We sought to address gaps in the general YPAR and adolescent obesity intervention literature through the implementation of the bolded components of the theoretical model found in figures one and two. YPAR is typically conducted with older adolescents, as a standalone curriculum or project, and within social change focused after school programs or elective classes in high schools (Jacquez et al., 2013; Ozer et al., 2010: Vaughn et al; 2013). Yet, middle school is an opportune time to intervene to change health behavior (Benson et al., 1998; Millstein & Litt, 1993; Scales et al., 2000), and integrating YPAR into a PA intervention in pre-existing aftercare programs increases reach to underserved at-risk youth and aligns the intervention with youth values and interests (Cammarto & Fine, 2008), which can improve intervention effectiveness. To address gaps in research, we implemented YPAR as usual and YPAR alongside a PA intervention with middle school students within two pre-existing aftercare programs. We successfully adapted general YPAR and photo voice methods for implementation with middle school youth, within aftercare programs, and alongside a PA intervention.
Fidelity to YPAR essential elements has been examined in elective high school classrooms implementing general YPAR (Ozer & Douglas, 2015), but the fidelity of health focused YPAR has not been evaluated. Adolescent participatory obesity
neglects to measure intraindividual processes, such as empowerment, that are critical mechanisms in health behavior change (Damon et al., 2003, Suleiman et al., 2006). To address these measurement gaps, we set out to design and explore the feasibility of implementing health focused YPAR. We systematically measured fidelity of
implementation to health focused YPAR essential elements within those programs using the modified observational tool that can be found in Appendix A, and we measured the impact of participation on youth empowerment using the measure from Appendix B.
Trained raters successfully documented the implementation of the YPAR
essential elements in both programs. Adult partners in the YPAR only program achieved adequate dose on more essential elements than adult partners in the YPAR + PA
program. In contrast, adult partners in the YPAR + PA program achieved adequate fidelity on more YPAR essential elements than adult partners in the YPAR only program, and youth in this program reported increased empowerment between baseline and post intervention. The essential elements of both programs that were implemented with adequate dose and acceptable fidelity are underlined and starred in the note section in figures one and two. Although there were unique implementation challenges identified in both settings, through a concurrent, mixed method triangulation design integrating both quantitative and qualitative data, we determined that it is feasible to implement and evaluate health focused YPAR within a pre-existing aftercare program, and integrated within a PA intervention in a pre-existing aftercare program. A summary and evaluation of the triangulation results are also displayed in table 3.11. In the current work, we aimed to 1) fit YPAR to middle school youth, aftercare, and a PA intervention, 2) examine the dose and fidelity of implementation of the YPAR essential elements and
compare/contrast differences between the YPAR only design and the YPAR + PA design, 3) examine the impact of YPAR on youth reported empowerment, and 4) explore
triangulation to generate hypotheses about the feasibility of this new approach. I reflect on the achievement of the aims in detail in the following sections.
4.1 Reflections on developmental processes and YPAR
As part of aim one, YPAR was modified to fit middle school youth, aftercare settings, and a PA intervention. The development of the health focused YPAR curriculum was guided by PYD (Lerner et al., 2005), TYPE (Wong et al., 2010), and SDT. SDT proposes that individuals have basic socioemotional needs (i.e., relatedness, competence, autonomy) which become increasingly important during adolescence (Deci & Ryan, 2000). We infused the basic socio-emotional needs of SDT into the health focused YPAR curriculum to align with the guiding framework of the larger PA intervention. The
promotion of relatedness, autonomy, and competence within a PA intervention in a pre- existing aftercare program can create a socio-emotional climate that fosters youths’ intrinsic motivation for positive, goal directed behavior (Damon et al., 2003; Sullivan & Larson, 2010; Deci & Ryan, 2008).
Adult partners implemented with quality the components of the curriculum that align with socioemotional needs (i.e., relatedness, autonomy, competence) of SDT (Ryan & Deco, 2000). For example, “highlight youth strengths” and “show interest in youths’ lives outside the program” were implemented with quality by adult partners in every session. To meet the socioemotional need for relatedness with peers, relationships that are increasingly important during adolescence (Steinberg, 2014) adult partners reminded
aligned with youths’ need for relatedness. Youth worked collaboratively with peers throughout the research process. Youth qualitative responses indicate fulfillment of the need for relatedness through YPAR. Many youth in both programs shared that the part of the program they liked the most was walking around and taking pictures with their
friends, and that their friendships were enhanced through involvement.
In addition to fulfilling youths’ needs for relatedness, adult partners promoted autonomy through the power-sharing Y-A partnership. They provided opportunities for youth to take leadership roles and be involved in decision making about the overall project and the general group processes. Power-sharing processes occurred within groups, in which youth talked more than adult partners and group discussions centered on youth ideas. The research process was also autonomy promoting. Youth had choices within the larger PA focus, such as the location of pictures within school grounds, whether to change a PA strength or challenge, and whether to make a change in the program or school. Some youth qualitative survey responses provide evidence for adult partner promotion of autonomy. For example, youth in the YPAR + PA program noted that they enjoyed having creative control in the project and that they were able to take the lead.
