Can a school-based civic empowerment intervention support adolescent health?

Abstract

Meaningfully engaging and supporting youth in their communities can promote their sense of efficacy and potentially their health and wellbeing. The objective of this study was to test whether a school-based youth civic empowerment program, Generation Citizen (GC), was associated with self-reported mental and physical health among participants, and whether these associations differed by two potential modifiers: civic self-efficacy and a sense of meaningful contributions to one's community. Participants were middle and high school students (N = 364) who participated in GC in the fall semester of 2014 and completed surveys at the beginning and end of the semester. Analyses revealed a small but statistically significant increase in self-reported physical health after GC and no statistically significant change in self-reported mental health. There was evidence of effect measure modification by civic self-efficacy such that the difference in physical health as civic self-efficacy increased was smaller post-intervention compared to pre-intervention. This could suggest that GC participation is particularly beneficial for those with lower civic self-efficacy. While our findings suggest that public health interventions may benefit from centering empowerment opportunities for youth, future research is warranted to better understand the particular role of civic self-efficacy in that process.

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Preventive Medicine Reports
journal homepage: www.elsevier.com/locate/pmedr
Can a school-based civic empowerment intervention support adolescent
health?
Parissa J. Ballard
a,⁎
, Alison K. Cohen
b
, Catherine d.P. Duarte
c
a
Family & Community Medicine, Wake Forest School of Medicine, Piedmont Plaza 1, 1920 W. 1st St, Winston-Salem, NC 27104, USA
b
Public and Nonprofit Administration, School of Management, University of San Francisco, San Francisco, CA, USA
c
Division of Epidemiology, UC Berkeley School of Public Health, USA
ARTICLE INFO
Keywords:
Adolescent health
Public health
Self-rated health
Social capital
Empowerment
Psychosocial factors
ABSTRACT
Meaningfully engaging and supporting youth in their communities can promote their sense of efficacy and
potentially their health and wellbeing. The objective of this study was to test whether a school-based youth civic
empowerment program, Generation Citizen (GC), was associated with self-reported mental and physical health
among participants, and whether these associations differed by two potential modifiers: civic self-efficacy and a
sense of meaningful contributions to one's community. Participants were middle and high school students
(N= 364) who participated in GC in the fall semester of 2014 and completed surveys at the beginning and end of
the semester. Analyses revealed a small but statistically significant increase in self-reported physical health after
GC and no statistically significant change in self-reported mental health. There was evidence of effect measure
modification by civic self-efficacy such that the difference in physical health as civic self-efficacy increased was
smaller post-intervention compared to pre-intervention. This could suggest that GC participation is particularly
beneficial for those with lower civic self-efficacy. While our findings suggest that public health interventions
may benefit from centering empowerment opportunities for youth, future research is warranted to better un-
derstand the particular role of civic self-efficacy in that process.
1. Introduction
Adolescence is a transitional life stage; young people are figuring
out who they are, what is important to them, and how they envision
their role in community and society. While adolescents are generally
healthy, adolescence is also a sensitive developmental period where
health issues can emerge and shape long-term health trajectories (Viner
et al., 2015). Notably, these civic and health developmental trajectories
may be interconnected. For example, a civic empowerment gap exists,
such that young people from structurally marginalized backgrounds are
systematically civically disempowered (Levinson, 2012). Specifically,
this disempowerment manifests as exclusion from mainstream forms of
civic engagement (e.g., voting), and a devaluation of involvement in
alternative direct-action, participatory politics (e.g., organizing) (Pope
et al., 2019). This empowerment gap has been linked in the literature to
health inequities (Wallerstein, 2002). Civic connection and empower-
ment in one's community, by contrast, can promote wellbeing among
adolescents, perhaps playing an especially important role among po-
pulations, such as racially and ethnically minoritized communities, who
have been structurally excluded from civic engagement over time
(Hope and Spencer, 2017). Relatedly, psychological empowerment may
be critical for promoting and sustaining wellbeing (Christens, 2012).
Given this, programs that increase adolescents' civic self-efficacy
and meaningful contribution to one's community may also promote
health and wellbeing (Ballard and Ozer, 2016). From a policy per-
spective, this may indicate that promoting adolescent health could in-
volve not only specific health-focused initiatives, but empowerment-
focused initiatives as well. However, few empirical studies assess the
health implications, and especially physical health implications, of civic
self-efficacy and meaningful contribution to one's community.
