Examining the role of youth empowerment in preventing adolescence obesity in low-income communities

Journal of Adolescence 68 (2018) 242–251

Contents lists available at ScienceDirect

Journal of Adolescence journal homepage: www.elsevier.com/locate/adolescence

Examining the role of youth empowerment in preventing adolescence obesity in low-income communities

T

Nancy Muturia,∗, Tandalayo Kiddb, Ann Michelle Danielsc, Kendra K. Kattelmannd, Tazrin Khana, Erika Lindshieldb, Susan Ziese, Koushik Adhikarif a

A.Q. Miller School of Journalism and Mass Communications, Kansas State University, USA Department of Food, Nutrition, Dietetics and Health, Kansas State University, USA c Department of Counseling and Human Development, South Dakota State University, USA d Department of Health and Nutritional Sciences, South Dakota State University, USA e Family and Consumer Sciences, Ohio State University Extension, USA f Department of Food Science and Technology, University of Georgia, USA b

A R T IC LE I N F O

ABS TRA CT

Keywords: Youth empowerment Obesity Self-efficacy Perceptions Barriers Motivation Low-income Ethnic

Introduction: Youth empowerment programs have increasingly gained attention in public health as emphasis shifts on children and adolescents as decision makers in their health and well-being. Adolescence obesity is among the public health concerns that require more active engagement at individual and community level while empowering adolescents to take charge of their own health. This study examines the influence of youth empowerment on nutritional and physical activity factors associated with adolescence obesity. Methods: Data were gathered through a self-administered survey among adolescents (N = 410) ages 11–15 years in three U.S. States - Kansas, Ohio and South Dakota. Results: Findings show that youth empowerment significantly influences adolescents' self-efficacy, perceptions for healthy food choice, healthy eating, attitudes towards physical activity and the overall motivation for health. Gender differences exist in adolescents' self-efficacy for physical activity whereas ethnicity played a role in perceived youth empowerment and perceived barriers to healthy eating. Age was also a significant contributor in efficacy for healthy food choice and perception of healthy food availability. Conclusions: This study suggests more focus on youth empowerment in interventions that seek to reduce obesity and improve adolescents' overall health by creating environments where they can play a more active decision-making role. With empowerment, adolescents are more likely to be motivated to adopt healthier dietary habits and engage more in physical activity. Further research would establish the impact of youth empowerment on obesity reduction and other public health problems that impact children across ages.

1. Background In the past, programs for behavior change on the individual level within a youth program or school have seen limited success. This

∗

Corresponding author. E-mail addresses: [email protected] (N. Muturi), [email protected] (T. Kidd), [email protected] (A.M. Daniels), [email protected] (K.K. Kattelmann), [email protected] (T. Khan), [email protected] (E. Lindshield), [email protected] (S. Zies), [email protected] (K. Adhikari). https://doi.org/10.1016/j.adolescence.2018.08.001 Received 5 May 2017; Received in revised form 2 August 2018; Accepted 3 August 2018 0140-1971/ © 2018 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

Journal of Adolescence 68 (2018) 242–251

N. Muturi et al.

may be due to the fact that programs did not include change within the environmental settings and youth's participation (Branas & MacDonald, 2014). Specifically, programs often lacked the opportunity for youth empowerment (Zimmerman et al., 2018). In other words, the youth do not only lack a voice within the system of change but also lacked a platform to utilize their voice as well. Empowerment, which is defined as a process through which people gain control over their lives so they can make decisions to improve their existing state (Rogers & Singhal, 2003), has been promoted in public health especially among vulnerable and marginalized populations. It is the process of acquiring power for oneself or making the acquisition of power possible for others, providing them with newfound choices and voices (Braithwaite, 2000). According to Zimmerman (2000), there are three interconnected empowerment mechanisms. The intrapersonal component, which entails the youth believing that one has some control in life and can make a difference. The second mechanism is the interactional or awareness of what variables or forces can influence one's life. This mechanism also requires the youth to understand what is needed to make one's goals a reality. Finally, the third component is the behavioral component. This component specifically applies to the youth's actions and how they can affect change within the environment. Increasingly, youth empowerment programs (YEPS) have gained attention from practitioners and funders that focus on engaging highly in youth-driven decision-making processes that aim at strengthening positive attitudes, skills, and behaviors that improve their health and well-being (Morton & Montgomery, 2013). Definitely, empowerment includes sociopolitical control. This type of control has been defined as including perceptions of self-efficacy, motivation, competence, and perceived control with the sociopolitical area. Zimmerman and Zahniser (1991) suggested sociopolitical control as a way of understanding and measuring the intrapersonal component of psychological empowerment. Furthermore, studies in public health and health education (e.g., Holden, Evans, Hinnant, & Messeri, 2005, 2004; Ozer & Schotland, 2011), youth development (e.g., Russell, Muraco, Subramaniam, & Laub, 2009) and community psychology (e.g., Kohfeldt, Chhun, Grace, & Langhout, 2011) have investigated sociopolitical control as a component of psychological empowerment among young people. Other studies have focused on the concept of locus of control, the belief system regarding who controls behavior and life events (Drummond, Barnard & Mehnert, 1985), as an important explanatory variable in understanding adolescence behavior (Ahlin, 2014). This is based on the understanding that adolescents with an external locus of control, the belief that they do not control outcomes associated with their behavior, are more likely to engage in risky behavior whereas internal locus of control contributes to positive youth outcomes such as general well-being (Ahlin & Antunes, 2015). This is particularly important in addressing serious health issues that impact the youth and where their engagement in preventive decision making is crucial. Adolescent obesity is among the serious public health concerns impacting youth and where their active engagement and informed decision-making are crucial. In the United States, about 17 percent of adolescents ages 12–19 years are categorized as overweight (Ogden, Carroll, Kit, & Flegal, 2012). Research shows that children born in the year 2000 who are now in their adolescence, or later have a 1 in 3 chance of developing diabetes (Shubrook, 2011). The problem spans across state boundaries although racial and ethnic groups are disproportionately impacted where Hispanics and African Americans account for 25% and 19% of childhood obesity, respectively (Crespo et al., 2012; Wang, Orleans, & Gortmaker, 2012). Behavioral, social-economic, and cultural factors contribute to obesity, but there are also environmental factors including inadequate resources for healthier diets and/or safe natural or build environment for physical activity that make low-income communities vulnerable (Li et al., 2014; Sallis & Glanz, 2006). The high obesity prevalence in the ethnic and limited-resource communities foreshadows a public health crisis as most obese children and adolescents tend to become obese adults (Rosenkoetter & Loman, 2015). There is evidence supporting obesity in adolescents tracks into adulthood and is associated with higher risks of morbidity and mortality (Robbins, Pender, Ronis, Kazanis, & Pis, 2004). Such risks include serious obesity-related health consequences among adolescents, some of which include cardiovascular, endocrine, renal, respiratory, musculoskeletal, pulmonary gastrointestinal disease and psychosocial issues which include poor selfesteem, negative self-image and lower quality of life (Merikangas, Mendola, Pastor, Reuben, & Cleary, 2012). The elevated risk of chronic diseases has been associated with premature death (Criss et al., 2016) and with lifespans that are shorter than their parents for the first time in modern history (Bond, Richards, & Calvert, 2013, Olshansky et al., 2005; Shubrook, 2011). There are also increased costs in healthcare associated with childhood obesity which increases the burden among affected individuals and the society at large (Daniels, 2006). Despite the identified health risks, adolescence health care remains a challenge compared to that of adults not only due to their rapidly evolving physical, intellectual and emotional development but also because they require a specialized skill set for interpersonal communication and interdisciplinary care (Salam, Das, Lassi, & Bhutta, 2016). Researchers and practitioners have put emphasis on prevention strategies which include changing the obesogenic environment that contributes to the high prevalence of childhood obesity in low-income and ethnic communities (Rosenkranz & Dzewaltowski, 2008; Rossen, 2014) while promoting built environment in communities to address sedentary lifestyles among children of various ages (Sallis & Glanz, 2006). The Centers for Disease Control and Prevention (CDC, 2016) has suggested the use of school-based prevention strategies that include policies to enhance physical activity and healthier diets, as well as collaborations with local communities in developing strategies to support healthier food environments. Others put emphasis in awareness and nutrition literacy, which can be achieved via various communication and education strategies that integrate a technology component (Nutbeam, 2008; Silk et al., 2008) to enhance knowledge and understanding of health risks associated with obesity. As Mallya, Mensah, Contento, Koch, and Barton (2012) suggests, it is critical to not only encourage youth to think about the personal benefits of healthy choices but to engage them in the role of reducing the obesity epidemic. A knowledge-practice gap (Rogers, 2003), however, persists in the adoption of healthy lifestyles in preventing overweight and obesity among Americans across age groups. As Anderson, Winett, and Wojcik (2007) points out, people living in the U.S. are generally aware of the health consequences of overweight and obesity and there is a growing understanding of dietary 243

