Adolescents as Agents of Parental Healthy Lifestyle Behavior Change: COPE Healthy Lifestyles TEEN Program

Abstract

Introduction:

Obesity is a leading health crisis around the world. An intervention strategy scarcely utilized for behavior change is that of a child as change agent. The purpose of this study was to describe the impact of teens reviewing newsletters from a healthy lifestyle intervention with their parents.

Method:

Evaluation data from a randomized controlled trial, COPE Healthy Lifestyle TEEN Program, was analyzed. A descriptive study was conducted of parents’ and teens’ lifestyle behaviors as reported by parents.

Results:

One hundred sixty-nine parents completed evaluations. Two thirds of parents reported changing a behavior as a result of the program. Nearly three quarters of parents reported behavior changes in their teens. Over 90% reported they would recommend this or a similar program.

Discussion:

The obesity epidemic shows no signs of reversal, and hence multiple approaches to impact healthy lifestyles are urgent. Including children as a change agent is a potential target for interventions addressing obesity. J Pediatr Health Care. (2020) XX, 1–9

INTRODUCTION

One of the leading health crises around the world is obesity, with more than 1.9 billion adults aged 18 years and older being overweight in 2016, of which 650 million were obese (World Health Organization, 2020). Similarly, over 340 million children and adolescents worldwide, aged 5–19 years, were overweight or obese in 2016 (World Health Organization, 2020). It is projected that 50% of the population in the United States will be obese by 2030 (Ward et al., 2019).

Despite significant efforts to curtail the increase in overweight and obesity, the prevalence of overweight and obesity continue to rise. Studies and community programs and/or ordinances for obesity prevention and treatment have focused on multiple levels of the social ecological model, including individual and family-focused interventions, changes impacting the environment and, more recently, government limits on the purchasing size of foods or adding taxes to foods (Crino, Sacks, & Wu, 2016; Lee et al., 2019; Vo, Albrecht, & Kershaw, 2019). Interventions have had varied responses, with most failing to achieve meaningful longterm improvements in overweight or obese status (McEvedy, Sullivan-Mort, McLean, Pascoe, & Paxton, 2017; Sim, Lebow, Wang, Koball, & Murad, 2016). The upward trend of obesity is likely to continue until the obesogenic environment of our society drastically changes and returns to healthy eating patterns consisting of whole, minimally processed foods that are primarily plant-based (Turner-McGrievy, Mandes, & Crimarco, 2017). Regrettably, businesses that create unhealthy foods, which greatly contribute to the epidemic of obesity, profit from the purchase of highly or ultraprocessed foods.

The necessity for strategies to address the obesity epidemic continues to be paramount. In addressing childhood obesity, researchers have assessed parent-only interventions, child–parent interventions, and child-only interventions. An intervention strategy that has been less studied is that of a child acting as a change agent within the family environment. In this context, an intervention is provided to children, and then the children diffuse the information to their families and communities.

Studies using children as change agents have had a wide focus of interventions, including malaria prevention, infectious disease prevention, cancer screening, hypertension awareness, HIV awareness and prevention, increasing fruit and vegetable intake, and diet and physical activity (see Table 1). Researchers have examined both qualitative and quantitative data to describe not only the effectiveness of interventions but also to capture the experience of adults and children interacting in a nontypical role for children as information providers. Concern has been voiced regarding the potential negative impact of children serving as change agents in that they may feel anxiety or negative thoughts about the person with the behaviors they are trying to impact (Burrows, 2017). Indeed, these concerns may occur, but little evidence of this has been identified in the qualitative studies reported in the literature. These qualitative studies have found that parents are receptive to the messages children have shared (Breese, Caruso, Sales, Lupele, & Freeman, 2016; Gadhoke, Christiansen, Swartz, & Gittelsohn, 2015; Milakovich et al., 2018; Mwanga, Jensen, Magnussen, & Aagaard-Hansen, 2008; Onyango-Ouma, 2003; Simonds, Kim, LaVeraux, Milakovich, & Cummins, 2019). Researchers have noted the importance of children being taught how to present information, that the messages presented should be prescriptive and simple (Breese et al., 2016), and the interaction should strengthen the bidirectional relationship of child and adult (Milakovich et al., 2018).

TABLE 1.

