age was 14.9 years, the mean weight was 162 pounds, and there were eight girls (53%). In Year II (summer 2014), 26 students enrolled in MTS from eight public schools in Baltimore. Twenty-three participants (88.5%) completed the program (three left for family reasons). Among the 15 participants who completed MTS in Year I, seven (47%) also completed MTS in Year II. Of the 23 students who completed the program in Year II, the mean age was 15.5 years, the mean weight was 160 pounds, and there were 10 girls (43%). All of the MTS participants (100%) in both Years I and II were African-American.

Quantitative Results

Accelerometry data revealed high levels of physical activity and caloric expenditure among the participants during MTS program hours (9 a.m.–3 p.m.). In Year I, program participants burned a mean of 484 calories and took a mean of 7158 steps during program hours each day. In Year II, program participants burned a mean of 604 calories and took a mean of 7417 steps during program hours each day. Over the two years of MTS combined, participants burned a mean of 544 calories and took a mean of 7288 steps during program hours each day.

There were no changes in CDC YRBS – Fruit and Vegetable Questions from baseline to the end of the MTS program or follow-up during Year I (p > 0.05). However, the Block Kids Food Screener food frequency questionnaire responses revealed numerous positive changes in healthy eating habits from baseline to the end of program and to follow-up assessment periods during Year II. There were increases from baseline to the end of the MTS program in the number of days during the last week that participants ate: tomatoes (0.46–1.22, P = 0.01), “other vegetables (like com, carrots, greens, and broccoli)” (1.25–2.43, P = 0.02), and whole wheat bread or rolls (not white bread) (1.04–2.87, P – 0.007). There were decreases from baseline to the end of the MTS program in the number of days during the last week that participants ate: hot dogs, com dogs, or sausage (1.50–0.48, P = 0.0003), hamburgers or cheeseburgers (1.13–0.52, P = 0.006), and ice cream (1.46–0.70, P = 0.01). There were also several self-reported changes in dietary habits from baseline to the follow-up assessment period eight weeks after the conclusion of the MTS program. There were decreases from baseline to follow-up in the number of days during the last week that participants ate hot dogs, com dogs, or sausages (1.50–0.61, P = 0.01), hamburgers or cheeseburgers (1.13–0.50, P = 0.01), and ice cream (1.46–0.42, P = 0.003).

Table 1 provides mean scores for the Perceived Stress Scale, Child and Adolescent Mindfulness Measure, and Physical Activity Questionnaire for Adolescents at baseline, end of program, and follow-up for both Years I and II of the MTS program. The results of the t-tests assessing changes from baseline to end of program and follow-up are also provided. In brief, while there was a statistically significant improvement in mean score on the Physical Activity Questionnaire for Adolescents from baseline to end of program in Year I (P = 0.008) and a trend towards improvement in mean score on Perceived Stress Scale from baseline to follow-up in Year II (P = 0.07), there were few meaningful changes in these three outcome measures.

Table 1.

Changes in Mean (Standard Deviation) Self-Reported Outcomes^a during Years I & II of MTS.

Outcome	MTS Year I			MTS Year II
	Baseline (n = 17)	End of Program (n = 15)	Follow-up (n= 15)	Baseline (n = 24)	End of Program (n = 23)	Follow-up (n = 23)
Perceived Stress Scale	20.8 (7.8)	17.4 (7.9) [P = .3]	15.8 (6.0) [P = .07]	17.2 (4.8)	17.0 (6.6) [P = .9]	16.2 (6.5) [P = .6]
Child and Adolescent Mindfulness Measure	21.9 (9.2)	22.1 (8.4) [P = .9]	19.9 (8.8) [P = .3]	15.0 (7.6)	14.1 (8.9) [P = .3]	16.0 (8.5) [P = .4]
Physical Activity Questionnaire for Adolescents	1.8 (0.9)	2.1 (0.8) [P = .008]	1.6 (0.7) [P = .6]	1.7 (1.1)	2.2 (1.1) [P = .08]	2.0 (1.7) [P = .5]

MTS—Mission Thrive Summer.

^aP values are for paired t-tests comparing baseline outcomes with those at end of program and follow-up.