Journal of Adolescence 68 (2018) 242–251

N. Muturi et al.

recommendations to reduce the risk of such consequences. This knowledge may, however, be limited among adolescents because they have not been adequately targeted either in research or prevention interventions (Wong et al., 2004). A call from researchers and public health practitioners has been to empower those impacted by health problems with information about how to adopt and maintain recommended health behaviors (Beaudoin, Thorson, & Hong, 2006). This implies investing in research to understand factors that would enhance or inhibit youth empowerment and address them accordingly. On the contrary, research has not adequately focused on the youth in the context of health decision making. Review studies have reported that much of literature in adolescence journals can be characterized as adult-centric (Daiute & Fine, 2003; Wong, Zimmerman, & Parker, 2010). They suggest shifting the focus on children and adolescents from traditionally viewing them as problems or as subjects to viewing them as resources of participatory action research where they can voice their opinions or participate in research and program development (Wong et al., 2010). The goal of the current study is to determine the extent to which youth empowerment influences obesity preventive factors among adolescents. It is based on a project titled “Ignite: Sparking Youth to Create Healthy Communities” that uses a community-based participatory approach to engaging adolescents in taking initiative in preventing overweight and obesity in their respective community. When applied in health programs, the participatory approach allows people to engage in identification of problems that face their communities and to participate fully in designing interventions that are culturally appropriate (Israel, Schulz, Parker, & Becker, 2001). The current study reports data from the baseline research that was used to inform the project intervention. Baseline data were gathered in six communities across three states, Kansas, Ohio and South Dakota, after which a three-year community-based intervention was implemented that fully engaged adolescents in nutrition and physical activity decision-making. 1.1. Communication for empowerment in obesity prevention The United Nations Development Program defines communication for empowerment as an approach that puts the needs and interests of disempowered and marginalized groups at the center with the goal of ensuring that they have the capacity to generate and provide information that is relevant to their needs while getting the opportunity to voice their perspectives (McCall, 2010). There is a growing focus on communication for empowerment in health programs that use the participatory approach and seek to engage individuals and communities in decision-making. Empowering youth and other vulnerable populations to play an active role in their health is one of the key foci of the participatory approach in promoting healthy communities (Minkler, Garcia & Wallerstein, 2012). This is based on the premise that constructive community engagement is associated with identity, well-being, self-perception and educational attainment (Mahoney, Harris, & Eccles, 2006). The participatory communication approach in health decision-making has been promoted in health programming over several decades emphasizing empowerment and an opportunity to be involved and heard (Melkote & Steeves, 2001). Sustainable empowerment takes place at both individual and social or collective levels (Braithwaite, 2000). At an individual level, people are enabled to participate in activities that enhance their health and well-being while collective empowerment occurs within the wider social systems with some expected, desired or deserved outcome (Cook, 2007; Jennings, Parra-Medina, Hilfinger-Messias, & McLoughlin, 2006; Zimmerman, 2000). Empowerment at the community level would also include collective action to access community resources (Perkins & Zimmerman, 1995) to support the change needed in addressing the identified health problems. Empowerment at either level would contribute to building healthier communities (Minkler, Garcia, Rubin, & Wallerstein, 2012), but as Jennings et al. (2006) suggests it would also require support from the community, which includes the establishment of structures and skills to support the change. As researchers have affirmed, empowerment-based programs for youth have focused on providing supportive contexts where youth build assets, connect with local resources and adult role models, and engage in community change activities (Gardner, Roth, & Brooks-Gunn, 2008). 1.2. Empowering youth in obesity prevention Empowering the youth to enhance their decision-making role is important because, as Charbonneau, Cheadle, Orbé, Frey, and Gaolach (2014) points out, empowerment would affect change in their lives. Specifically, with support from their communities and it would result in healthier youth and communities. It is a strategy that enables adolescents to participate in the decision-making process at an individual level, but engaging them at a community level is more likely to be a protective factor in their health and greater well-being (Morton & Montgomery, 2013). With empowerment, the youth become more active participants in influential decision-making settings as they become significant resources for themselves and others (Charbonneau et al., 2014). Wong, Zimmerman, and Parker (2010) observes that this form of engagement not only enables them to voice their opinions but also enhances positive development while building their intrinsic strengths and actively involving them in addressing issues they identify with. Empowerment among adolescents in preventing obesity is particularly necessary not only because they are in the process of growth and development, but may also be experimenting with many activities that may contribute to nutritional deficits or other risktaking behaviors (Jenkins & Horner, 2005). This would require empowering them with the necessary information and skills to enhance self-efficacy toward nutrition and physical activity, the two necessary components in obesity prevention. In examining youth advocacy in nutrition and physical activity changes, research shows self-efficacy to play a mediator role (Millstein, Woodruff, Linton, Edwards, & Sallis, 2016) but, like in other health risks associated with obesity, their motivation to achieve overall health, perceptions 244