Growth in youths’ competence occurred while working with adult partners and peers in a cyclical and iterative photo voice research process. For example, youth learned a research method that they can utilize to advocate for change that benefits them. In their qualitative responses, youth listed a variety of skills that they gained through involvement in YPAR. Skill building is one component of fulfilling youths’ socio-emotional need for competence.
The health focused YPAR essential elements aligned with the basic- socioemotional needs from SDT (Deci & Ryan, 2000) the guiding framework that informed the development and implementation of the larger PA intervention. In the current study, we determined that health focused YPAR can be successfully implemented and increase youth empowerment within an intervention with similar theoretical
grounding. Future work should examine whether health focused YPAR is feasible to implement in health interventions with different theoretical underpinnings, such as behavioral or cognitive focused adolescent obesity interventions.
Health focused YPAR was designed to meet adolescents’ socio-emotional needs for autonomy, relatedness, and competence, and it also can support developmental processes that emerge during adolescence. Youth gain behavioral autonomy during psychosocial development in early to middle adolescence. Behavioral autonomy is the capacity to make independent decisions and follow through with them. These changes improve youths’ abilities to simultaneously hold multiple viewpoints in their minds, which allows them to compare perspectives. Enhanced role-taking capabilities permit them to consider someone else’s perspective. Adolescents become able to think in hypothetical terms, which improves their abilities to weigh long-term consequences of choosing one course of action over another (Steinberg, 2014). Value autonomy,
conceptions of moral, political, ideological, and religious issues, or ideas of what is right or wrong, also develops during adolescence. It typically occurs later (i.e., between the ages of 18 to 20), following the development of emotional and behavioral independence. Growth in value autonomy allows adolescents to become increasingly abstract in the way they think. Furthermore, their beliefs become rooted in general principles that have an
ideological basis, and begin to be founded in their own value system rather than ones passed on by parents or authority figures (Steinberg, 2014).
Observational ratings of dose and fidelity of the YPAR essential elements are consistent with the developmental literature on behavioral and value autonomy. Adult partners were able to implement elements of the YPAR curriculum that related to
behavioral autonomy with higher dose and fidelity than elements that may have required psychosocial processes of value autonomy. For example, youth received adequate dose and fidelity across programs on subcomponents of essential elements related to strategic thinking, such as planning for next steps in the project, project tasks being guided by youths’ strengths, democratically deciding on a change area, and working together to follow through on poster completion. Adult partners were not able to implement other elements of strategic thinking of adequate dose and fidelity across programs, however. Adult partners in the YPAR + PA program struggled to support youth in asking questions of each other and learning new ways of thinking from each other, while adult partners in the YPAR only program had difficulty guiding youth in analyzing alternative points of view and youth potentially changing their perspective based on new information. The essential elements related to value autonomy, such as “authentic analysis of social reality” and “discussion of power differentials,” were not implemented by adult partners with adequate dose and fidelity in both programs.
Processes related to the development of behavioral and value autonomy may partially explain why discussions of abstract concepts, such as cultural influences on health and who holds power to make health decisions that impact youths’ lives, were difficult to initiate and sustain within groups. Since the growth of value autonomy occurs
later in adolescence, youth in the current study may not yet have developed the cognitive abilities to abstractly reflect on the societal, historical, and cultural influences on their health, and how power differentials between youth and adults impact their health (Steinberg, 2014). Evidence in an adult partner journal aligns with this hypothesis. She reflected that youth in her group could state that being healthy was important and list reasons why when asked. However, she noted that they did not seem to have an intrinsic understanding of the concepts, the desire to make positive health behavior change, or the knowledge of how the project related to their lives. An alternative explanation is also possible; Youth may have had the ability, but perhaps the length and structure of sessions, or the strategies we used to promote discussion, did not align with this sample of youths’ needs. Since other studies have had some success in helping younger youth reflect on these areas together (Langhout & Fernandez, 2015; Langhout & Thomas, 2010) examining other strategies for doing this that have been effective with elementary and middle school youth will be fruitful for future work.
Participatory projects in the empowerment evaluation and YPAR literature have been successfully implemented with elementary school students. As one example, in an empowerment evaluation focusing on empowerment capacity building, fourth and fifth grade students in an after-school program engaged in effective evaluation research cycles to improve their school using photo voice, focus groups, and other research methods. The authors mapped each phase of the project onto the ten empowerment evaluation
principles (Langhout & Fernandez, 2015), similar to the mapping of the participatory research principles in the current study. However, the authors did not systematically evaluate implementation of the empowerment evaluation principles, nor did they examine
the essential elements of “authentic analysis of youths’ social reality” and “discussion of power differentials.” Based on these differences from the current study, Langhout and Fernandez (2015) likely focused on the critical and collective inquiry and action
components of YPAR praxis rather than reflection. There may be evidence that younger youth can participate in these cognitive processes, though perhaps through more action or research oriented procedures, and likely not in the same way as older adolescents.
