Research Article | Open Access

¹Marshall County Health Department, Benton, Kentucky
²Tennessee State University, Department of Public Health, Health Administration, and Health Sciences, Nashville, Tennessee

*Corresponding author: Miranda Sue Terry, Tennessee State University, Department of Public Health, Health Administration, and Health Sciences, Nashville, Tennessee

Abstract

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The objective of this intervention was to conduct visioning sessions with focus groups of youth at each of the public schools in a rural Western Kentucky county as part of the community health assessment process. The participants were provided a sheet of paper with “What Would My Healthy Community Look Like?” The target population was youths who participated in student groups or organizations that were selected to be focus groups from the public schools in the county. The visioning session results were analyzed through a two-phase qualitative coding process. The top feature identified by the visioning sessions was farmer’s markets/access to healthy food (n=86). Youth are our future generation; their perspectives on the health needs and issues in the community must be included in community health assessments.

Keywords: Youth; Community Health Assessments; Rural Health
Abbreviations: CHA: Community Health Assessment, CHNA: Community Health Needs Assessment, MARC: Mid-America Regional Council, BMI: Body Mass Index

Introduction

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Communities are made up of people from different ethnicities, race, cultures, genders, sexual orientation, and age. The community health assessment process should try to capture as many of these different facets that make each community unique, including providing a platform and voice to the most vulnerable populations in the community. A Community Health Assessment (CHA), also known as a Community Health Needs Assessment (CHNA), uses data collection and analysis to identify health needs and issues in a community [1]. The CHA process should provide everyone in the community an opportunity to participate and have their voice be heard. The CHA process in a rural Western Kentucky county provided a variety of opportunities for the community to participate through focus groups, town halls, and the community survey.
One of the often-overlooked groups is youth. UNICEF Convention on the Rights of the Child states “that children are not just objects who belong to their parents and for whom decisions are made, or adults in training. Rather, they are human beings and individuals with their own rights” [2]. It goes on to say “children must be allowed to grow, learn, play, develop and flourish with dignity” [2]. With this perspective, and given that youth are the future, it is important they have a voice in identifying community health needs, which impact their growth, learning, and development. Therefore, youth in this paper is defined as an individual up to the age of 18 years of age to align with UNICEF Convention on the Rights of the Child [2].
Youth make up 22.1% of the U.S. population [3] and 20.3% of the rural Western Kentucky county this intervention took place [4]. According to the Mid-America Regional Council (MARC) research, young people are likely to be medically vulnerable [5]. Minority youth and those who live in poverty often have limited access to quality care, health, food, or opportunities for recreation and physical activity [5]. In this rural Western Kentucky county, children in poverty are 15%, 5% uninsured children, and 50% of children are eligible for free or reduced-price lunch [4]. Per the County Health Rankings, this county had 39% adult obesity, 31% physical inactivity, and only 48% of the population has adequate access to locations for physical activity [4]. The food environment index of the county was rated at an 8.2, with the best counties in the U.S. rated at an 8.8 [4]. These factors demonstrate that this rural county may hinder the health of its residents, especially its youth.
The local health department in partnership with the public schools in the county track body mass index (BMI) of the students. During the 2021-2022 academic school year, the BMI among the students at the elementary schools indicated 17% were overweight and 29% were obese; among the students at the middle schools indicated 19% were overweight and 27% were obese; and among the students at the high school indicated 16% were overweight and 26% were obese. Poor health habits and outcomes in early years can lead to life-long health problems [5]. University of Michigan Adolescent Health Initiative found that “empowering youth to actively participate in their health care leads to more preventive visits and lifelong engagement in their health and well-being;” therefore, hopefully, the visioning sessions will encourage lifelong engagement in their community’s health [6]. To ensure this vulnerable population had a voice, more of a voice than in the past, during the 2022-2025 CHA cycle, the CHA team created an intervention with the youth in the community, visioning sessions.