Qualitative Results

Of the 15 participants who completed MTS in Year I, 12 (80%) were interviewed after the program at two-week follow-up. Seven (47%) chose to return for Year II. Of these seven, six (86%) took part in a focus group at the beginning of Year II. Of the 23 participants who completed MTS in Year II (including the seven returnees), 22 (96%) were interviewed after the program at eight-week follow-up. At the close of Years I and II, among the parents and guardians who attended the final cooking competition, three each year, for a total of six, agreed to be interviewed about their own and their child’s experiences of the program.

Participant Responses.

In participant interviews, several youth spoke of a shift in their health awareness prior to MTS, which appears consistent with precontemplation and contemplation, the early stages of health behavior change:

• –The summer before I started [MTS] … I ate French fries, like, every single day. Like, I was addicted. And I got fatter, and when I went back to school, people told me that my face looked chubbier. But I will never do that again.
• –I realized that I’m getting older and wanted a healthier body.

One participant noted that, when considering taking part in MTS, she “expected more hard stuff than fun stuff” in the program. Despite the perceived challenge, she applied to join, thus demonstrating the stage of preparation, her intention to act.

The fourth stage of health behavior change in the TTM is that of action, in which individuals engage in significant lifestyle change. In describing their experience over time, nearly all MTS participants reveal health behavior change occurring through multiple, overlapping forms of action. Such actions included learning, trying, doing, collaborating, interacting with positive role models, substituting healthy behaviors for unhealthy ones, and taking new learning and new behaviors home to their families. Participant responses show that these actions are embedded in MTS program components (farming, nutrition, cooking, physical activity, yoga and mindfulness, leadership, and field trips) and expressive of the four core values (“try it on,” healthy choices, teamwork, and accountability).

Noted above is one participant’s realization that eating French fries daily had caused her to gain unwanted weight in 2012. Her further statements, collected at three points during 2013 and 2014, demonstrate her actions and insights over time, realized in the context of MTS program components and core values (Box 1).

Box 1–One Participant’s Experience Over Time.

MTS Year I (Two-week follow-up, August 2013):

• –I learned more exercises and yoga positions. And I learned how much sugar to eat in a day.

MTS Year II (Program start, June 2014):

• –I came back to [MTS] because I just like how last year we learned a lot, and we got a chance to try a lot of new things and cook a lot of new things. And I came back to see and to learn more exercises and how to stay fit.… [MTS] made me eat more healthier and check nutrition facts and watch what I eat. And I cook more and I’m more healthy.

MTS Year II (Eight-week follow-up, October 2014):

• –I played soccer this year.… I exercise at home. I do leg lifts… and then I do squats. I do push-ups. I do planks. I started that after [MTS], the first year. I learned planks from you!
• –I eat more lettuce and more vegetables.
• –[MTS] can get you on the right track … and tell you more healthy alternatives to eating that junk food. They can get you in shape, girl!
• –Oh my God, we had to use so much teamwork!… We really had to work together to get things done, like pulling weeds… moving compost, like, having to pull the barrel, like, we needed people to take the shovels and put it in the barrel, and then people to move it to the next spot.
• –It’s hard to cook with other people.… I think I got better at it, ‘cause my group, we didn’t argue as much on the last time we cooked. I miss them.
• –Like, I would be the most mature person in my group, well, besides my crew leader. Oh my God, I miss her! You know, I still talk to her.… But yeah, sometimes my crew would be acting up, because it was mostly all boys … and I would get them back in shape and tell them to do this and do that. So I think my leadership, it did change.
• –My family, we grew, like, a bunch more things in our backyard this year. So I grew, my father grew, banana peppers, … tomatoes, cucumbers. Now we’re growing mustard greens. And I’m just so proud of my banana pepper plant.… The last pepper that came off it was huge!… Me and my family – it’s my grandmother, my father, and me – we were tearing the stems off the mustard greens, because there was, like, so many, so we did that as a family.

Data gathered from nearly all MTS participants showed a large majority to be successful in applying MTS core values in the context of program activities, with associated changes in health-related awareness, behaviors, and family activity (examples, Box 2). Of note, a strong emergent theme in the data was the youth-friendly topic of “fun.” Many described MTS as “fun” for a range of reasons (Box 3).

Box 2–MTS Core Values in Program Context.