Studies including children as agents of change

Focus of study	Quantitative	Qualitative	Target(s) for behavior change
Cancer screening	1		Adult family relatives
Diet and physical activity		1	Adults
Fruit and vegetable intake	1		Children asking behaviors, home fruit and vegetable availability
HIV and/or AIDS	1		Adult beliefs and children’s effectiveness to teach
Hypertension awareness	1		Parent and/or guardian seeking care
Infectious disease prevention	1	1	Knowledge, trust, practices
Schoolchildren as health change agents		1	Community support
Vector-borne disease (e.g., malaria)	4	1	Knowledge, attitude, practices, health communication
Water preservation	1	2	Knowledge, attitudes, behaviors

Creating Opportunities for Personal Empowerment (COPE) Healthy Lifestyles Thinking, Emotions, Exercise, and Nutrition (TEEN) Program is a 15-session manualized cognitive–behavioral skills-building curriculum and/or program that has been found to positively impact a teen’s physical, mental, and/or emotional health and healthy lifestyle behaviors. The program has been designated as a research-tested intervention program for obesity control in adolescents by the National Cancer Institute and given the highest score for its dissemination capability (https://rtips.cancer.gov/rtips/programDetails.do?programId=22686590). The COPE Healthy Lifestyles TEEN Program is typically delivered in a group format and has primarily been delivered in the school or after-school setting by teachers or facilitators as a preventive intervention program. Early studies testing the efficacy of this program attempted to have parents attend an educational session in which they would learn about information in the program so that they could reinforce the skills with their children at home. However, parent participation was extremely challenging. Therefore, to reach parents with the information, four parent newsletters were created for teens to share with their parents to (1) reinforce the children’s learning by teaching the information, (2) inform the parents of information that could improve their child’s and their own health, and (3) impact the home environment to be healthier regarding physical activity and nutrition. The purpose of this project was to describe the impact of the teens’ reviewing the newsletters with their parents on the teens’ and their parents’ lifestyle behaviors through open-ended evaluation responses.

METHODS

A secondary analysis project was conducted to describe parents’ and teens’ lifestyle behaviors as reported by parents. The study was approved by the University Institutional Review Board and each participating school district.

Sample

Students were invited to participate if they were aged 14–16 years and enrolled in a health education course at 11 high schools from two school districts within a large metropolitan city in the southwestern United States. To participate in the study, teens needed to provide assent, parental consent, and be free from medical conditions that would not allow them to participate in the physical activity component of the program if they were randomized to the COPE Healthy Lifestyle TEEN group. Parents of the teens were invited to participate by sending home a letter describing the study and consent form with their teen. Participation by parents was not mandatory. Teens returned consents of parents who chose to participate. Teens and parents were compensated for their participation in the study at three time points. All parents who returned questionnaires at postintervention were included in this study. A more detailed description of the study methods has been published previously (Melnyk et al., 2013).

Intervention

The COPE Healthy Lifestyle TEEN Program is a manualized prevention intervention designed to empower teens to engage in healthy lifestyle behaviors and learn to regulate their emotions, including stress, anxiety, and depressive symptoms, through cognitive–behavioral and/or coping skills. Teens received the 15-week COPE Healthy Lifestyle TEEN intervention during a mandatory school health class. The COPE Healthy Lifestyle TEEN Program is based on cognitive–behavioral therapy, which emphasizes that how an individual thinks directly affects how they feel and how they behave (Beck & Beck, 2011). Skill-building follows each of the weekly sessions so that the teens can put into practice what they are learning in the sessions. Sessions 1–7 focus on cognitive–behavioral skills-building and Sessions 8–15 focus on nutrition and physical activity (see the Box). Fifteen to 20 min of physical activity is built into each of the COPE Healthy Lifestyle TEEN sessions.

BOX. Intervention curriculum.

• Healthy lifestyles

• Self-esteem and positive thinking

• Setting goals and problem-solving

• Stress and coping

• Dealing with emotions in healthy ways

• Personality and effective communication

• Activity—let’s keep moving

• Heart rate and stretching

• Nutrition basics

• Reading labels

• Portion sizes

• Eating for life and social eating—party heart(y)

• Snacks

• Healthy choices

• Wrap up

Four times during the program, teens received newsletters that contained information about the content in the COPE Healthy Lifestyle TEEN Program. They were instructed to share the newsletters with their parents, teaching them the content and skills that they were learning. Teens were encouraged to return a signed portion of the newsletter to their teachers after discussing the content with their parents.

Data Collection

Parents completed questionnaires at pre- and postintervention that were sent home with their teens in either English or Spanish. Teens returned completed questionnaires to their teachers, which were then collected by research team members.