To our knowledge, the present is the first to directly assess for po-
tential spillover of a civic empowerment intervention on health. We
hypothesized that a school-based youth civic empowerment initiative,
called Generation Citizen (GC), would be associated with increased
mental and physical health, and associations would be stronger for
participants who, after the intervention, had higher (1) civic self-effi-
cacy and (2) a sense of having made meaningful contributions to their
communities.
https://doi.org/10.1016/j.pmedr.2019.100968
Received 15 December 2018; Received in revised form 8 August 2019; Accepted 9 August 2019
⁎
Corresponding author.
E-mail address: pballard@wakehealth.edu (P.J. Ballard).
Preventive Medicine Reports 16 (2019) 100968
Available online 23 August 2019
2211-3355/ © 2019 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).

2. Method
2.1. Participants
Eligible participants were middle and high school students enrolled
in schools across GC's 4 locations (the metropolitan areas of Providence,
Rhode Island; Boston, Massachusetts; New York City, New York; and
the San Francisco Bay Area, California) that participated in the GC
curriculum in Fall 2014 (N= 1154). Of the eligible participants, our
final analytic sample consisted of those who agreed to participate in the
study, completed both pre-intervention and post-intervention surveys,
and had no missing data on any variables included in analysis
(N= 364; mean age = 15.0, SD = 2.2). Participants in the complete
case sample were enrolled in 38 classrooms across 22 schools. For those
who self-reported their racial/ethnic identity, they primarily identified
as Hispanic/Latino (44.4%); African American or Black (19.2%); White
(16.5%); Asian and/or Pacific Islander (9.6%); and other (10.2%).
Approximately half (53.7%) identified as female, while 46.3% identi-
fied as male. Compared to full eligible sample, the analytic sample was
similar on reported sex composition (P= 0.286) and slightly younger
(eligible sample mean age = 15.6 years; P< 0.001); with a greater
proportion of students who identified as White, a smaller proportion
who identified as Asian and/or Pacific Islander, African American or
Black, and other, and a similar proportion who identified as Hispanic/
Latino. This research was approved by the Institutional Review Boards
at Tufts University and Wake Forest School of Medicine and conforms
to the principles of ethical research.
2.2. Civic intervention
GC offers a semester-long curriculum taught twice weekly by
trained college student volunteer “democracy coaches”in partnership
with classroom teachers. GC's curriculum is student-centered, action-
oriented, and community-driven, and teaches civic skills through youth
empowerment (Cohen et al., 2018;Stolte et al., 2014). GC's action ci-
vics process involves classes collectively choosing a local issue, learning
strategies and skills for taking action, and developing and implementing
an action plan accordingly (Pope et al., 2011). Examples of issues
participants have previously selected include bullying, quality of school
lunches, and homelessness in local communities. Participating in GC
has been shown to be associated with increased civic self-efficacy
(Ballard et al., 2016) and associations with a sense of making mean-
ingful community contributions are unknown.
2.3. Outcomes and effect measure modifiers
Our study's two outcome measures were self-reported mental health
and physical health. Each was measured through a one-item question
(Bowling, 2005) answered on a 5-point scale (1 = poor, 2 = fair,
3 = good, 4 = very good, 5 = excellent): “In general, how would you rate
your mental/physical health?”(DeSalvo et al., 2006;Eriksson et al.,
2001). The two effect measure modifiers under consideration were civic
Table 1
Associations between Generation Citizen (GC) and mental and physical health.
