Bold Ideas for the 4 th H in 4-H : Teen Identified Concerns and Actions

This article summarizes a literature review; teenidentified health concerns and issues; and teen bold ideas for actions. Findings from the National 4-H Council and Molina Healthcare Teens Take on Health initiative are provided and implications for 4-H programming tied to the new Cooperative Extension National Framework for Health and Wellness are addressed. The article is intended as background for Extension educators, volunteers and administrators as they review the 4-H Healthy Living Mission Mandate, learn what mattered to teens and consider how to incorporate the findings into state and local 4-H youth development programming.


Introduction
4-H has long emphasized health and safety as a focus for youth development programming.The 4 th H stands for health, which is addressed by Cooperative Extension in educational programming.In 2014, the Extension Committee on Policy (ECOP) adopted a new Cooperative Extension national framework on health and wellness with positive youth health development identified as one of six priorities (ECOP, 2014).
In 2009, 4-H released its 4-H Healthy Living Mission Mandate Strategic Framework for Progress (2009) with the intent of repositioning the place and importance of health in 4-H youth development programming.The framework was to guide planning, implementing and evaluating healthy living programming.
In 2012, National 4-H Council and Molina Healthcare launched an initiative, Teens Take on Health, to empower teens to take responsibility for their health and promote healthy living.The initiative was designed to get teens to identify their health concerns, think critically about solutions to health challenges, identify bold ideas and take leadership in the process both now and as they grow into adulthood.
This article summarizes a literature review; teen-identified health concerns and issues; and bold ideas for actions.It offers implications for 4-H programming tied to the new Cooperative Extension focus on health and wellness.The article is intended as background for Extension educators, volunteers and administrators as they review the 4-H Healthy Living Mission Mandate, learn what mattered to teens and consider how to incorporate the findings into state and local 4-H youth development programming.While this project was completed with 4-H youth, the findings and recommendations could be of use to other youth development professionals.

Literature Review
An extensive literature review was conducted to answer this question: What is the current state of health research, policies and programs associated with youth?The review focused on seven health-related concepts: • Health • Youth perceptions of health

Summary of Literature Review
Health.Health is both a resource and a dynamic state of physical, mental and social well-being affecting the daily living of youth (WHO, 1946;4-H, 2009).
Youth Perceptions of Health.Among diverse youth, there is agreement that health is multidimensional-mental, physical, social-and affected by both personal behaviors and impacts of family and community.Youth reported they are concerned for themselves and for their family, schools and community as a whole (Clark, & Irwin, 2013;Woodgate, & Leach, 2010).
Health Equity, Disparity and Social Determinants of Health.Health is not just a matter of personal inheritance and behavior.Health is affected by social and physical environments where teens live, learn and play.When those environments are negative, health status is lessened.When those environments are positive, health is enhanced (Bogart, et al., 2014;CDC, 2014).
Health Literacy.Health disparities among teens often exist with low levels of health literacythe ability to understand and act on health information and access health services and programs.Health literacy goes beyond individuals to include families, communities and public policies that help or hinder health understanding and positive action.High levels of health literacy reduce health care costs and are needed for positive health outcomes (Institute of Medicine, 2004;Pleasant, et al., 2013).
Health and Youth Empowerment.To be empowered is to have confidence to act and a sense of control.It goes beyond having health information and understanding.Youth gain empowerment through learning experiences that develop their confidence, control and capabilities to live healthfully.Youth empowerment is one component of youth development.Empowered youth can make a difference on matters of health and healthy living when they become civically engaged (Bersgma, 2004;Zimmerman, 2000).
Health and Youth Development.Youth development is what creates mature young people as they assimilate skills, knowledge and the capacity to become productive, healthy citizens.Youth develop through many kinds of learning experiences.Positive youth development leads to physical, emotional and social well-being.The 2013 Tufts University study of 4-H programming over time found that 4-H youth empowerment and development programs result in youth excelling beyond their non-4-H peers in the contributions they make to their communities, civic activity, and healthy lifestyle choices (Cargo, et al., 2003;Lerner, & Lerner, 2013;Roth, & Brooks-Bunn, 2003).
Systems Approach to Youth Health Development.A systems approach recognizes that humans live in, and are exposed to, multiple environments and situations that influence their behavior and beliefs and ultimately, their health.An understanding of these systems can be used to create positive youth development experiences.An appropriate organizing framework, backed by research is the Social Ecological Model (Atkiss, et al., 2011;McLeroy, et al., 1988).

