A Mixed Methods Study to Identify Characteristics and Practices of Effective Student Health Advocates

Purpose: Students can serve as key advocates for healthier environments in their schools. This study employs the Youth Advocacy for Obesity Prevention Framework to investigate associations between advocacy skills for environmental and policy change and both self-efficacy and health behaviors, and explores applications of advocacy skills for health among 9-15 year-old elementary and middle schoolers. Design: Convergent, nested mixed-methods approach. Setting: Elementary and middle schools in a mid-Atlantic U.S. state. Subjects: 457 low-income elementary and middle students. Measures: Validated questionnaires were administered to 457 students attending 33 elementary or middle schools serving low-income communities in 5 school districts, assessing self-efficacy for physical activity (PA) and healthy eating (HE), PA and HE behaviors, and advocacy skills. Semi-structured interviews with a subset of 199 students explored advocacy applications. Analysis: Hierarchical linear regressions assessed associations between students’ self-efficacy for PA and HE, PA and HE behaviors, and advocacy scores, accounting for school-level clustering and controlling for student factors (eg, gender, race, and BMI category). Integrated analysis of quantitative and qualitative data explored conceptualizations of advocacy skills. Results: Self-efficacy for PA (b = .24; P < .001), self-efficacy for HE (b = .39; P < .001), and engagement in PA (b = .10; P < .001) were associated with higher advocacy scores. Mixed methods findings further operationalized advocacy skills including leadership participation and history, self-efficacy for health promotion, and assertiveness in advocacy. Conclusion: Promoting youth self-efficacy for health behaviors may enhance advocacy efforts for healthier school environments. Future research should further explore methods to foster youth advocacy and assess its impact on promoting healthier school environments.