Core Value 1: “Try it On”

• –They taught us, don’t say “Ewww” to a food before you actually taste it, and, like, a couple of weeks into the program, I started not doing that.
• –Eating is not just about unhealthy things that taste good. It’s about trying new things.
• –I’ve tried tomatoes before, but I didn’t like them. I tried one of the little ones at the farm and it was okay. So then when I went on vacation, I had tomatoes two times and it wasn’t bad. My goal is to eat a whole tomato one day.
• –I never thought I would learn about yoga.… I do the sunrise [salutation] when I wake up.

Core Value 2: Healthy Choices

• –I stopped drinking soda. Used to be about one a day, now it’s not very often. That’s because I got used to drinking lots of water over the summer.
• –I’m starting to crave fruits and vegetables.
• –I bought … some granola with almonds, ‘cause I like almonds now.… and then I let my little sister try some too.
• –Now I make vegetable smoothies. I’ve started eating veggies, and I work out more. I do push-ups and sit-ups and weights at my house now.
• –I joined the gym with my mom. We go every day. My calves and stomach are getting smaller.
• –After doing more fitness this summer, I started to go running in my neighborhood. I tried to get my younger brother to come, but he didn’t want to. [His brother participated in MTS the following year.]

Core Value 3: Teamwork

• –Teamwork was one of the biggest accomplishments you had to do. You had to work with your team to pickup the [vegetable] roots. So one person would hold the basket, one person would clip it, one person would clean it off. Things like that. You had to work well with others, so you wouldn’t be, like, rude and talking the wrong way to a certain person. You had to DO teamwork.
• –I actually love my group.… Especially cooking. Lots of teamwork happened. If somebody wasn’t good at working in a team, I gotta say something.

Core Value 4: Accountability

• –Like, the crew leaders, if you mess up, they’ll tell you to, like, do it over. And they’ll teach you what to do. Yeah, also, like, the crew leaders be cracking down. Like, you need to be early, stop coming late. You need to be on task.
• –[Accountability] wasn’t really just negative, it was also positive. So after we would farm, they would say, “Who would you wanna give a shout out?” And people would be like, “Shout out myself, I really did a hard job today.”

Box 3–Emergent Theme – Fun.

• –[MTS] is a lot of work, but also fun.
• –I expected it would be boring, but it was fun.
• –I thought farming would be the worst thing I’ve ever done in my life, but it
• –was actually fun.
• –Moving the mulch was hard physically, but it was still fun.
• –The hardest thing was working [outside]. It was fun because people was energized and happy, so that got me through it.
• –Yoga was fun. It helped me learn how to not think about any problems.
• –The field trips on Fridays was, I gotta say, the most fun part.
• –One of the fun things we did … was when we went to the Inner Harbor to play volleyball [field trip, after which she joined her high school volleyball team].

The fifth stage of the TTM is maintenance, as the overt behavior changes realized through the stage of action lead to increasing self-confidence and self-efficacy. Several processes of change may be significant. In the TTM, a fundamental process of health behavior change is that of self-reevaluation, a mental–emotional shift in self-image that develops through experiencing oneself “with and without a particular unhealthy habit,” e.g., sedentary behavior. Interacting with healthy role models may also facilitate this changing self-awareness. With regard to minority populations in particular, the TTM identifies important processes of social liberation and empowerment, i.e., change that increases opportunities to achieve social wellbeing and improve health.²³

Responses from many MTS participants suggested that the program not only motivated overt health behavior changes, such as increased physical activity and improved nutrition, but also stimulated mental–emotional development, consistent with TTM processes of self-reevaluation and empowerment (Box 4). Participant statements pointed to new knowledge, skills, and shared responsibility as laying a foundation for engagement with community through work and leadership. Noteworthy in the data are emergent themes of self-awareness and self-regulation. Several participants described their MTS experience as an interaction of body and mind, where multiple program activities and increasing fitness led to new self-knowledge and changing feelings. The responses of several participants also pointed to an increase in their ability to regulate attention, anger, or actions. One youth attributed his greater emotional self-regulation to his new practice of yoga and meditation.

Box 4–Self-Reevaluation and Empowerment.