Despite similarities between the current project and Langhout and Fernandez’ (2015), there are capacity differences that make implementation of the critical reasoning components of the YPAR methods perhaps more feasible in the empowerment evaluation project. Langhout and Fernandez’ (2015) after-school program lasts for two years, so youth are involved in the project for a much longer time. Additional time allows adults to teach youth reflection processes in groups, critical analysis of power and systems level impacts, and a variety of research methods at an appropriate developmental level, and to modify the teaching style and information to fit youths’ needs. Unlike the current study, Langhout and Fernandez (2015) did not “fit” their project within a larger, pre-existing aftercare program; their after-school program was created by their community research team at the University of California at Santa Cruz. Due to its upkeep by a research team, essential processes that work in their program may not be feasible in general aftercare programs serving underresourced youth. The social change focus of their program likely led to the engagement of students already interested in the topic, which is a selection effect. Additionally, youth may have had previous experience with volunteering or social action, and been accustomed to discussions of more abstract topics. In contrast, in the current study, all students participated that were present in aftercare, regardless of stated
interest, in order to promote inclusion. Due to the inclusive nature of the work, youths’ interest, abilities, and opinions about the feasibility of health focused social change ranged on a wide continuum in the aftercare programs.
There are other alternative explanations for the difficulty adult partners had with engaging youth in discussions related to power in larger systems in pre-existing after care programs in the current work. For example, two adult partners from the YPAR only program reflected in their journals that youth did not feel that their voices mattered at their school and that people in power would listen to their change ideas and take them seriously. Therefore, youth attitudes, perceived understanding, and level of engagement in the health focused YPAR curriculum can also be impacted by the values and norms of settings, such as the aftercare program, school and neighborhood contexts in youths’ day- to-day lives.
4.2 Reflections on differences in dose of implementation in each program
In addition to the impact of the broader systems, the structure of the design can also impact the feasibility of the implementation of the health focused YPAR curriculum. I reflect on implementation differences between programs that could impact dose as part of aim two. The YPAR only program implementation occurred for 75 minutes once a week, compared to 20-30 minute sessions in the YPAR + PA program. The additional 30-45 minutes that the adult partners in the YPAR only program had each session likely provided more opportunities for dosage: to get to know the youth and their perspectives on their communities on a deeper level, promote critical dialogue, and trouble shoot and try different methods for reflection on a multitude of topics. Additionally, having more
time together each session promotes a natural “cyclical and iterative process,” as there is additional opportunity for idea generation, research, and revisions based on youth feedback.
Though there were more sessions in the YPAR + PA program when compared to the YPAR only program, the sessions were shorter in length and groups rotated through YPAR, so each adult partner ran multiple groups on the same topic during an hour time frame. Perhaps due to the structure, adult partners in the YPAR + PA program had difficulty achieving adequate dosage in some sessions on the subcomponents of essential elements that required a deeper level of analysis or depth of connection. Specifically, the subcomponents that were implemented with inadequate dose by adult partners in the YPAR + PA program are related to information that is easier to obtain the more time individuals spend together. Due to the fast pace of the group session, and the shorter time, it may have been difficult to find ways to promote discussion of program strengths or youth views on their communities. If it was difficult for adult partners to find ways to obtain this information in discussions during the first and second sessions, then they lacked a solid base of information from youth about their program and school which they could expand on within each group in future sessions.
The YPAR + PA program groups had only one adult partner, which made it difficult to achieve a deeper connection while balancing the basic implementation of the curriculum and group order. In contrast, in the YPAR only program, there were two adult partners per group, one which seemed to organically take on the role to promote order and monitor the curriculum to ensure the group stayed on task, with the other focused on relationships and getting to know youth in depth. Adult partners splitting tasks in this
way in the YPAR only program may have assisted them in more closely adhering to the dosage of the curriculum as developed. As evidence, one adult partner reflected in his journal that in his group, it worked well to have one person focus on the implementation of the curriculum, maintaining group order, and adherence to the group generated rules, while the other focused more on bonding, getting to know the youth, pointing out their strengths, and making the process fun and engaging. Furthermore, adult partners in the YPAR only program found ways to integrate the discussion of school and program strengths, and how the photo voice project is relevant to youths’ lives during the picture taking process and small group activities. In contrast, in the YPAR + PA program, adult partners did not capitalize on using the picture taking and poster making time during sessions three through six to expand discussion on program and school strengths or how the project is relevant to youths’ lives.
The lack of expansion in the YPAR + PA program may be because the adult partners led the groups alone versus in pairs like in the YPAR only program, and so may have been focused on more basic group processes. In the YPAR + PA program,
maintaining order and keeping youth on task, while also attempting to implement all components of the curriculum for the day, may have taken precedence over in depth discussion or high quality of implementation for these adult partners. Two adult partners may be necessary for adequate dose and quality of implementation when conducing photo voice projects with groups of middle school youth in pre-existing after care programs paired with an intervention in order to effectively promote critical, in depth discussion of more complex topics during a shorter time period.