Measures and Data Analysis

Parents completed demographics before study commencement. At postintervention, parents completed a program evaluation including questions regarding whether the teens shared the newsletters with them, whether they or their teen made behavior changes during the intervention, and, if yes, what changes were made. Data were analyzed through descriptive statistics and by categorizing narrative responses.

RESULTS

Ninety-two percent of the 200 parents in the COPE Healthy Lifestyle TEEN group completed baseline assessments (see Table 2), and 77% were Hispanic. Body mass index was calculated from self-reported height and weight, with 74.5% reported to be either overweight or obese (body mass index ≥ 25). More than half of the parents reported an annual income of ≤ $20,000. Forty-six percent of parents had less than high school education.

TABLE 2.

Parent demographics

Characteristic	COPE TEEN (n = 200)
	M	SD
Age, years	40.73	6.83
BMI	30.07	6.16
	n	%
Parent BMI
Underweight	0	0.00
Normal	36	18.00
Overweight	71	35.50
Obese	78	39.00
Not reported	15	7.50
Sex
Female	184	92.00
Male	16	8.00
Race
American native	7	3.50
Asian	4	2.00
Black	11	5.50
White	21	10.50
Hispanic	154	77.00
Other	2	1.00
Not reported	1	0.50
Ethnicity
Hispanic or Latino	154	77.00
Marital status
Married	115	57.50
Unmarried	85	42.50
Not reported	0	0.00
Education
Less than high school	92	46.00
High school graduate	49	24.50
Some college	40	20.00
College graduate	18	9.00
Not reported	1	0.50
Public assistance
No	99	49.50
Yes	99	49.50
Not reported	2	1.00
Annual household income
≤ $7,000	30	15.00
$7,000–$10,000	23	11.50
$10,001–$15,000	23	11.50
$15,001–$20,000	33	16.50
$20,001–$30,000	27	13.50
$30,001–$40,000	19	9.50
≥ $40,000	31	15.50
Not reported	14	7.00

Note. COPE, Creating Opportunities for Personal Empowerment; TEEN, Thinking, Emotions, Exercise, and Nutrition; M, mean; SD, standard deviation; BMI, body mass index.

At postintervention, 169 (85%) parents completed the open-ended questionnaires (see Table 3). Most parents reported that their teen shared information with them through the newsletters regarding the program (n = 134; 79.3%). Approximately 75% of parents (n = 126) responded that the information their teen shared was helpful. Teens primarily shared information regarding nutrition and physical activity. Two thirds of parents reported changing a behavior as a result of the program (n = 108; 63.9%), with changes primarily affecting nutrition (n = 71; 51.8%) and physical activity (n = 29; 21.2%). Nearly three quarters of parents reported behavior changes in their teens (n = 122; 72.2%), with the largest percentages for nutrition (n = 64; 39.0%) and physical activity (n = 47; 28.7%). Over 90% (n = 154) reported they would recommend participation in this program or a similar program to a family member or friend. Parent comments regarding behavior change included, “drank more water, sleep more, more exercise, more energy and lost weight,” “I am more patient with everything, I don’t stress so much like I did before taking this program,” and “I use less oil and we eat more vegetable.” Parents commented the program helped “to have better nourishment for my family and exercise more,” “to make better purchases at the grocery store,” and “me realize that food choices we make every day are very important.”

TABLE 3.

Postintervention responses

Did your teen share any of the information from the program with you?			If yes, what did your teen share with you?
Response	n	%	Category	n	%
Yes	134	79.3	Nutrition	70	50.0
No	29	17.2	Physical activity	38	27.1
Missing	6	3.6	Healthy lifestyle	11	7.9
Total	169	100	All	6	4.3
			Alcohol and/or drugs	3	2.1
			Cholesterol	3	2.1
			Emotions and/or depression	3	2.1
			Disease	2	1.4
			Information	2	1.4
			Newsletters	2	1.4
			Total	140	100.0
Have you changed any of your behaviors because of the program?			If yes, what behaviors have you changed?a
Response	n	%	Category	n	%
Yes	108	63.9	Nutrition	71	51.8
No	48	28.4	Physical activity	29	21.2
Missing	13	7.7	Other	11	8.0
Total	169	100	Communication	9	6.6
			More water	6	4.4
			Watching less television	4	2.9
			Less stress	4	2.9
			Emotional regulation	3	2.2
			Total	137	100.0
Have you seen any changes in your teen’s behavior because of participating in the program?			If yes, what behaviors have you seen?
Response	n	%	Category	n	%
Yes	122	72.2	Nutrition	64	39.0
No	41	24.3	Exercise	47	28.7
Missing	6	3.6	Relationships and communication	8	4.9
Total	169	100.0	Healthier	5	3.0
			Water	5	3.0
			Better attitude and person	4	2.4
			Encourages parent	4	2.4
			Positive	4	2.4
			Happier	3	1.8
			Watching less television	2	1.2
			More calm	2	1.2
			More energy	2	1.2
			Lose weight	2	1.2
			Emotional regulation	1	0.6
			Goals for college	1	0.6
			More aware of issues in school	1	0.6
			More respect for others	1	0.6
			Says will not drink alcohol	1	0.6
			Sleeps better	1	0.6
			Studies more	1	0.6
			Talked about health a little more	1	0.6
			Thinks before eating something unhealthy	1	0.6
			Wakes up early to go to school	1	0.6
			Way of doing things	1	0.6
			Wants to do more things after school	1	0.6
			Total	164	100.0