Making Sense of the Research for 4-H Healthy Living Programming
Seven key points emerged from the research.There is a large body of evidence conveying that: 1.The health of youth affects both their current and long-term health and well-being.2. Health disparities result from social determinants of health that go beyond individual biology and behavior.3. Health literacy affects understanding, decisions, actions and costs of health care.4. The health of youth is affected by the multiple systems in which they work, learn and play.5. Youth are both a target of public policy and can be active agents of policy change.6.Recent public policy is emphasizing prevention of chronic disease and factors associated with chronic disease among youth.7. Youth development programs can make a difference in personal, family, community and societal physical, mental, emotional and social well-being.

Findings from the Teens Take on Heath Initiative
Teens Take on Health was designed to empower youth.While there are numerous 4-H programs on topics such as nutrition and physical activity, bullying, mental health and substance abuse decision-making/cessation, National 4-H Council and Molina wanted to listen to youth perspectives on health and healthcare in order to develop innovative, youth-led solutions.
Data were collected from nearly 1000 youth in late 2012 through early 2014 via three techniques: 1.A social media campaign using Facebook and an online survey.2. A national video contest.
3. Town hall conversations targeting youth in five states and at the National Youth Summit for Healthy Living.
Partner organizations serving low-income teens (including schools, teen centers, Boys & Girls Clubs, etc.) were engaged in techniques 2 and 3 to increase the likelihood that diverse teens were included.The social media campaign was limited to 4-H members for privacy and safety concerns.Each phase informed the development of the next one.
An analysis of results was conducted to answer the question: What is important to teens about personal, family and community health?The analysis revealed four key health concerns and issues that mattered most: Obesity Mattered.Teens focused on obesity as an urgent personal health concern and a public health issue.They knew that they and their families were eating less healthy food and not getting enough water.Teens also understood that physical activity is important.They knew they and their families were not active enough to prevent or reduce obesity.They had many ideas for actions to be taken by themselves, their families, their communities and through public policy.
Health Care Access Mattered.Teens recognized that they and their families needed access to health care and that health care costs are high and therefore health insurance is important.They had strategic ideas for what to do within their families and their communities or through public policy.Teens recognized that they needed family, community and public policy support to increase access to quality health care.
Sleep, Stress and Mental Health Mattered.Teens reported they weren't getting enough sleep, needed help with stress and were concerned about mental health needs in their communities.They had limited ideas for what to do beyond their personal actions but knew they needed support beyond their own actions.Teens across all economic and demographic levels saw sleep, stress and mental health as vital components of "health"-highlighting the growing urgency of these issues.
Personal, Family, Community and Public Policy Action Mattered.Teens understood that health is present at multiple systems levels-personal, family, organizational, community and policy.Teens had multiple ideas about how to make changes in their personal health behavior, and that of their families and communities, including public policy changes.Even more compelling and exciting is that teens understand that there won't be quick fixes in the journey toward better health.They see the complexity of health issues and they realize that solutions must come from all sectors.

Teen Big Bold Ideas for Action
Teens were asked to identify Big Bold ideas to address health matters.Some are highlighted below.

Ideas Informing Local Action:
• Replace content of typical vending machines in schools with healthy options.
• Open free facilities and offer free programs promoting healthy living best practices.

