4-H Health Ambassador Programs: A Survey of Organizational and Programmatic Aspects

Introduction

Health is the fourth H in 4-H, and "Healthy Living" is a national 4-H mission mandate, one of three (National Institute of Food and Agriculture, 2011), that has received increased emphasis for more than a decade. States conduct a variety of health programs, and 4-H members complete projects in health-related subject areas. 4-H's focus on health was bolstered by the Cooperative Extension National Framework for Health and Wellness (Braun et al., 2014), which includes youth development as a priority area.

In a national survey, state 4-H professionals identified the need for strategies to empower youths to promote and adopt healthful living practices (Franck, Donaldson, Toman, & Moody, 2014). 4-H has had success overall with using teen leader approaches, and several states have undertaken efforts involving teen health ambassadors (Arnold et al., 2016; Ripberger, Devitt, & Gore, 2009; Strong, Christensen, & Carter, 2008; Weybright et al., 2016). These teen ambassadors represent the 4-H program and support its goals. Programs based on a teens-as-teachers model allow teens to develop skills, personal qualities such as self-confidence and responsibility, and relationships with adults and peers (Arnold et al., 2016; Bolshakova, Gieng, Sidhu, Vollinger, & Gimeno, 2018; Weybright, Diaz Martinez, Varella, Deen, & Wright, 2018; Worker, Iaccopucci, Bird, & Horowitz, 2019). As such, these programs embody the core elements of positive youth development (Roth & Brooks-Gunn, 2003).

On the other hand, some Extension educators have perceived barriers to conducting youth health programs, citing time constraints, lack of curricula, scarce resources (e.g., funding, volunteers), and lack of interest as limiting factors (Kumaran, Fogarty, Fung, & Terminello, 2015; Lynch, Fuhrman, Duncan, & Hanula, 2015). Despite the demonstrated potential of health ambassador programs in 4-H, information about the extent and scope of these programs has not been gathered. Therefore, in the study reported here, I sought to describe current practices and provide information that could assist those who might be interested in starting or expanding an ambassador-type program.

Methodology

The purpose of the descriptive study reported here was to gather information about 4-H health ambassador–type programs and how they function. I designed the survey instrument specifically for the study, with two reviewers providing feedback to ensure that all pertinent areas were addressed. The 27-question survey included both fixed-choice and open-ended questions. Questions addressed organizational aspects of such programs (i.e., recruitment and selection, number of participants, funding, staffing, group leadership structure, communication methods, meeting frequency, and length of service), and programmatic aspects (i.e., training and curriculum, ambassador activities, reporting and evaluation, accomplishments, and lessons learned).

I used Qualtrics to create the survey and collect responses and emailed the survey link to 114 Healthy Living contacts at 70 land-grant universities (LGUs) on a list maintained by the National 4-H Council. I requested that only one individual per LGU complete the survey. After the initial launch, three email reminders were sent over a 4-week period.

I calculated frequencies to summarize fixed-choice responses. I reviewed open-ended responses for themes and then categorized them inductively (Thomas, 2006).

Results

Of the 36 individuals who responded (representing 51% of LGUs), 15 indicated that their LGUs had a health ambassador program, and 13 of those respondents completed the remaining questions. There were many commonalities across the health ambassador programs, but there was considerable variation regarding certain aspects of them. In the following sections, I summarize the trends that emerged from the analysis.

Organizational Aspects

Recruitment and Selection

Most respondents used the term ambassador to describe their teen participants, but three used advocate. Organizers recruited teens through local county clubs and 4-H programs, schools, and partner organizations. They used contacts with county staff, newsletters, social media, and word of mouth to recruit participants.

The ambassador selection process included reviewing applications submitted by interested teens (80%), conducting interviews (50%), or both (30%). Two LGUs allowed all interested youths to participate. One LGU differentiated between those who received 6 hr of training and those who were active participants in subsequent activities (448 and 45 youths, respectively). Nine LGUs had county-level participants; one LGU described its club-level health officers as a subset of its ambassador program. Eight LGUs had county-level ambassador groups, eight had state-level groups, and six had both county- and state-level groups.

Number of Participants

The number of participants in a program ranged from a low of 18 to a high of 900. This higher number was an outlier that occurred at the LGU that included club-level health officers in its health ambassador definition. Membership for approximately two thirds of the responding LGUs (69%) was 100 members or fewer.