Self-Awareness

• –[In MTS] you’re very active.… You learn a wide variety of things, like, not just about the program, but about yourself too.
• –When you’re getting fit, it changes how you feel about yourself and you have more energy.
• –[MTS] helped me with my attitude problem, ‘cause I don’t have it no more like I used to.
• –I’m able to look at myself during conflicts.

Self-Regulation

• –I do yoga a lot. I get mad a lot. I’m calm now. Meditation. I just close my eyes and I just think.
• –Now when other people are talking in class, I just keep doing my work or listening. Before [MTS], I would have talked to my friends in class.
• –I think before I do stuff.

Self-Efficacy

• –I came back because I like the farm, and I like to plant stuff. Like, you have to, like, try a lot of new things. Make you, you build your confidence.
• –All I knew how to use before was the microwave, but now I know how to cook for real.
• –I’m much safer in the kitchen now. I have safer knife skills and know about cross-contamination.
• –[With my MTS paycheck] I went to the market and shopped for myself. I got some bananas.
• –I do things, like, get up and do things on my own, like chores and stuff. [My parents are] happy that I do that.

Role in Community

• –Working together to do the Health Expo, helping people, and teaching at the booths and the table made me feel more responsible.
• –I was teaching other people stuff that I didn’t know myself at the start of the summer. So they probably didn’t know it either.
• –Having to show up on time could be hard for some people, but it’s a job, so you just do it.
• –This experience helped me get another job [with a local-food caterer]. They liked that I had experience with real food.
• –This summer made me think about why we don’t have more farms around the city or more stores to sell fresh food from the farms.

Parent Responses.

Parents described MTS as “a great experience,” “something different, positive healthwise,” and “a lot of fun” (Box 5). Some had doubted that their children would want to work on the farm and were surprised at the positive response. One mother reported that her daughter “keeps saying we have to change our eating habits,” while another spoke of her worry at seeing no improvement in her son’s unhealthy diet. Two mothers mentioned with surprise their sons’ new desire to cook. Two noted positively their daughters’ fatigue at the end of the day with their increased physical activity, and two parents observed that their children liked yoga. One mother said that her son had had a hard time motivating himself to go to MTS every morning and that he complained about working outdoors on hot days. Another expressed pleasure at her daughter learning to be on time and to call if she would be late, “just like you would with a job.” While fewer parents than participants were interviewed, parent responses generally supported the participants’ views of the experience.

Box 5–Parent Responses.

Farming

• –He brought home a tomato plant that they gave him at the farm. He’s on the computer, researching how to care for it. He thinks he can get it to grow.… I didn’t think he would like the farming stuff, but he’s really excited about it. He looked up what kind soil it needs. He really wants to plant that tomato.

Nutrition

• –I put some lima beans in a bowl for her. She didn’t eat them all, but it’s more than what she did before.
• –He never ate fruit before.… Now he loves to sample things.
• –She brought kale home from the farm and I cooked it.
• –She is drinking a lot more water.

Cooking

• –He’s asking me if he can cook. I never used to let him in the kitchen, but now I let him cook a little. Before, I wouldn’t let him near the knives, but he told me that they learned how to use a knife, so I said okay, since you learned.
• –He’s talking about new seasonings for food. He’s telling me how to cook.

Teamwork

• –I like this program because it brings kids from all over [the city] and when they have to get something done, they have to learn how to work together. If there is a problem, they have to work it out.

Fun

• –He’s like a different person. He was quiet and into computers. Now he talks and dances. He danced at the family reunion!

DISCUSSION

The healthy, whole-person development of youth in a city with serious health and socioeconomic challenges is a matter of public health importance. The Mission Thrive Summer program was found to be feasible for its four community partners and acceptable to two cohorts of African-American high school students in Baltimore. Of those who joined MTS in Years I and II, 86.1% completed the program and provided quantitative outcomes data. Of those who completed the program, 90.3% provided qualitative outcomes data. The successful program delivery, high rate of retention, and compliance with data collection were due in part to the extensive collaboration of the public and private partners in the design, implementation, and evaluation of MTS. Paid summer employment was likely another factor in the high rate of participant retention in MTS. Moreover, many participants described the program as “fun,” which appeared as a strong theme in the qualitative data. Some cited positive feelings about program leaders and crew members as well. These strengths of fun and relationship may help to explain why almost half of Year I participants returned to take part in Year II, and why nearly all participants returned after the program’s end to take part in follow-up evaluations for which they did not receive compensation