Main effects models Model 1 Model 2
Mental health Physical health
Predictors Estimates CI P Estimates CI P
Fixed effects
(Intercept) 3.96 3.85, 4.06 < 0.001 3.68 3.56, 3.79 < 0.001
GC 0.02 −0.08, 0.12 0.657 0.15 0.06, 0.23 0.001
Random effects
Class random effect (SD) 0.128 0.150
Student in class random effect (SD) 0.722 0.746
Effect modification by civic self-efficacy Model 3 Model 4
Mental health Physical health
Predictors Estimates CI P Estimates CI P
Fixed effects
(Intercept) 3.96 3.85, 4.07 < 0.001 3.68 3.57, 3.78 < 0.001
GC 0.02 −0.07, 0.12 0.640 0.15 0.06, 0.23 0.001
Civic self-efficacy (mean centered) 0.26 0.15, 0.37 < 0.001 0.32 0.21, 0.43 < 0.001
GC × civic self-efficacy (mean centered) 0.09 −0.04, 0.22 0.189 −0.10 −0.22, 0.02 0.104
Random effects
Class random effect (SD) 0.124 0.126
Student in class random effect (SD) 0.673 0.703
Effect modification by community contributions Model 5 Model 6
Mental health Physical health
Predictors Estimates CI P Estimates CI P
Fixed effects
(Intercept) 3.96 3.84, 4.07 < 0.001 3.68 3.57, 3.78 < 0.001
GC 0.02 −0.08, 0.12 0.674 0.14 0.06, 0.23 0.002
Community contributions (mean centered) 0.16 0.06, 0.26 0.002 0.24 0.15, 0.34 < 0.001
GC × community contributions (mean centered) 0.09 −0.03, 0.21 0.156 0.04 −0.07, 0.16 0.442
Random effects
Class random effect (SD) 0.159 0.126
Student in class random effect (SD) 0.681 0.676
P.J. Ballard, et al. Preventive Medicine Reports 16 (2019) 100968
2

self-efficacy and community contributions. Items for each were an-
swered on a 5-point scale (1 = strongly disagree to 5 = strongly agree).
Civic self-efficacy comprised five items averaged to create a composite
score (e.g.: “I believe I can make a difference in my community”)
(α
pre
= 0.84 and α
post
= 0.85) and community contributions comprised
three items averaged to create a composite score (e.g., “I have a
meaningful role in my community”)(α
pre
= 0.87 and α
post
= 0.88). See
Appendix Table 1 for more details.
2.4. Analysis
We conducted a complete case analysis to test the association be-
tween GC participation and self-reported mental and physical health.
To account for the nested structure of these data (i.e., by classroom,
with students nested within classrooms), we fit linear mixed-effects
models. We tested for effect measure modification on the additive scale
by including interaction terms in our linear-mixed effects models. The
interaction terms, civic self-efficacy and community contributions, were
mean-centered to facilitate meaningful interpretation. For the main
effects models, statistical significance was assessed at an alpha level of
0.05. As recommended for the purposes of increasing power to detect
effect measure modification, statistical significance for the interactions
was conservatively assessed at an alpha level of 0.10, recognizing that
Selvin suggests an alpha level as high as 0.20 (Selvin, 2004). All ana-
lyses were conducted in R statistical software version 3.5.1 (R Foun-
dation for Statistical Computing, Vienna, Austria).
3. Results
After accounting for the nested structure of these data, the un-
adjusted model found no statistically significant difference in self-re-
ported mental health after participating in the GC intervention
(pre = 3.96, post = 3.98, P= 0.657; 95% CI: −0.08–0.12) (Table 1,
Model 1). Participating in the GC intervention was statistically sig-
nificantly associated with a 0.15-unit increase (pre = 3.68;
post = 3.82) in self-reported physical health (P= 0.001; 95% CI:
0.06–0.23) (Table 1, Model 2).
In the model examining effect measure modification by community
contributions of the association between GC participation and self-re-
ported mental health, the interaction between GC participation and
community contributions was not statistically significant at the 0.10
alpha level (P= 0.189; 95% CI: −0.04–0.22) (Table 1, Model 3). By
contrast, there was evidence of effect measure modification by civic
self-efficacy. Specifically, we observed a 0.10-unit decrease in self-re-
ported physical health per unit increase in civic self-efficacy post-GC
participation compared to pre-GC participation (P= 0.10; 95% CI:
−0.22, 0.02) (Table 1, Model 4). As illustrated in Fig. 1, this indicates
that the mean difference in physical health per unit increase in civic
self-efficacy was smaller post-GC intervention compared to pre-inter-
vention.
In the models examining effect measure modification by community
contributions of the associations between GC participation and self-
reported mental and physical health, the interaction terms were not
statistically significant (Table 1, Model 4 and Model 5).
As noted previously, to account for the nested structure of these
data, we fit a mixed effect term for varying intercepts by classroom, and
for students that are nested within classrooms. In each model, the
standard deviation around the mean outcomes at each level was small,
suggesting limited variation in the association between GC and health
across students within classrooms or across classrooms (Table 1). We
then summed the total variance of the random effects to estimate the
proportion attributable to each random effect. Estimates suggest that
across models, between 49.9% and 59.1% of the total variance of the
random effects was attributed to the nested effect of students within
classrooms and that the effect of class alone was smaller, ranging from
1.7% to 2.7% of the random effects' total variance. Put differently,
across models, the variance in the outcome between classes is much
smaller than the variance among students within classes. This may be
expected given that all classrooms in the sample shared similar char-
acteristics (e.g., urban-based school districts, serving primarily low-in-
come students and students of color).