Journal of Adolescence 68 (2018) 242–251

N. Muturi et al.

of support provided to them and influence of their peers all play a role in the decision-making process (Muturi et al., 2016). Adolescence is also a time in which the youth form their own identity (Wong et al., 2010) and therefore many habits and health behaviors in adulthood begin during this stage (Millstein & Litt, 1993). Common adolescent behaviors that contribute to obesity include consumption of energy-dense foods that are high in fat, a decrease in the consumption of fruits and vegetables, and calciumrich foods, skipping meals and a decrease in physical activity (Story, Neumark-Sztainer, & French, 2002). Research shows that children's level of physical activity also declines during adolescence (Biddle & Wang, 2003). With these risk factors for adolescence, obesity empowerment can play an important role in enhancing knowledge and self-efficacy in prevention strategies (Skinner, Hanning, & Tsuji, 2006). 1.3. Empowering youth to overcome barriers to obesity prevention Empowerment is also critical in overcoming barriers to behavior change. Janz and Becker (1984) view barriers, whether real or perceived, as the most significant element in the process of change because they determine overall behavior change. Within the context of locus of control, adolescents with an external locus of control may believe that they do not control outcomes associated with their behavior (Ahlin & Antunes, 2015), which may exacerbate perceived barriers. In obesity prevention, barriers are associated with food choice, healthy eating and with physical activity. Barriers to healthy eating and weight maintenance among adolescents include the lack of healthy food environments or neighborhood that lack access to healthy food outlets and recreational facilities (Black & Macinko, 2010; Crespo et al., 2012). Studies have associated childhood obesity with higher levels of environmental eating, consumption of what's available to them within their environment, in the absence of hunger to negative nutritional outcomes such as overeating and weight gain (Bellisle, 2003; Hawks, Madanat, Smith, & Novilla, 2006; Lluch, Herbeth, Mejean, & Siest, 2000). Barriers to physical activity may be a multitude of personal perceptions, environmental limitations or social factors. Whereas adolescents differ from adults in levels of physical activity and may often meet daily recommendation (Schwarzer & Luszczynska, 2006), they still face a multitude of personal, social and environmental barriers to engaging in physical activity. Studies have identified several barriers that include lack of transportation to participate in organized sports, lack of accessibility or availability physical activity resources, high levels of screen time (e.g. television, video-games, etc.), safety concerns of outdoor activities, lowquality physical education and uneasiness with changing locker rooms, especially among girls, and the general lack of motivation for physical activity (Goh et al., 2009; Kumar et al., 2016; Power, Bindler, Goetz & Daratha, 2010). The current study sought to examine the following: 1) whether youth empowerment affects the nutritional and physical activity factors associated with adolescence obesity (e.g. self-efficacy for food choice, healthy eating and physical activity); 2) whether adolescents’ perceptions of the health food environment (e.g. healthy food availability) and other forms of support from communities (e.g. support for physical activity including facilities) are affected by youth empowerment, and 3) if there is a correlation between youth empowerment and the overall motivation for health among adolescents. 2. Methods and measures 2.1. Sample and data collection The study was conducted among adolescents in 6th to 8th grades in three U.S. States, Kansas, Ohio and South Dakota, following ethics approval from the Institutional Review Boards (IRB) in the three states. Two communities in each state and one school from each community were randomly selected. Physical education classes, which were mandatory for 6th to 8th grades, were targeted with a combined total of 625 students. However, only students whose parents provided consent were allowed to participate in the study (n = 410), which yielded about a 66% response rate. Respondents' ages ranged from 11 to 15 years, which required parental consent to participate as well as participant's assent. As Table 1 shows, the sample was fairly distributed by gender with 176 males (43%), 230 females (56%) and four participants (1%) who did not reveal their sex. The sample was ethnically diverse with the majority being Hispanics (40%). Others included White/Caucasian (22%), Black/African Americas (16.1%), American Indians (8%), Asian (1%), and other or multiple ethnicities (13%). Participants’ ethnicity varied by the state where the majority of participants from Kansas were Hispanics or Latinos (n = 159), the majority of participants from South Dakota were American Indians/Alaska Natives (n = 30), whereas the majority of participants from Ohio were African Americans/Blacks (n = 61). Paper and pencil method was used to complete the survey which consisted of 32 items adapted from various validated tools and four demographic questions. Due to the length of the survey and differences in literacy levels, cognitive testing was conducted prior to survey administration. Students were then guided through the questionnaire by researchers who read out and clarified the questions, where necessary, to ensure a clear understanding of each question. 2.2. Measures Past research has created youth empowerment items by adapting them from the developmental asset framework conceptualized by the Search Institute (Leffert, Benson, Scales, Sharma, Drake, & BIyth, 1998). In fact, the 40 Developmental Assets include a subset of empowerment items (Search Institute, 2005). Such items include the community valuing the youth, the child feeling included in decisions at home and in the community, the child having opportunities to help others in the community and the child feeling safe at 245

Journal of Adolescence 68 (2018) 242–251

N. Muturi et al.

Table 1 Sample characteristics by state. Variable

Kansas

South Dakota

Ohio

Total

Male Female

114 143

26 31

36 56

176 230

American Indian & Alaska Native Asian Black/African American Hispanic/Latino White/Caucasian Multiple ethnicities Other

2 4 5 159 66 11 9

30 0 0 0 18 5 4

1 0 61 4 6 17 3

33 4 66 163 90 33 16

6th 7th 8th

63 92 102

30 13 14

53 17 21

146 122 137

11 12 13 14 15

13 60 85 84 15

11 20 20 5 15

24 34 20 11 6

48 114 125 100 23

Gender

Chi-Square (DF) .892(2)

Ethnicity

461.26 (12)

∗∗∗

41.15(4)∗∗∗

Grade

Age

55.96(8)

∗∗∗

Chi-Square to indicate differences by state *p < .05, **p < .01, ***p < .001.