Methods

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Objective
The purpose of the visioning sessions intervention was to communicate and provide additional opportunities for a vulnerable population, the youth, in the community to participate in the CHA process. The objective of this intervention was to conduct visioning sessions with focus groups of youth at each of the public schools in the county.
Intervention
A member of the CHA team met with the focus groups of youth at each of the public schools, which consisted of six elementary schools (n=14; 27; 9; 22; and 28), two middle schools (n=17; 102), and one high school (n=8). The students who participated in the intervention were a part of selected student organizations or groups at each school. The youth focus groups were provided an 8.5-inch by 14-inch sheet of white paper with “What Would My Healthy Community Look Like?” written across the top, the middle portion blank as a space to draw, and a box at the bottom for the students to have a space to write an answer to the posed question instead or to describe their picture. Figure 1 is an example of what the youth focus groups were provided at each session.
The visioning sessions intervention took place at the public schools in a rural Western Kentucky county during December 2021 through February 2022. This intervention did not go through IRB approval process since it was conceived and implemented by the local health department in partnership with the local schools. Participants provided consent prior to the start of the focus group session. Participants’ anonymity was protected by not collecting names or other identifying information on the visioning session forms or through focus group participation. The focus groups participants came from elementary, middle, and high school students. While the age of the participants was not collected for this intervention, the age range is estimated to be between 7 and 18. Data analysis was completed through a consulting contract with an associate professor at a public university, who signed a confidentiality agreement with the local health department. This CHA intervention activity was not funded.

Participants
The elementary school focus groups were members of Team Ultra. Team Ultra is a community health program created by the health department and is a partnership with the public elementary schools in the county. The mission of Team Ultra is to teach students about physical activity, good nutrition, and upstanding character traits and is offered for grades 3-5. For the two middle schools, the Explore Learning Pathway students and the BETA club students were selected to participate in the focus groups. For the high school, the focus group was a group of youth that were part of Marshall Mission, which work to improve diversity and inclusion within the school and serve as student ambassadors for community members and new students.

Results

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The visioning sessions were evaluated using a two-phase qualitative coding process. Inductive analysis was used during the initial coding phase as codes were developed from the data itself [7]. The second phase was coding for patterns in the data. There was a total of 227 students who participated in the visioning sessions. The top ten features identified by the participants of what makes a healthy community were: (1) farmer’s markets/access to healthy food (n=86); (2) cheap or free healthcare or medicines (n=43); (3) nicer and more accepting people in the community with less homophobia, transphobia, sexism, racism, and ableism decisions made (n=42); (4) mental health (n=31); (5) clean environment (n=28); (6) bike paths/walking paths (n=26); (7) bigger parks for all ages and abilities and more/bigger community pool (n=25); (8) free or cheap gym or recreation center (n=24); (9) homeless shelters (n=11); and (10) better school food.
There were no known adverse effects for the visioning sessions intervention. One potential adverse effect could be emotional distress if the student drew or wrote about a personal aspect of the community that could be triggering to past adverse child experiences.
Implications for Policy and Practice
• Visioning sessions are a low-cost intervention to provide a voice and empower the community’s next generation, youth, to participate in the community health assessment process.
• The visioning session form is ideal to use with populations with low literacy skills as it provides a space for drawing and sentence writing.

Discussion and Conclusion

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The results from the visioning sessions provided insights to the local health department. For example, the most common feature mentioned was farmer’s markets and access to healthy food. There are farmer’s markets offered in the county; therefore, additional marketing through the public schools maybe be needed to raise awareness of these. Access to healthy food feature was an interesting result as it is opposite of the County Health Rankings findings of the food environment index of the county was rated at an 8.2 [4]. Given the obesity rates of the youth, lack of access to locations for physical activity [4], and the results of the visioning sessions, the community needs to find ways to better support and encourage the health of the youth.
The CHA process is a required aspect for health departments in Kentucky to achieve and maintain accreditation. All community members should be given an opportunity to participate in the CHA process. One often overlooked group to include in the CHA process is youth. Given youth make up almost a quarter of the U.S. population and as youth are our future generation, it is important to hear their thoughts on the health of their community and their perspectives on the health needs and issues in the community. Visioning sessions are a low-cost intervention. The visioning session form is ideal to use with populations with low literacy skills, such as children, to enable them to participate in the CHA process.

References:

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1. Centers for Disease Control and Prevention (CDC). (2018) Public Health Professional Gateway Community Health Assessment. [Ref.]
2. UNICEF (n.d.). Convention on the Rights of the Child. [Ref.]
3. Ogunwole SU, Rabe MA, Roberts AW, Caplan Z. (2021) Population Under Age 18 Declined Last Decade. [Ref.]
4. County Health Rankings & Roadmaps. (2022) Marshall County, Kentucky. [Ref.]
5. Mid-America Regional Council (MARC). (2022) MARC Research Health Status Data for Greater Kansas City Vulnerable Populations. [Ref.]
6. University of Michigan (n.d.) Adolescent Health Initiative. [Ref.]
7. Patton MQ. (2002) Qualitative Research & Evaluation Methods (3rd edition). SAGE Publications, Inc. [Ref.]