There were also a number of notable limitations of the MTS intervention and outcomes evaluation. One limitation of the MTS intervention is that the number of youth who can participate in the MTS program model each summer is relatively small, due to the limited amount of work that can be done at once on a small farm and the limited space in one classroom kitchen. As a result, the sample size for the outcomes evaluation was not adequately powered to detect statistically significant differences in certain quantitative outcomes between time points. It was evident, nevertheless, that during the six weeks of MTS participants attained high levels of physical activity and caloric expenditure (as expressed by the gold standard of accelerometry) and numerous improvements in their nutrition (as expressed by Block Kids Food Screener food frequency questionnaires).

A further limitation of this study is the use of written questionnaires to elicit self-reported outcomes among a population whose reading ability may not be at grade level. In 2013, only 62% of eighth-grade students in Baltimore passed the Maryland State Assessment examination in reading.⁴⁴ This factor should be considered in the future selection of outcomes measures. A recently published mindfulness meditation intervention conducted among a similar sample of high school students in Baltimore uncovered no statistically significant changes in questionnaire-based measures, while numerous improvements appeared in the qualitative data analysis.⁴⁵ Similarly in the present study, qualitative data showed substantial evidence that MTS participants had experienced health-related changes that were not reflected in written questionnaires.

Qualitative data provided in participant interviews and a focus group revealed a range of ways in which health behavior changes occurred during the program and continued beyond the summer. These data revealed further that the experience of MTS had benefited not only participants, but some families as well. Some participants described encouraging or working with parents or siblings to grow vegetables at home or to engage in exercise together. A few participants described buying, or asking a mother to buy, healthier foods, and some said that they themselves were now cooking at home. Beyond overt changes of physical activity and nutrition, the qualitative data also offered insights into subtler, but meaningful changes that the participants observed in themselves. These included a growing self-awareness, with some recognition of the relationship of body, mind, and emotions; self-regulation, both emotional and behavioral; and self-efficacy, revealing experiences of enjoyment, accomplishment, or responsibility. Further participant responses show a realization that new learning and achievement has led to changing roles and engagement with the community.

While the mixed-methods outcomes evaluation provided a more comprehensive assessment of the acceptability of the multi-modality MTS integrative health intervention and its immediate and persistent outcomes than could be captured by either quantitative or qualitative data alone, a limitation of the quantitative outcomes evaluation is that many of the improvements in short-term outcomes among MTS participants may have been a product of participating in a structured program of any sort during the summer. Thus, the degree of inference that can be made with respect to the MTS intervention specifically and its long-term effects beyond summer is somewhat limited. That said, the qualitative data revealed particularly high acceptability and enjoyment of many MTS modalities, such as yoga, meditation, cooking, and farming, that are unlikely to be experienced in most other structured summer programs. Yet, while both self-reported and “gold standard” physical activity assessment (ActiGraph accelerometry) in the quantitative outcomes evaluation suggested high levels of physical activity during MTS program hours, self-reported physical activity on the validated quantitative metric returned to pre-intervention levels at follow-up during the following school years.

A final limitation of the MTS intervention relates to the replicability of the model itself. MTS requires an urban farm or community garden, access to a group cooking facility, and staff able to teach agricultural, nutritional, and culinary concepts and practices. While this may appear daunting, online resources identify numerous urban farm and garden projects and trainings, both nationally and regionally.^46–49 Models and curricula for existing programs are also readily accessible.^50,51 Many schools and churches have large kitchens and may welcome a similar community partnership for healthy youth development. Additional staff to facilitate physical activity, yoga, and mindfulness can strengthen the program and are not difficult to find, especially in urban settings.

MTS is an ongoing program, currently in planning for its fourth summer in 2016. MTS continues to be embraced by all of the cross-sector community partners involved and the participating high school students in Baltimore. Refinements in the collection and evaluation of outcomes continue to be made, and models for scalability of the program are being developed. Currently, the feasibility, participant compliance, and promising preliminary outcomes suggest that the MTS model is an integrative, whole-person intervention that may support healthy youth development and help mitigate some of the health risks experienced by African-American high school students in urban settings during the summer.