home, at school, and in his or her neighborhood. Consequently, youth empowerment within this study was measured with six items that were adopted from the Youth Empowerment and Developmental Assessment (YEDA). The YEDA was an observational checklist that was also based on the Search Institutes’ 40 Developmental Assets. The checklist included items such as sports and recreation, positive community environment, and healthy choices. It has been used by, among others, Paxton, Valois, and Drane (2005) who modified a previous scale (Reininger et al., 2003) by rewording some items after a pilot test to study middle school adolescents. The six items used in the current study to measure youth empowerment were adapted from the original checklist and previous knowledge of how the Developmental Assets have been utilized as well as the goals of the study, examined adolescents' sense of selfcontrol and of being valuable members of their communities. For example, “I often feel that my future is out of my control (reversecoded)’; “I believe I can make a positive impact on my future:’ and “I believe I can make a difference and strong impact in my community because I have skills, talents, and knowledge that are important.” The items were measured on a 5-point scale ranging from 1 (not at all agree) to 5 (strongly agree) and comprised one composite measure (M = 3.94, SD = .768, Cronbach α = 0.70). Nutritional factors examined included efficacy for healthy food choice, efficacy for healthy eating and perceptions on healthy food availability. Efficacy for healthy food choice was measured with four items (Dewar, Lubans, Plotnikoff, & Morgan, 2012) that examined adolescents' ease in making healthier food choices, for example, “I find it easy to eat at least 1 ½ to 2 cups of fruit each day” and “I find it easy to eat at least 2 to 3 cups of vegetables each day”. The items were measured on a scale of 1 (not at all agree) to 5 (strongly agree and comprised a reliable internal consistency (M = 3.1967, SD = .912, Cronbach α = 0.74). Efficacy for healthy eating, on the other hand, was measured by asking them to indicate how sure they are about their confidence in selecting to eat healthy foods in several situations that included ‘when hungry after school”, with friends, at a fast food restaurant, or eating dinner with family. The four items (adopted from Neumark-Sztainer, Story, Hannan, Perry, & Irving, 2002) were measured on a scale of 1 (not at all sure) to 5 (extremely sure) also with a reliable internal consistency (Cronbach α = 0.60). Their perceptions of healthy food environment were measured with six items (Neumark-Sztainer et al., 2002) examined their views on the availability of fruits and vegetables in their living environment (e.g. school, home, grocery stores etc.) The items were measured on a scale of 1 (never) to 5 (always) and comprised a reliable composite measure (M = 4.37, SD = .628, Cronbach α = 0.78). To examine the effect of youth empowerment on physical activity, attitudes and self-efficacy for physical activity were measured. Attitudes towards physical activity were measured with five items (Stevens et al., 2005) and on a 5-point scale ranging from 1 (Not at all agree) to 5 (Strongly agree). The scale included negative perceptions of physical activity, for instance, “boring” “makes me tired”, and “makes me feel embarrassed.” After reverse-coding the items the scale had a reliable internal consistency (M = 4.20, SD = .780, Cronbach α = 0.76). Self-efficacy for physical activity, on the other hand, was measured with one item that was adopted and modified from Bandura's self-efficacy instrument (Ajzen, 1991). The item asked participants to indicate the extent to which they agreed with the following statement: “I am confident that I can be physically active for at least 60 min, every day of the week.” The item was measured on a scale of 1 (Not at all agree) to 5 (Strongly agree) and results show moderately high confidence (M = 4.02, SD = 1.25). Their perceptions of community support for physical activity was measured with three items were also measured on a 5-point Likert scale ranging from 1 (Not at all agree) to 5 (Strongly agree). The items included: 1) There are plenty of opportunities to be physically active in my community; 2) It is important for me to have physical activity programs or classes available in school or in my community; 3) Most people who are important to me approve of my choices of physical activity. The three items have a reliability of reliability of perceptions for physical activity support (Cronbach α = 0.74) with a mean of 3.93 (SD = .96). 246

Journal of Adolescence 68 (2018) 242–251

N. Muturi et al.

Perceived barriers to physical activity were examined with a 7-item scale that was developed following focus group discussions that have been published elsewhere (Kumar et al., 2016) and cognitive testing of the overall survey. The items used included “there is no space to be active”, there is no choice for activities”, there is no equipment facility, there are no other kids my age at the physical activity facilities”; and “I don't have transportation.” The scale was also measured with a 5-point scale from 1 (Not at all agree) to 5 (strongly agree) and the composite measure was reliable (M = 1.81, SD = .838, Cronbach α = 0.794). Barriers to healthy eating were measured with 3 items (M = 1.86, SD = .932) that examined their perceptions of healthy eating. For example, “I'm too busy to eat healthily”, or “kids my age don't need to be concerned about their eating habits”. The motivation for health was measured with seven items (Neumark-Sztainer et al., 2002) that asked students to rate how much they cared about various aspects that contributed to physical health and appearance. The items were measured on a five-point scale with 1 (Do not care at all) to 5 (Care very much) and included; 1) Eating healthy foods; 2) Controlling your weight; 3) Staying in shape; 4) Exercising; 5) Being healthy; 6) How you look; 7) Doing well in sports. The aggregated scale showed a reliable internal consistency (Cronbach α = 0.83) with a mean of 4.30 (SD = .71). 3. Results 3.1. Descriptives Participants reported a moderately high youth empowerment (M = 3.94, SD = .768) with no significant differences based on age, gender, grade level. Differences were observed in their assessment based on their state or geographical region. Ethnicity played a role in youth empowerment, but only between African Americans and Hispanics/Latinos (p < .05). Specific differences were also observed between Kansas and Ohio and between Ohio and South Dakota (p < .05), but not between Kansas and South Dakota. Similarly, their motivation for health differed between Kansas and South Dakota (p < .05). There were also differences in their motivation based on grade-level and ethnicity (p < .05) and but no other differences were observed. With regards to physical activity, state or geographical region played a role in adolescents’ attitudes. An ANOVA analysis shows differences between Kansas and South Dakota and between South Dakota and Ohio (p < .05) but not between Kansas and Ohio. Their perceptions of physical activity support in their environment (e.g. schools and community) also differed based on ethnicity where Caucasians were more positive (M = 4.13, SD = .866) compared to ethnic minorities (M = 3.83, SD = 1.05) but age was insignificant (p > .05). Gender was significant in their self-efficacy for physical activity where males reported higher efficacy (M = 4.17, SD = 1.24) compared to females (M = 3.92, SD = 1.23). On nutritional factors, efficacy for healthy food choice did not differ based on the demographic factors. There was also a difference by age [F(4,398) = 4.12, p < .05)] with significant differences occurring between 11- and 13-year age groups and between 11- and 14- year age groups. There was also a significant difference in efficacy for healthy eating based on grade-level [F (2,395) = 10.02, p < .001] where significant differences were observed between those in 6th and 7th grades (p < .001) and between those in 6th and 8th grades (p < .005), but no difference between those in 7th and 8th grades. Their perception of healthy food availability was relatively high (M = 4.37, SD = .627) and differed only by age (p < .05) whereas barriers for healthy eating differed by ethnicity but no other demographic were significant (Table 2). 3.2. Youth empowerment and nutritional factors The study examined the effect of youth empowerment on nutritional factors, specifically on self-efficacy for healthy eating and healthy food choice. Results show a significant effect of youth empowerment on their efficacy for healthy eating (Table 3). Demographic factors (Age, gender, grade-level, and ethnicity) contributed to the variance in their efficacy for healthy eating [F (4,391) = 4.14, p = .003)] explaining about 4% of the model variation (R2 = 0.041) but none of the factors singularly had a significant effect. Youth empowerment has a significant effect [F(5,390) = 6.61, p = .000)] and explained about 8% of model variation (R2 = 0.078). Results also show that youth empowerment had a significant effect on adolescents’ efficacy for healthy food choice (p = .000). After controlling for demographic factors, which did not contribute significantly to the model variance (p > .05), youth Table 2 Descriptives for study variables. Variable