Funding

Most states received grant funding that supported their ambassador programs. The LGU that included club officers in its ambassador program membership did not receive funding for this aspect of the program.

Staffing

There was no consistent staffing model; that is, some programs were staffed with state specialists, some with program assistants, and others with volunteers, or they used some combination of these options. Despite these differences, these individuals shared similar responsibilities—serving as an advisor to the ambassadors, keeping track of ambassadors' activities and communicating with them, managing meetings, implementing grant requirements, and conducting training.

Group Leadership Structure

Although some ambassador groups included officers (four LGUs), others did not have a formal group structure. Some groups operated with shared leadership between adult advisors and youths. Table 1 summarizes variations in group leadership structure.

Table 1.
4-H Health Ambassador Group Leadership Structures

Program level	Examples of leadership structure	Frequencya
County	There is a youth–adult partnership in each participating county; each county sets up its own structure.	3
	There is no formal group structure at the state level; after training, ambassadors go back to their respective counties and help with Healthy Living programming.	1
	State staff coordinate with county-based staff for special events involving ambassadors.	1
State	The ambassador group has youth officers or a leadership committee.	5
	There are no officers; an adult advisor from the state 4-H office works with the group.	2
	The ambassador group is staff directed to ensure fulfillment of grant requirements.	1
aSome respondents reported more than one leadership structure.

Communication Methods

Email was the most commonly used communication method between staff and teens (10 LGUs). States varied in their social media use: Five LGUs used social media, and four had a web page.

Meeting Frequency

Meeting frequency varied considerably. Ambassadors met as frequently as twice a month at one LGU, but another only held an annual training. Most of the meetings took place in person (nine LGUs), but conference calls also were used (four LGUs).

Length of Service

Ambassadors typically served for 1 year. Most LGUs gave teens the option to renew for additional years.

Programmatic Aspects

Training and Curriculum

LGUs varied greatly with regard to training topics, curricula, and amounts of training time and formats used (Table 2). Five LGUs mentioned using more than one curriculum. Training included such formats as a 1-hr training for club officers, 6 hr of training in 1 day, and multiday training events.

Table 2.
Summary of Training Topics, Curricula, and Training Time and Formats Used in 4-H Health Ambassador Programs

Training element	Examples	Frequencya
Topics	Ages and stages of development	2
	Basic nutrition; cooking	5
	Best practices for teaching	3
	Communication	1
	Experiential learning	1
	Snack preparation	1
	Workforce skills	1
	Youth–adult partnerships	2
Curriculab	Choose Health: Food, Fitness, and Fun	2
	Fuel Up to Play 60	1
	Get Moving—Get Healthy with NJ 4-H	1
	Health Officer Curriculum	1
	Health Rocks!	3
	Up for the Challenge	1
	Yoga for Kids	1
	Youth Advocates for Health	3
Amounts of training time and formats	1-hr training for club officers	1
	6-hr training in a specific curriculum	2
	16 hr total training	1
	Monthly meetings	1
	Annual statewide training weekend	2
	Three multiday retreats spaced throughout the year	1
aAn open-ended question allowed respondents to provide more than one response. bSee appendix for sources of curricula.

Ambassador Activities

Respondents could choose from three activity types and had the opportunity to add other activities. The most common activity for ambassadors was teaching younger youths (11 LGUs). Other activities included making presentations (four LGUs) and creating communication campaigns (four LGUs). Six respondents listed other activities. These included leading activities at club meetings; hosting county events and fairs (e.g., health fairs, summer nutrition camps); staffing community endeavors such as cooking and food demonstrations, fitness demonstrations, and community gardens; conducting community service projects of their choosing; being involved in participatory research; and assisting at statewide events. Projects were determined by grant requirements, were decided as opportunities arose, were based on local need and program priorities, or depended on ambassadors' interests.

LGUs varied with regard to organizational level targeted for the ambassadors' activities (club, county, or state level) and activity locations, such as club meetings, county events, afterschool programs, in-school programs, and summer nutrition camps.