^aItem left blank n = 58.

DISCUSSION

The COPE Healthy Lifestyle TEEN Program was well received by both teens and parents. Open-ended responses by parents indicated behavior change occurred, both in themselves and their teens. More than 90% would recommend this program or a similar program to a family member or friend. Although exact dietary changes were not elicited, over half of the parents indicated making dietary changes, and parents reported that 39% of the teens also made dietary changes. In addition, 21.2% of parents reported changing physical activity behaviors, with 28.7% of teens changing physical activity behaviors. Changes were reported for numerous behaviors that were addressed in the intervention, including communication, stress, and emotional regulation.

The obesity epidemic shows no signs of reversal, and hence, multiple approaches to impact healthy lifestyles are urgent. Including children as a change agent is a potential target for interventions addressing obesity. Prior studies using a child agent change model have had positive effects (Ayi et al., 2010; Deepthi, Kumar, Kamath, & Rajeshwari, 2014; Kamo, Carlson, Brennan, & Earls, 2008; Mosavel & Genderson, 2016; Nonaka et al., 2008; Onyango-Ouma, Aagaard-Hansen, & Jensen, 2005; Sedighi, Nouri, Sadrosadat, Nemati, & Shahbazi, 2012). Of the 10 studies reporting quantitative findings, six were conducted outside the United States with an emphasis on infection prevention (e.g., malaria, infections, or HIV; Table 4). The four studies in the United States had an emphasis on cancer screening, hypertension screening, fruit and vegetable intake, and water environmental health. Studies identified improvements in knowledge, increased cancer screening, decrease in malaria infection, improved malaria prevention practices, and greater follow-up or intention for follow-up for blood pressure. Six studies reported qualitative findings with emphasis on malaria, child as a general health change agent, diet and physical activity, and water preservation (Table 5). These studies identified qualitative support for children as agents of change.

TABLE 4.