Meana

Std. Deviation

Cronbach alpha (α)

Youth empowerment Attitudes towards physical activity Motivation for health Efficacy for healthy food choice Efficacy for healthy eating Perceptions of healthy food availability Self-efficacy for physical activity Perceived barriers to healthy eating Perceived barriers to physical activity Perceived physical activity support

3.94 4.20 4.30 3.31 3.20 4.37 4.02 1.86 1.81 3.89

.768 .780 .714 .757 .911 .628 1.25 .933 .838 1.017

.70 .76 .83 .60 .74 .78 – .60 .79 .74

a

All scores range from 1 to 5 with 5 being the highest. 247

Journal of Adolescence 68 (2018) 242–251

N. Muturi et al.

Table 3 Impact of Youth Empowerment on Nutrition and Physical activity Perceptions. Predictor Variablea Nutritional Perceptions Youth empowerment

Efficacy for healthy eating Efficacy for healthy food choice Perceptions of healthy food availability

Physical Activity Perceptions Youth empowerment

Attitudes toward physical activity Self-efficacy for physical activity Perceptions of support available for physical activity Perceived Barriers and Motivation Youth Empowerment Perception of barriers to healthy eating Perception of barriers to physical activity Adolescents' motivation for overall health

β

t

R2

.195 .308 .254

3.984*** 6.451*** 5.196***

.078 .111 .075

.296 .339 .346

6.146*** 7.150*** 7.308***

.095 .131 .127

. −186 . −199 .294

−3.722*** −4.022*** 6.079***

.044 .158 .098

β values are standardized coefficients ∗p < .05, ∗∗p < .01, ∗∗∗p < .001. a None of the demographic factors (age, gender, ethnicity, grade-level) were significant (p > .05).

empowerment contributed significantly to the model variance, [F(5,395) = 9.83, p = .000) and explained about 11 percent of the variance in adolescents efficacy for healthy eating (R2 = 0.111). Additionally, youth empowerment had a significant effect on adolescents' perceptions of healthy food availability (β = 0.254, p = .000). After controlling for demographic factors (p > .05) youth empowerment contributed to the variation in their perceptions [F(5,391) = 6.36, p = .000) and explained about eight percent of the model variance (R2 = 0.075). 3.3. Youth empowerment and physical activity The effect of youth empowerment on adolescents' attitudes towards physical activity as well as their perceived barriers to physical activity were examined. Results from a hierarchical multiple regression show youth empowerment had a significant effect on adolescents' attitudes toward physical activity (β = 0.296, p = .000). After controlling for demographics, which did not play a significant role, youth empowerment was a significant contributor in the variation of adolescents’ attitudes towards physical activity [F (5,394) = 8.31, p = .000) and explained about 10 percent of the variation (R2 = 0.095). Self-efficacy for physical activity is influenced by youth empowerment. Results show a significant contribution to youth empowerment to the variance in their self-efficacy [F(5,390) = 11.70, p = .000) explaining about 13% of the variance (R2 = 0.131). Youth empowerment has a significant effect on their self-efficacy (β = 0.339, p = .000). Among demographic factors only gender has a significant role in the model variance (p < .05), but overall they were insignificant and explained two percent of the model (R2 = 0.017). Youth empowerment also had a significant influence on adolescents’ perceptions of support available for physical activity support in their environments (e.g. home, school, and community). Youth empowerment was a significant contributor to the model variance [F(5,394) = 11.44, p = .000) explained about 13 percent of the model variance (R2 = 0.127) but none of the demographic factors has a significant role (p > .05). 3.4. Influence of youth empowerment perceived barriers and health motivation An examination of how youth empowerment affects the perception of barriers to healthy eating showed a significant effect (β = . −186, p = .000). After controlling for demographic factors, youth empowerment also contributed to the variance observed in adolescents perceptions of barriers of healthy eating [F (5,388) = 3.60, p = .003) and explained about four percent of the variance (R2 = 0.044). Correspondingly, youth empowerment had a significant effect on adolescents' perceptions of barriers to physical activity (β = .-199, p = .000). None of the demographic factors had a significant contribution to the variance in their perceived barriers to physical activity (p > .05), but youth empowerment was a significant contributor [F (5,392) = 4.11, p = .001) explaining about 16% of the variance (R2 = 0.158). The relationship between youth empowerment and adolescents’ motivation for overall health was significant (Table 3). Youth empowerment contributed to the model ([F(5,390) = 8.44, p = .000) and explained about 10 percent of the variance (R2 = 0.098), but none of the covariates played a significant role. 4. Discussion The goal of this study was to examine the extent to which youth empowerment influences nutritional and physical activity factors which are associated with adolescence obesity. A key finding is the correlation between youth empowerment and adolescents' selfefficacy for food choice and healthy eating. Specifically, youth empowerment influences adolescents’ belief that they can make healthier nutritional decisions. Adolescence is not only a time for physical development but also a time for behavioral experiment habit and formation (Millstein & Litt, 1993; Wong et al., 2010). Consequently, with empowerment, they are likely to gain the necessary skills to engage in healthier nutritional habits, food choices, and eating habits. 248