Ideas Requiring Funding:
• Every community should have a one-to-two acre community garden where citizens can plant fruits and vegetables that everyone can take home.The local government can donate the land.• Have health care providers (with patient's consent) group together people with similar health conditions (i.e.high blood pressure, obesity, diabetes) and create a team program/support system.Those who participate in a 'team' and work with others to improve their condition, get insurance discounts.
Ideas Requiring System Change and Funding: • Food Card -You're rewarded for buying healthy food with points on a card at the grocery store.Points can be redeemed (like cash) to purchase healthy foods.Points are subtracted for buying junk food and other unhealthy foods.• Start a line of food trucks that only serve healthy food.
• Set an age limit on energy drinks and regulate herbs in them.Have workshops and seminars about ways to naturally increase energy.• Invent a program or get companies such as Facebook and Apple to put timers on electronics, devices, and websites.After a certain amount of time the TV, iPad, website, and video gaming systems will shut off.• Bike Plan -for youth to have an affordable way to ride and exercise, contact bike companies, procure bikes, split bikes up by schools; check out bikes like books; place time limits on how long to rent the bikes; and rent to all people, kids and adults.• Have free health check-ups (every six months) for all Section 8 elementary, middle and high school students.Start by implementing free clinics in Section 8 housing areas.Find groups of abandoned buildings to tear down or renovate for the facilities.• Involve family by grocery shopping together and doing physical activities as a group through family fitness nights or "play days." Technology as a tool emerged as a subtheme related to changes.The social media survey specifically asked for ideas that use electronic technology to improve health.Ideas focused on programs or apps that encourage activity, make exercise more fun through gaming, monitor food intake and track physical activity.Teens suggested a program or app that shows consequences of health and wellness decisions.
For the complete report and the executive summary, go to the 4-H Healthy Living Research website located at: http://www.4-h.org/about/youth-development-research/health-research/.

Making Sense of Teen Views and Research
Teen views of health, their ideas for actions and the research are complimentary.In summary, they are: 1.The concerns of teens, obesity, health care and costs, mental health, and systems approaches are validated in the research.2. Teens put an emphasis on reducing obesity through healthy eating and physical activity, an objective for all Americans in Healthy People, 2020 (DHHS, 2008).3. Teen ideas for solutions are also present in both studies of youth and strategic action documents.4. Teens identified solutions in multiple systems congruent with research that reinforces the need for systems interventions.
5. Teens agree that youth empowerment and development programs are important to positive health outcomes and suggest expansion of 4-H Healthy Living programs validated as having an impact over time (Lerner, & Lerner, 2013).

Implications:
If the 967 teens who participated in the Teens Take on Health Initiative of Molina Healthcare and National 4-H Council are representative of other youth, they are ready to take on healththeir own and that of their families and communities.Molina, Council, and state and local 4-H programs can act on the ideas.This finding gives rise to a fourth question: Is the Cooperative Extension system ready to expand youth health programming?
In 2014, ECOP adopted a new health focus by approving the Cooperative Extension's National Framework for Health and Wellness.That framework used the new National Prevention Strategy (2011) goal for the foundation of health and safety education across the lifespan.Included among the six priorities for action was "positive youth development for health." Figure 1 shows the social ecological model used to illustrate the goal, the focus on individual healthy and safe choices and healthy and safe environments, the six priorities and potential partners (ECOP, p. 3).

Figure 1
Cooperative Extension's National Framework for Health and Wellness The ECOP social ecological model complements and supplements the National 4-H Healthy Living Social Ecological Model (4-H, 2009) shown in Figure 2. We used the model to: 1) Place teens' suggested actions by systems levels and 2) Show similarities and differences.Topics suggested by the teens and not in the 4-H model are shown in blue.Teens are eager for programs that will enhance the health and wellbeing of them, their family and community.The youth who participated in Teens Take on Health appear ready to create a culture of health.Now, it is time for adults to support youth in this endeavor.Extension educators, volunteers and administrators have the passion, ability and skills to begin making the youth dreams a reality.It is now the responsibility of adults to help youth actualize the 4 th "H" in 4-H and lead in the creation of a new culture of health.

Figure 2 National 4 -
Figure 2 National 4-H Healthy Living Social Ecological Model with Additional Suggested Topics from Teens

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Health equity and disparities • Health literacy • Health and youth empowerment • Health and youth development • Systems approach to youth health development The entire review of literature is contained in a report located at the 4-H Healthy Living Research website http://www.4-h.org/youth-development-programs/kids-health/: what follows is a summary of the review.