Child as change agent quantitative studies

Author (year), location, focus	Sample (population)	Design	Purpose	Intervention	Measures	Outcomes
Onyango-Ouma et al. (2005), rural Kenya (Luo ethnic group), malaria, diarrhea, and hygiene	Eighty children (9–14 years), 40 adults (24–68 years)	One group quasiexperimental (pre-post)	To determine the potential of schoolchildren as health change agents in a rural community.	Two months. Student-centered-involved the use of drawings, roleplay, drama, songs, and poems. Preventive issues, etiology, and recognition of symptoms. Hygiene-body and clothing care, household maintenance, food preparation, sanitation, refuse disposal, water safety, and how they impact on people’s health.	Structured observations and questionnaire survey	Significant increase in knowledge related to malaria, diarrhea, and hygiene.
Ayi et al. (2010), Ghana, malaria	Intervention group: 105 children and 250 community adults; control group: 81 children and 133 community adults. (Dangme-East district of the Greater Accra Region, Ghana, between 2007 and 2008. Three schools)	Two groups, non-RCT	To determine the impact of school-based malaria education intervention on schoolchildren and community adults.	Participatory health education. One-day anti-malaria campaign educated village residents on malaria through recreational activities, provided picture charts and posters on malaria transmission and prevention, marched through the village singing the “pumi song” with the school band, invited community members to their school. At the gathering, children educated people about malaria through drama and poetry recitals. Nurse showed the correct procedure for the treatment of conventional bed nets using insecticide tablets and explained the benefits of sleeping under treated bed nets and other malaria information. Residents had their conventional bed nets freshly treated or retreated at no cost.	Questionnaire-based interviews and parasitological surveys. Knowledge, practices, and parasite prevalence. Observational survey. The observation with a simple check-list focused on possible mosquito breeding sites around the house, presence or absence of mosquito-proof netting on windows and/or trap doors and bed nets, and the condition of those mosquito prevention tools.	Within group analysis- community adults who treated a bed net with insecticide in the past 6 months increased from 21.5% to 50.0% (p < .001). parasite prevalence in schoolchildren decreased from 30.9% to 10.3% (p = .003).
Deepthi et al. (2014), India, vector born disease prevention	Two-hundred high-school students (government and private schools)	One group pre-post	Evaluate the effectiveness of participatory school health education on vector-borne diseases.	Education included lectures, roleplay, and community-based group activity. Teachers were doctors of Sri Devaraj Urs Medical College in the local language.	Knowledge: vector-borne disease, mosquito breeding sites, diseases transmitted by them, and mosquito control measures.	Average overall pretest score was 11.8 § 5.03, which increased significantly to 19.3 § 4.69 after the intervention.
DeSmet et al. (2017), United States, FV intake	Four groups; n = 100 child–parent dyads (children from fourth to fifth grade of elementary school, having home access to high-speed Internet, and a parent fluent in English or Spanish).	Secondary analysis of RCT data. All groups analyzed together for this study.	To assess if FV asking behaviors predicated home FV availability pre- and postintervention. Did the intervention game increase FV asking behaviors?	Three-month intervention. Children-10-episode online videogame. Squire’s Quest II serious game intervention aimed to increase asking behaviors to improve home FV availability and children’s FV intake. Parents received information via electronic newsletters and a Web site. Parent Web site provided practical tips on creating a home environment promoting a healthy diet, such as FV recipes, grocery shopping tips, fast healthy meal suggestions (e.g., veggie wrap, paella), and information on promoting family physical activity.	Questionnaires; child FV intake was measured using 24-hr dietary recalls	Baseline child asking behaviors predicted baseline home FV availability. The intervention increased child asking behaviors and home FV availability. However, increases in child asking behaviors did not predict increased home FV availability. Increased child asking behaviors and home FV availability also did not mediate the increases in child FV intake.
Kamo et al. (2008), Tanzania, HIV and/or AIDS	Children aged 10–14 years (Moshi municipality Tanzania)	Community clustered RCT	Increase local competence to control HIV and/or AIDS through actions initiated by children and adolescents aged 10–14 years.	Learn about and understand the corporal and social context of HIV and/or AIDS. Teach through skits by personifying the roles of HIV and specialized cells of the immune system interacting within the human body. They depict the microbiology to expose the community to the scientific principles behind HIV transmission, testing, and treatment. Fifteen groups performed skits in the community for more than 10,000 person-hours.	Beliefs about the efficacy of children as HIV and/or AIDS primary change agents. survey conducted in the 30 trial mitaa measured attitudes and knowledge about HIV and/or AIDS and perception of young adolescents’ roles as community health promotors.	Surveys of neighborhood residents, differences were found between adults who did and did not witness the skits in their beliefs about the efficacy of children as HIV and/or AIDS primary change agents (significant changes were noted in knowledge and opinions about children and HIV and/or AIDS).
Mosavel & Genderson (2016), United States, cancer screening	Baseline 48 dyads (n = 96) youth mean age 15 years; average adult age 52 years (low-income AA families in the Southern United States)	Two group design	Test the feasibility and impact of female youth-initiated messages encouraging adult female relatives to obtain cancer screening.	Sixty-min interactive workshops in which youth were assisted in preparing a factual and emotional appeal to their adult relative to obtain specific screening. Control: provided with a pamphlet with information about cancer screening and specific steps about how to encourage their relatives to obtain screening.	Message shared, message shared same day, youth asked an adult to get screened; youth said screening is important, youth followed up after the first conversation.	Intervention youth (86%; p < .04) and adults (82%; p < .05) reported message was shared with 71% of control group. More intervention group reported obtaining a screen directly based on the youth’s appeal. Intervention group uptake: mammogram 42%, cervical cancer 29%, and 80% talked to a provider about the need for colon screening.
Nonaka et al. (2008), Lao, PDR, malaria	One hundred thirty children Grades 3–5 at two primary schools, 103 guardians of these children, and 130 married women without children in target grades (schoolchildren).	One group pre-post	Evaluate the efficacy of malaria education for schoolchildren on improving the knowledge, attitudes, and practices of community residents. For malaria control in rural Lao, PDR.	Presentation of a flipchart at home and a 1-day campaign conducted by the schoolchildren and aimed at the community. Schoolchildren presented the flipchart to their family members and anyone living in their village.	Questionnaire on knowledge, attitudes, and practice.	Significant within-group and between-group increases in knowledge, attitudes, and practices for groups.
Sedighi et al. (2012), Iran, infectious disease prevention	Seven kindergarten classes. One hundred and three parents	One group pre-post selected seven kindergartens by simple random method	Test an innovative method of knowledge transfer to improve health literacy about pediatric infectious disease prevention in families.	Taught kids seven musical poems regarding infectious disease. Children were not allowed to take home texts, but they were asked to sing the poems at home and had their parents rewrite the poems on a paper and give them the papers to take to the kindergarten.	Knowledge test	The percentage of correct answers has increased in 23 of 24 questions. The percentage only decreased by one question.
Simonds et al. (2019), United States, water preservation	Forty-four children aged 9–13 years (Apsáalooke [Crow] Nation)	One group repeated measures design	To provide a feasibility valuation of an increasingly sophisticated environmental health literacy program for children.	Functional literacy including cultural components addressed in all programs: water cycle, water chemical properties, water and life, hydration and the human body, water quality, formation of springs, water conservation, roles and responsibilities of guardians, visits to culturally important water sources, community members sharing stories about the importance of water, discussions on integrating western and indigenous science, and Crow names for local water sources.	Water-related knowledge; behavior and attitudes toward engaging in action; water-related science knowledge and skills; attitudes toward engaging in action	Although quantitative measures suggested limited changes in knowledge, qualitative findings were promising, with both parents and children discussing concepts they had learned through the programs.
Viera & Garrett (2008), United States, HTN awareness	Seventy-six parents (middle school curriculum—3 fifth grade classrooms)	Cross-over design	Evaluate a school-based program to raise community awareness about hypertension.	(1) Improve children’s knowledge about high BP, (2) raise parental knowledge of high BP by encouraging children to review with their parents what they learned, and (3) serve as an innovative means to deploy home BP monitors for short-term use (“self-screening”) by parents and/or guardians.	Outcomes of parental knowledge about high BP and their reports of having seen or intending to see a health professional about their BP.	Significantly more participants in the early intervention either saw a provider about their BP or intended to.