Journal of Adolescence 68 (2018) 242–251

N. Muturi et al.

Results also show that youth empowerment influences adolescents’ perceptions of healthy food availability within their living environment – home, schools, and community. This means that regardless of the actual situation, empowered youth were more likely to view their food environment positively. On the other hand, an inverse correlation was observed (Table 3) where more empowered youth are less likely to report barriers to healthy eating and to perceive their food environment negatively. This finding is in line with previous studies that have found an association between perceptions of the food environment and barriers to healthy eating (Black & Macinko, 2010), a significant factor in adolescence obesity. Studies have reported an association between higher levels of environmental eating in the absence of hunger to negative nutritional outcomes such as overeating and weight gain especially among children (Bellisle, 2003; Hawks et al., 2006; Lluch et al., 2000). Barriers to physical activity are also influenced by their sense of self-control. Although research shows that adolescents are more likely to meet the recommended physical activity guidelines compared to adults (Schwarzer & Luszczynska, 2006), they also face barriers that may prevent them from meeting those guidelines. Their internal locus of control is likely to contribute to positive youth outcomes and the general well-being (Ahlin & Antunes, 2015). In the current study, youth empowerment is negatively correlated with perceived factors that may generally influence healthy eating and physical activity. Such barriers, commonly also observed in the literature (Goh et al., 2009), include lack of space, choice of activities, transportation, equipment/facilities, unsafe environments due to traffic, kids to play with and adult supervision. The level of empowerment among adolescents is likely to influence how they perceive them as barriers. Conversely, adolescent perceived available support is related to their efforts in adopting recommended changes in obesity prevention. This includes support for nutrition and physical activity at different levels. In this study, youth empowerment affects their perceptions of such support, which includes available opportunities for physical activity and their perceptions of how well they feel supported by their communities. YEPs that focus on giving young people the sense of control have received global attention (McCall, 2010; Morton & Montgomery, 2013) but it is important for communities to demonstrate their ultimate support to the youth as part of empowerment programs. Furthermore, adolescents’ overall motivation for health was influenced by their level of empowerment. Health communication and other disease prevention interventions that address risk-taking behaviors focus on motivating change in risk-taking behaviors through enhancement of knowledge about risk factors, risk-perception, and promoting protective behaviors (Rogers, 2003; Snyder et al., 2004). As results have shown, with empowerment adolescents are more likely to be motivated to adopt a healthier lifestyle, which could include healthier dietary habits and more engagement in physical activity, the two critical components of obesity prevention. Overall health is the ultimate goal of health promotion and preventive programs, and youth empowerment adds value to the effectiveness of interventions, especially when they play a role as active decision makers in healthier lifestyles. 4.1. Study limitations The study is not without limitations. First, data were self-reported during this observational study, therefore casual inferences can be reported. The length of the questionnaire may also have been an issue especially among the younger children and those in the lower grades. The researchers attempted to mitigate that problem by reading out the questionnaire and giving them enough time to read through and respond. Cognitive testing was also conducted prior to the study to ensure language appropriateness but this would not guarantee complete comprehension of the questionnaire or information requested. It is also likely that comprehension was not equivalent across states or ethnicities. Adolescents' level of nutrition literacy was not examined, which could also have influenced external validity. This was addressed through the clarification of terms while reading out the questions, visually demonstrating portion sizes (e.g. one cup of fruits or vegetables) and allowing them to ask questions if anything was unclear. To address the potential threat to construct validity, which could also result from participants lack of comprehension, several items were used to measure the main study constructs (e.g. Youth empowerment, self-efficacy, perceptions etc.), performed variable inter-correlations, which showed significant relationships between the independent variable and dependent variables as predicted based on theoretical constructs. Additionally, the study used validated scales to measure study constructs where reliability analysis using Cronbach's alpha showed internal consistency across all variables. 4.2. Conclusion Creating an environment where individuals can feel empowered is a crucial component in programs targeting behavior change. While much is documented in youth, especially in regards to violence (Daiute & Fine, 2003) and other risk-taking behaviors, researchers have raised concern about the limited number of youth-oriented programs that deal with childhood obesity and the limited involvement in research and planning of obesity prevention interventions that target them (Wong et al., 2004). The Ignite project focuses on understanding youth and engaging them in the design and implementation of obesity prevention interventions. The project is based on the premise that early prevention, targeting youth and empowering them, encourages healthful behaviors paramount in preventing obesity (Comstock et al., 2016). This study provides evidential insights in regards to youth empowerment and its influence on attitudes and perceptions of youth towards healthier diets, physical activity and the overall motivation for health. Youth empowerment also influences self-efficacy for healthy eating and for food choices as well as efficacy for engaging in physical activity. This implies the need to focus on youth empowerment as a key factor in interventions that focus on improving adolescents’ nutrition and physical activity and overall health. Empowering youth allows them to have a meaningful role in their lives and communities (Charbonneau et al., 2014). Empowering adolescents to play an active role in health decisions is particularly important in preventing obesity, where incidence rates have 249