4. Discussion
This analysis provides preliminary evidence that programs designed
to empower youth, such as Generation Citizen, could spill over to po-
sitively affect health. Specifically, we found that implementation of GC,
an empowerment-focused civic program, was associated with an in-
crease in self-reported physical health in the total sample. There was
also evidence of effect measure modification by civic-self efficacy such
that, on average, as civic self-efficacy increased, the difference in
physical health was smaller post-GC intervention compared to pre-in-
tervention. This may suggest that programming to empower youth
could be particularly meaningful for young people with lower civic self-
efficacy. Thus, while our findings suggest that public health interven-
tions to improve physical health may benefit from centering empow-
erment opportunities for young people, future research is warranted to
better understand the specific role of civic self-efficacy. We discuss the
limitations of our analyses and the implications of these observations
for future research below.
Fig. 1.
P.J. Ballard, et al. Preventive Medicine Reports 16 (2019) 100968
3

4.1. Limitations and future research directions
The present study was limited in important ways. For example, at-
trition was high (68.5%) and those in the analytic sample were slightly
younger and more likely to identify as White compared to GC partici-
pants generally. In addition, the health measures were self-reported
one-item measures. The relatively small sample size did not provide
adequate power to assess for differences by structurally marginalized
status (e.g., race/ethnicity) and pre/post data were not available for a
comparison group to be able to better isolate the impact of Generation
Citizen. Additionally, results should be interpreted in light of the
overall small magnitude of associations.
These preliminary findings present many opportunities for future
research to rigorously test links between youth empowerment and
health. First, studies should include a comparison group using a sample
not involved in a civic program or involved in a program focused on
civic skills and knowledge as opposed to empowerment. Additionally,
analyses should adjust for other potential confounders of the associa-
tion between the primary intervention (GC) and health. Second, in
addition to the one-item measures of self-reported health used here,
studies should include multi-item self-report measures of health as well
as medical records and/or biomarkers of psychosocial stress. Third,
given both the existing literature on civic self-efficacy and the findings
of our effect measure modification analysis, a mediation analysis could
facilitate a better understanding of the mechanisms underlying these
observed associations. Fourth, other potential mediators of the link
between civic programs and health should be tested; for example,
finding meaning or purpose, increasing social capital, increasing social
connectedness, and observing structural change as a result of youth-led
action. Fifth, future work can examine whether findings generalize to
earlier and later in adolescence and test whether links between civic
self-efficacy and health outcomes differ by structurally marginalized
status, particularly by race/ethnicity. Sixth, researchers could assess the
health effects of different types of student-centered, action-oriented
experiential learning programs beyond action civics, including service
learning and youth participatory action research. Finally, the potential
for threshold effects should be tested given that some activities that are
empowering can also present challenges for adolescent health (Ballard
et al., 2018).
4.2. Implications for health promotion, public health policy, and evaluation
Many public health and community psychology scholars argue that
empowerment, especially among those who have historically been and
are currently systematically excluded from civic participation, can
promote better health (Ballard and Ozer, 2016;Ballard and Syme,
2016;Ginwright et al., 2006;Wallerstein, 2002;Zimmerman, 1995).
While further evidence is needed to test how empowerment programs
might produce changes in adolescent health, initial findings from this
study may have two implications for public health promotion inter-
ventions, policy, and evaluation. First, public health interventions to
promote adolescent health could focus on empowering civic engage-
ment that centers civic self-efficacy. These interventions may include
both programming at the school- or community-level, as well as youth-
led policy change to shift the conditions in which they live, work, and
go to school (Tkacik, 2019). Second, interventions meant to build youth
empowerment can measure health outcomes to gather evidence
regarding whether and how empowerment might itself be a public
health intervention for healthy adolescent development. In the context
of current philanthropic enthusiasm for understanding and promoting
civic engagement, the present study offers an opportunity for public
health practitioners and researchers to join this burgeoning interest by
considering connections between civic engagement and health and
wellbeing.
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.pmedr.2019.100968.
Acknowledgements
This study was funded in part by a Robert Wood Johnson
Foundation Health and Society Scholars Program small grants award.
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