Reporting and Evaluation

Reporting requirements varied with regard to frequency and type of report. One LGU had no reporting requirements for ambassadors; at other LGUs, ambassadors completed end-of-year reports. LGUs used online survey findings, photos, and success stories to document their results. One LGU used time sheets to track ambassadors' involvement. As specified in grant funding requirements, many LGUs used 4-H Common Measures for evaluation.

Accomplishments

Respondents listed many accomplishments of their ambassador programs (Table 3). Notable accomplishments were expanding the LGU's outreach to underserved audiences, having an impact on participants, conducting research, and establishing health as a strong 4-H program focus.

Table 3.
Summary of Accomplishments of 4-H Health Ambassador Programs

Theme	Description	Frequencya
Focus	Established health as a strong focus of 4-H programs	2
Reach and involvement
Awareness	Increased awareness of Healthy Living programs	4
Audience	Met or exceeded the goal for number of ambassadors recruited	4
	Met or exceeded the number of participants reached by ambassadors	2
	Brought a pilot program to scale	1
	Expanded outreach to underserved audiences	1
	Created new program opportunities (e.g., camp)	1
External partners	Engaged with schools, afterschool programs, and summer camps	1
Internal partners	Partnered within Extension with Supplemental Nutrition Assistance Program-Education/Expanded Food and Nutrition Education Program, or SNAP-Ed/EFNEP, and 4-H clubs	1
Resources	Developed high-quality curriculum and resources	3
	Were successful in obtaining grant funding	1
Opportunities for teens	Had leadership opportunities available for teens; allowed teens to serve as role models	4
	Sent delegates to the National Youth Summit on Healthy Living	1
	Held successful statewide summits	1
Outcomes	Increased youths' knowledge of Healthy Living topics	2
	Had an impact on children and teens, particularly regarding changes in nutrition, self-confidence, and communication skills	1
	Conducted research	1
aAn open-ended question allowed respondents to list up to three accomplishments.

Lessons Learned

Respondents identified a variety of lessons they had learned from implementing their health ambassador programs (Table 4). Some lessons were related to the time involved, the critical nature of funding, and the challenge of conducting evaluation. Others related to the dynamics of working with teens and keeping track of their activities. One LGU emphasized the need to base programs on best practices from research.

Table 4.
Summary of Lessons Learned from Conducting 4-H Health Ambassador Programs

Theme	Lesson(s) learned	Frequencya
Program foundation	Base the program on best practices from research. This lesson learned was driven by a concern that much of what is going on is piecemeal, atheoretical, and not based on best practices.	2
Time involved	Realize that establishing a new program takes time (years) and is time intensive to implement.	2
	Realize that teens are busy.	1
Recruitment	Consider recruiting participants from both inside and outside the 4-H system.	1
Training	Make training hands-on, engaging, and fun.	2
	Provide training to empower teens.	1
Working with teens	Keep track of teens, especially when enrollment is high.	1
	Address lack of follow-through and engagement from teens.	1
	Provide opportunities for teach-backs, incentives, and recognition.	1
Roles	Give teens responsibilities, and see that they respond positively to those expectations.	1
	Ensure that there are enough meaningful roles for the teens to fulfill at the local level.	1
Evaluation	Make evaluations smooth and as easy as possible to complete.	1
Funding	Realize that funding is critical to a successful program.	1
Working with county staff	Realize that because not all county staff are engaged in health-focused programming, they may need ideas for how to engage the ambassadors in their counties.	1
aAn open-ended question allowed respondents to list more than one lesson learned.

Discussion

The survey results reported here provide a snapshot of the scope of 4-H health ambassador programs across the country and provide useful information about program content and organizational structure to those considering this approach. Within the ambassador model, there are common elements but also many variations—in group structures, curricula, and training formats. It appears that this variation gives LGUs flexibility to meet their needs. Despite these differences, staff members had similar roles in relation to managing the ambassador program. However, it may be beneficial to apply consistent definitions and a more theoretical underpinning to these programs (cf. Simoni, Franks, Lahavot, & Yard, 2011).

The respondents noted that conducting a successful health ambassador program involves many facets. Implementing such a program model draws on all competencies required of 4-H youth development professionals, including elements of youth development; youth program development; volunteerism; equity, access, and opportunity; partnerships; and organizational systems (National Institute of Food and Agriculture, 2017). Those who provide professional development opportunities should consider assessing professional development needs and including these elements when planning such events. It might make sense to explore opportunities for networking among those staff members who facilitate health ambassador programs. Such forums could promote sharing of best practices.