Note. RCT, randomized controlled trial; FV, fruit and vegetable; AA, African American; PDR, People’s Democratic Republic; HTN, hypertension; BP, blood pressure.

TABLE 5.

Child as change agent qualitative studies

Author (year), location, focus	Sample (population)	Method	Findings
Onyango-Ouma (2003), rural Kenya, malaria, diarrhea, and hygiene	Forty children aged 10–15 years (poor rural community)	Ethnography	Children have the potential to act as partners in health communication.
Mwanga et al. (2008), Tanzania, schoolchildren as health change agents	Three-hundred and six participants (primary schoolchildren)	Focus groups (43 sessions)	Child acting as health change agents in the community was supported. Barriers were found: curriculum, time constraints, class size, teaching materials, and teachers’ skills and working conditions.
Gadhoke et al. (2015), United States, diet and physical activity	Twenty-five children aged 6–13 years (American Indian)	In-depth interviews	Interview evidence of kids acting as change agents.
Bresee et al. (2016), Zambia, sanitation and hygiene	Thirty-nine female guardians focus groups (five schools in rural Zambia)	Focus groups: lasted approximately 70 min	Mothers reported high levels of trust in children to relay health information. Pupils were able to enact small changes to behavior, but not larger infrastructure changes, such as the construction of latrines. Pupils can communicate knowledge and behaviors to family members; however, they need discrete activities and guidance.
Milakovich et al. (2018), United States, water preservation	Seven adults (Apsáalooke [Crow] Nation)	Interviews: lasted approximately 30 min	Parents perceived that their children had increased knowledge and positive changes in attitudes and behaviors related to environmental health. Recommend using materials for parents that facilitates bidirectional communication.
Simonds et al. (2019), United States, water preservation	Six children and seven adults (Apsáalooke [Crow] Nation)	Interviews	Although quantitative measures suggested limited changes in knowledge, qualitative findings were promising, with both parents and children discussing concepts they had learned through the programs. Our intervention shows promise for intergenerational learning and action in this area.

CONCLUSIONS

This project supports the positive impact of children sharing health messages with their families. Parents received the information, and a large percentage of them made changes to improve health behaviors. Children have been shown to positively impact behavior change in parents and other adult community members. The immense burden of the obesogenic environment in which we live requires all interested in improving their health to participate in creating healthier lifestyle behaviors.