Journal of Adolescence 68 (2018) 242–251

N. Muturi et al.

remained high. Although causal relationships were not observed in this study, results show a significant influence of youth empowerment on factors associated with adolescence obesity. The current study reinforces the need for further research on the role of empowerment in addressing obesity and other public health problems that impact children across ages. Acknowledgments This material is based upon work that is supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, under award number 2012-68001-19619. References Ahlin, E. M. (2014). Locus of control redux: Adolescents' choice to refrain from violence. Journal of Interpersonal Violence, 29(14), 2695–2717. Ahlin, E. M., & Antunes, M. J. L. (2015). Locus of control orientation: Parents, peers, and place. Journal of Youth and Adolescence, 44(9), 1803–1818. Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179–211. Anderson, E. S., Winett, R. A., & Wojcik, J. R. (2007). Self-regulation, self-efficacy, outcome expectations, and social support: Social cognitive theory and nutrition behavior. Annals of Behavioral Medicine, 34(3), 304–312. Beaudoin, C. E., Thorson, E., & Hong, T. (2006). Promoting youth health through social empowerment: A media campaign targeting social capital. Health Communication, 19(2), 175–182. Bellisle, F. (2003). Why should we study human food intake behaviour? Nutrition, Metabolism, and Cardiovascular Diseases, 13(4), 189–193. Biddle, S. J. H., & Wang, C. K. J. (2003). Motivation and self-perception profiles and links with physical activity in adolescent girls. Journal of Adolescence, 26(6), 687–701. Black, J. L., & Macinko, J. (2010). The changing distribution and determinants of obesity in the neighborhoods of New York City, 2003–2007. American Journal of Epidemiology, 171(7), 765–775. Bond, B. J., Richards, M. N., & Calvert, S. L. (2013). Media and obesity. The routledge international handbook of children, adolescents, and media. New York: Routledge. Braithwaite, R. (2000). “Empowerment”, encyclopedia of psychology, Vol. 3, Oxford: Oxford University Press193–194. Branas, C. C., & MacDonald, J. M. (2014). A simple strategy to transform health, all over the place. Journal of Public Health Management and Practice: JPHMP, 20(2), 157. Centers for Disease Control and Prevention. (2016). School-based obesity prevention strategies for state policymakers. Retrieved from https://www.cdc.gov/healthyyouth/ policy/pdf/obesity_prevention_strategies.pdf. Charbonneau, D. R., Cheadle, A., Orbé, C., Frey, M., & Gaolach, B. (2014). FEEST on this: Youth engagement for community change in the king county food and fitness initiative. Community Development, 45(3), 240–251. Comstock, C., Kattelmann, K., Zastrow, M., McCormack, L., Lindshield, E., Li, Y., et al. (2016). Assessing the environment for support of youth physical activity in rural communities. Journal of Nutrition Education and Behavior, 48(4), 234–241. Cook, D. T. (2007). The disempowering empowerment of children's consumer “choice” Cultural discourses of the child consumer in North America. Society and Business Review, 2(1), 37–52. Crespo, N. C., Elder, J. P., Ayala, G. X., Slymen, D. J., Campbell, N. R., Sallis, J. F., ... Arredondo, E. M. (2012). Results of a multi-level intervention to prevent and control childhood obesity among latino children: The aventuras para Niños study. Annals of Behavioral Medicine, 43(1), 84–100. Criss, S., Cheung, L., Giles, C., Gortmaker, S., Viswanath, K., Kwass, J. A., et al. (2016). Media competition implementation for the Massachusetts childhood obesity research demonstration study (MA-CORD): Adoption and reach. International Journal of Environmental Research and Public Health, 13(4), 403. Daiute, C., & Fine, M. (2003). Youth perspectives on violence and injustice. Journal of Social Issues, 59(1), 1–14. Daniels, S. R. (2006). The consequences of childhood overweight and obesity. The Future of Children, 16(1), 47–67. Dewar, D. L., Lubans, D. R., Plotnikoff, R. C., & Morgan, P. J. (2012). Development and evaluation of social cognitive measures related to adolescent dietary behaviors. International Journal of Behavioral Nutrition and Physical Activity, 9(36), 1–10. Drummond, R. J., Barnard, D. L., & Mehnert, I. (1985). Locus of control and attitudes of juvenile offenders toward self and the correctional environment. Journal of Offender Counseling, 5(1), 9–15. Gardner, M., Roth, J., & Brooks-Gunn, J. (2008). Adolescents' participation in organized activities and developmental success 2 and 8 years after high school: Do sponsorship, duration, and intensity matter? Developmental Psychology, 44(3), 814. Goh, Y. Y., Bogart, L. M., Sipple-Asher, B. K., Uyeda, K., Hawes-Dawson, J., Olarita-Dhungana, J., et al. (2009). Using community-based participatory research to identify potential interventions to overcome barriers to adolescents' healthy eating and physical activity. International Journal of Behavioral Medicine, 32(5), 491–502. Hawks, S. R., Madanat, H. N., Smith, T., & Novilla, M. L. B. (2006). Motivation for eating and the nutrition transition in the Philippines. Age, 20(72.1), 10–11. Holden, D. J., Crankshaw, E., Nimsch, C., Hinnant, L. W., & Hund, L. (2004). Quantifying the impact of participation in local tobacco control groups on the psychological empowerment of involved youth. Health Education & Behavior, 31(5), 615–628. Holden, D. J., Evans, W. D., Hinnant, L. W., & Messeri, P. (2005). Modeling psychological empowerment among youth involved in local tobacco control efforts. Health Education & Behavior, 32(2), 264–278. Israel, B. A., Schulz, A. J., Parker, E. A., & Becker, A. B. (2001). Community-based participatory research: Policy recommendations for promoting a partnership approach in health research. Education and Health, 14(2), 182–197. Janz, N. K., & Becker, M. H. (1984). The health belief model: A decade later. Health Education Quarterly, 11(1), 1–47. Jenkins, S., & Horner, S. D. (2005). Barriers that influence eating behaviors in adolescents. Journal of Pediatric Nursing, 20(4), 258–267. Jennings, L. B., Parra-Medina, D. M., Hilfinger-Messias, D. K., & McLoughlin, K. (2006). Toward a critical social theory of youth empowerment. Journal of Community Practice, 14(1–2), 31–55. Kohfeldt, D., Chhun, L., Grace, S., & Langhout, R. D. (2011). Youth empowerment in context: Exploring tensions in school-based PAR. American Journal of Community Psychology, 47(1–2), 28–45. Kumar, J., Adhikari, K., Li, Y., Lindshield, E., Muturi, N., & Kidd, T. (2016). Identifying barriers, perceptions, and motivations related to healthy eating and physical activity among 6th to 8th grade, rural, limited-resource adolescents. Health Education, 116(2), 123–137. Leffert, N., Benson, P. L., Scales, P. C., Sharma, A. R., Drake, D. R., & Blyth, D. A. (1998). Developmental assets: Measurement and prediction of risk behaviors among adolescents. Applied Developmental Science, 2(4), 209–230. Li, Y., Kidd, T., Lindshield, E., Kattlemann, K., Zies, S., Adhikari, K., et al. (2014). Measurement of built environment that support physical activity in low-income communities. Journal of Nutrition Education and Behavior, 46(4), S158. Lluch, A., Herbeth, B., Mejean, L., & Siest, G. (2000). Dietary intakes, eating style and overweight in the Stanislas Family Study. International Journal of Obesity, 24(11), 1493. Mahoney, J. L., Harris, A. L., & Eccles, J. S. (2006). Organized activity participation, positive youth development, and the over-scheduling hypothesis. Social policy report. Society for Research in Child Development, 20(4), 1–32. Mallya, A., Mensah, F. M., Contento, I. R., Koch, P. A., & Barton, A. C. (2012). Extending science beyond the classroom door: Learning from students' experiences with the Choice, Control and Change (C3) curriculum. Journal of Research in Science Teaching, 49(2), 244–269. McCall, E. (2010). Communication for empowerment global report. Oslo and South orange: UNDP Oslo governance centre & communication for social change consortium.