When viewing the survey responses from the social-ecological perspective (Fitzgerald & Saccarotella, 2009; McLeroy, Bibeau, Steckler, & Glanz, 1988; Sallis et al., 2006; Sallis & Glanz, 2009; Sallis & Owen, 2015; Stokols, 1996), which is the foundation of the National Framework for Health and Wellness (Braun et al., 2014), one notes that many activities undertaken by ambassadors target individual behavior change. With an increasing emphasis on public health approaches that focus on policy, systems, and environmental changes (Frieden, Dietz, & Collins, 2010; Larson & Story, 2009), program organizers should consider relevant lessons learned about how to incorporate these approaches into training and how to guide the types of activities undertaken by teens.

Youths can be effective advocates on health issues. In fact, youth advocacy has been called the next wave of social change in health (Millstein & Sallis, 2011). It may be helpful to examine other youth advocacy efforts (e.g., Barrett, Villalba, Andrade, Beltran, & Evans, 2017; Besenyi et al., 2014; Bogart et al., 2011; Frerichs, Brittin et al., 2015; Frerichs et al., 2012; Frerichs, Sjolie, Curtis, Peterson, & Huang, 2015; Ginis, Nigg, & Smith, 2013; Linton, Edwards, Woodruff, Millstein, & Moder, 2014; Millstein, Woodruff, Linton, Edwards, & Sallis, 2016; Smith & Holloman, 2014) to discern similarities and differences, key components, and lessons learned and to reflect on their relevance to 4-H health ambassador programs.

The study reported here is not without limitations. Distributing the survey during the busy summer season may have limited the response rate. It is also possible that LGUs have started new programs or modified existing ones in the time since I conducted the survey. A follow-up online survey could identify additional programs. A follow-up survey could include modified questions based on the responses generated from the study reported here. Alternatively, interviews could be conducted by phone; although more labor intensive, such an approach might ensure a better response rate and would allow the interviewer to probe for explanations to open-ended responses. No doubt as programs mature there will be additional accomplishments and lessons learned to share.

Conclusions

As an organization, 4-H is uniquely positioned to make a difference in the health of its members. Healthy Living is one of 4-H's national mission mandates, and health is receiving increased emphasis across the Extension system (Braun et al., 2014; Buys & Koukel, 2018; Rodgers & Braun, 2015; Smathers et al., 2018). With health representing the fourth H, many believe the concept of health should pervade all 4-H programming, not just programming for those members who complete projects in this area (Franck et al., 2014). A 4-H ambassador program focused on health provides a means for 4-H members to assume leadership roles and develop skills. With the critical need to improve the population's health, establishing a health ambassador program is a strategy worth considering. Such approaches could enable states to align with national priorities and achieve additional desirable outcomes.

Acknowledgments

Thanks to JoAnne Leatherman at National 4-H Council and to Katie Riemenschneider, who served as a graduate student intern on the project. An earlier version of this paper was presented at the 2016 National Association of Extension 4-H Agents Annual Conference, New Orleans, Louisiana.

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Appendix

Sources for Curricula Used in 4-H Health Ambassador Programs

Name of curriculum	Source	Web page for information
Choose Health: Food, Fitness, and Fun	Cornell University, New York	http://fnec.cornell.edu/for-partners/curricula/chfff/
Fuel Up to Play 60	National Dairy Council	https://www.fueluptoplay60.com/
Get Moving–Get Healthy with NJ 4-H	Rutgers University, New Jersey	http://nj4h.rutgers.edu/getmoving/
Health Officer Materials	West Virginia University	https://extension.wvu.edu/youth-family/4h/programs/healthy-lifestyles-initiative
Health Rocks!	National 4-H Council	https://4-h.org/parents/old-healthy-living/health-rocks/
Up for the Challenge	University of Maryland	https://extension.umd.edu/4-h/4-h-program-areas/challenge
Yoga for Kids	University of Arkansas	https://www.uaex.edu/health-living/health/youth.aspx
Youth Advocates for Health (YA4-H)	Oregon State University	http://oregon.4h.oregonstate.edu/projects/ya4-h/curriculum