250

Journal of Adolescence 68 (2018) 242–251

N. Muturi et al.

Melkote, S. R., & Steeves, H. L. (2001). Communication for development in the third world: Theory and practice for empowerment. Sage. Merikangas, A. K., Mendola, P., Pastor, P. N., Reuben, C. A., & Cleary, S. D. (2012). The association between major depressive disorder and obesity in US adolescents: Results from the 2001–2004 national health and nutrition examination survey. Journal of Behavioral Medicine, 35(2), 149–154. Millstein, S. G., & Litt, I. F. (1993). Adolescent health. In S. Feldman, & G. Elliot (Eds.). At the threshold: The developing adolescent (pp. 431–456). Cambridge, MA: Harvard University Press. Millstein, R. A., Woodruff, S. I., Linton, L. S., Edwards, C. C., & Sallis, J. F. (2016). Development of measures to evaluate youth advocacy for obesity prevention. International Journal of Behavioral Nutrition and Physical Activity, 13(1), 84–95. Minkler, M., Garcia, A. P., Rubin, V., & Wallerstein, N. (2012). Community-based participatory research: A strategy for building healthy communities and promoting health through policy change. University of California Berkeley. Morton, M. H., & Montgomery, P. (2013). Youth empowerment programs for improving adolescents' self-efficacy and self-esteem: A systematic review. Research on Social Work Practice, 23(1), 22–33. Muturi, N. W., Kidd, T., Khan, T., Kattelmann, K., Zies, S., Lindshield, E., et al. (2016). An examination of factors associated with self-efficacy for food choice and healthy eating among low-income adolescents in three US states. Frontiers in Communication, 1(6), 1–9. Neumark-Sztainer, D., Story, M., Hannan, P. J., Perry, C. L., & Irving, L. M. (2002). Weight-related concerns and behaviors among overweight and non-overweight adolescents: Implications for preventing weight-related disorders. Archives of Pediatrics & Adolescent Medicine, 156(2), 171–178. Nutbeam, D. (2008). The evolving concept of health literacy. Social Science & Medicine, 67(12), 2072–2078. Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2012). Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. Jama, 307(5), 483–490. Olshansky, S. J., Passaro, D. J., Hershow, R. C., Layden, J., Carnes, B. A., Brody, J., ... Ludwig, D. S. (2005). A potential decline in life expectancy in the United States in the 21st century. New England Journal of Medicine, 352(11), 1138–1145. Ozer, E. J., & Schotland, M. (2011). Psychological empowerment among urban youth: Measure development and relationship to psychosocial functioning. Health Education & Behavior, 38(4), 348–356. Paxton, R. J., Valois, R. F., & Drane, J. W. (2005). Perceived youth empowerment: Reliability and validity of a brief scale. American Journal of Health Studies, 20(3/4), 186. Perkins, D. D., & Zimmerman, M. A. (1995). Empowerment theory, research, and application. American Journal of Community Psychology, 23(5), 569–579. Power, T. G., Bindler, R. C., Goetz, S., & Daratha, K. B. (2010). Obesity prevention in early adolescence: student, parent, and teacher views. Journal of School Health, 80(1), 13–19. Reininger, B., Evans, A. E., Griffin, S. F., Valois, R. F., Vincent, M. L., Parra-Medina, D., ... Zullig, K. J. (2003). Development of a youth survey to measure risk behaviors, attitudes and assets: Examining multiple influences. Health Education Research, 18(4), 461–476. Robbins, L. B., Pender, N. J., Ronis, D. L., Kazanis, A. S., & Pis, M. B. (2004). Physical activity, self-efficacy, and perceived exertion among adolescents. Research in Nursing & Health, 27(6), 435–446. Rogers, E. M. (2003). Diffusion of innovations. New York: Free Press. Rogers, E. M., & Singhal, A. (2003). Empowerment and communication: Lessons learned from organizing for social change. Annals of the International Communication Association, 27(1), 67–85. Rosenkoetter, E., & Loman, D. G. (2015). Self-efficacy and self-reported dietary behaviors in adolescents at an urban school with no competitive foods. The Journal of School Nursing, 31(5), 345–352. Rosenkranz, R. R., & Dzewaltowski, D. A. (2008). Model of the home food environment pertaining to childhood obesity. Nutrition Reviews, 66(3), 123–140. Rossen, L. M. (2014). Neighbourhood economic deprivation explains racial/ethnic disparities in overweight and obesity among children and adolescents in the USA. Journal of Epidemiology & Community Health, 68(2), 123–129. Russell, S. T., Muraco, A., Subramaniam, A., & Laub, C. (2009). Youth empowerment and high school gay-straight alliances. Journal of Youth and Adolescence, 38(7), 891–903. Salam, R. A., Das, J. K., Lassi, Z. S., & Bhutta, Z. A. (2016). Adolescent health interventions: Conclusions, evidence gaps, and research priorities. Journal of Adolescent Health, 59(4), S88–S92. Sallis, J. F., & Glanz, K. (2006). The role of built environments in physical activity, eating, and obesity in childhood. The future of children, 89–108. Schwarzer, R., & Luszczynska, A. (2006). Self-efficacy, adolescents' risk-taking behaviors, and health. Self-efficacy beliefs of adolescents, 5, 139–159. Search Institute. (2005). Developmental assets profile: User manual. Minneapolis, MN: Search Institute. Shubrook, J. H., Jr. (2011). Childhood obesity and the risk of diabetes in minority populations. http://www.cecity.com/aoa/healthwatch/jan_11/print5.pdf. Silk, K. J., Sherry, J., Winn, B., Keesecker, N., Horodynski, M. A., & Sayir, A. (2008). Increasing nutrition literacy: Testing the effectiveness of print, website, and game modalities. Journal of Nutrition Education and Behavior, 40(1), 3–10. Skinner, K., Hanning, R., & Tsuji, L. (2006). Barriers and supports for healthy eating and physical activity for First Nation youths in northern Canada. International Journal of Circumpolar Health, 65(2), 148–161. Snyder, L. B., Hamilton, M. A., Mitchell, E. W., Kiwanuka-Tondo, J., Fleming-Milici, F., & Proctor, D. (2004). A meta-analysis of the effect of mediated health communication campaigns on behavior change in the United States. Journal of Health Communication, 9(S1), 71–96. Stevens, J., Murray, D. M., Catellier, D. J., Hannan, P. J., Lytle, L. A., Elder, J. P., ... Webber, L. S. (2005). Design of the trial of activity in adolescent girls (TAAG). Contemporary Clinical Trials, 26(2), 223–233. Story, M., Neumark-Sztainer, D., & French, S. (2002). Individual and environmental influences on adolescent eating behaviors. Journal of the Academy of Nutrition and Dietetics, 102(3), S40–S51. Wang, Y. C., Orleans, C. T., & Gortmaker, S. L. (2012). Reaching the healthy people goals for reducing childhood obesity: Closing the energy gap. American Journal of Preventive Medicine, 42(5), 437–444. Wong, F., Huhman, M., Asbury, L., Bretthauer-Mueller, R., McCarthy, S., Londe, P., et al. (2004). VERB™—a social marketing campaign to increase physical activity among youth. Preventing Chronic Disease, 1(3), 1–7. Wong, N. T., Zimmerman, M. A., & Parker, E. A. (2010). A typology of youth participation and empowerment for child and adolescent health promotion. American Journal of Community Psychology, 46(1–2), 100–114. Zimmerman, M. A. (2000). Empowerment theory. Handbook of community psychology (pp. 43–63). Springer US. Zimmerman, M. A., Eisman, A. B., Reischl, T. M., Morrel-Samuels, S., Stoddard, S., Miller, A. L., ... Rupp, L. (2018). Youth Empowerment Solutions: Evaluation of an after-school program to engage middle school students in community change. Health Education & Behavior, 45(1), 20–31. Zimmerman, M. A., & Zahniser, J. H. (1991). Refinements of sphere-specific measures of perceived control: Development of a sociopolitical control scale. Journal of Community Psychology, 19(2), 189–204.

251