‘Just stuff yourself’: Identifying health‐promotion strategies from the perspectives of adolescent boys from disadvantaged neighbourhoods

Abstract Context The prevalence of overweight and obesity among adolescents has risen dramatically in the last decade, disproportionally affecting adolescents from disadvantaged neighbourhoods. Adolescent boys from disadvantaged neighbourhoods are hard to reach for health promotion. Objective This study aims to understand perceptions of health and health‐promotion strategies among adolescent boys from disadvantaged neighbourhoods in order to identify opportunities for health promotion that are better tailored to their needs. Methods A qualitative, participatory research approach was used. Sixty‐three adolescent boys (aged 12‐18) were recruited from disadvantaged neighbourhoods in Amsterdam, the Netherlands. Semi‐structured interviews, participant observations and co‐creation sessions were conducted. Data were analysed using ethnographic content analysis. Results Boys associate the consumption of large portions of unhealthy foods, especially meat, with masculinity and autonomy. Buying junk food is an important part of their social lives. According to boys, current health promotion does not fit their needs. They stress that entertaining activities, humour and short‐term benefits of healthy choices must be central to health promotion. Some differing interests in health promotion appear between boys, but all boys plead for cheap, satisfying, tasty and healthy food options in their neighbourhoods. Conclusions Adolescent boys from disadvantaged neighbourhoods do see opportunities for health promotion. There is an emerging acceptance of boys taking care of their body and health, but the social norm of unhealthy consumption dominates. For health promoters, it is vital to gear health messages to who the boys are and wish to be, especially in relation to their peers.


| INTRODUC TI ON
The prevalence of overweight and obesity among adolescents poses a serious public health threat worldwide. 1 Around a third of European adolescents are overweight. This is an enormous problem, since 80% of these adolescents are likely to remain overweight for the rest of their lives. 2 Overweight during adolescence is associated with many physical and mental health problems. 3 Adolescents tend to have unhealthier lifestyles (ie high consumption of fast food, sugary beverages and insufficient physical activity) than people from other age groups. 2,4 This means that it is essential to promote a healthy lifestyle during adolescence; however, effective (obesity) interventions for adolescents are scarce. 5 Health promotion is particularly important for adolescents with a low socioeconomic position since overweight and obesity are more prevalent in this group. 6 According to the World Health Organization, 2 socioeconomic position (SEP) accounts for 27% of the risk of overweight European adolescents, including those in the Netherlands. In disadvantaged neighbourhoods (neighbourhoods with on average lower incomes, more unemployment, poverty and lower education level compared to other neighbourhoods) in Amsterdam, 29% of adolescents with a low SEP are overweight or obese, compared to 14% of adolescents with a higher SEP. 7 Several studies have found that the daily diet of adolescents with a low SEP diverges further from dietary recommendations compared to wealthier adolescents. 8,9 Although adolescents with a low SEP are known to be most at risk of becoming overweight, there is a lack of effective interventions. 10 It has been suggested that interventions might even increase the gap between adolescents with a low and high SEP, since these are more effective among the latter. 11 A review of obesity-prevention strategies among low SEP adolescents 10 found no clear evidence for effective strategies.
Besides SEP, gender also affects the likelihood of overweight in adolescents. Girls seem to take advantage of health interventions more often than boys. 11 Although there are strong indications that gender influences lifestyle and health, 12,13 research into adolescent (over)weight often overlooks gender differences. [12][13][14][15] Many studies focus on girls in relation to overweight and interventions to prevent this, as shown in a review by Spencer et al, 16 but there is comparatively little research on adolescent boys. 17,18 Research shows gender differences in health-related behaviour; for instance, girls tend to eat more healthfully than boys-more fruit and vegetables, 2 less junk food 18 and fewer sugary beverages. 19 Girls may eat healthier and show more interest in healthy eating and dieting because they want to be slim and align with Western beauty ideals. 20 According to Stok,21 this is why girls are often more open to joining healthy lifestyle interventions.
Many studies suggest that boys are more physically active than girls. 2 In general, boys are more satisfied with their weight, which they tend to underestimate, 22 but are just as dissatisfied as girls with their body overall. 23 Rowlands and Gough 14 argue that due to 'perfect' masculine bodies in (social) media, there is growing pressure for men to strive for a muscular body. This beauty ideal is complex, as the dominant social expectation is that boys should be muscular, but neither 'fat' nor 'skinny'. 14,16 Taking into consideration that overweight and obesity in adolescents are influenced by both gender and social background, tailored interventions may be most suitable and effective. In order to develop a tailored health promotion, however, there is a need for insights into how these boys perceive their health and lifestyle, as well as what opportunities they see for health promotion. There are multiple arguments for a participatory research approach. First, it is the right of children and adolescents to participate in matters affecting their health and lives as stated in the Convention on the Rights of the Child of the United Nations. Second, participation increases feasibility and validity of research, and eventually the chance of designing successful interventions. 21,22,24 In addition, participation in this type of research contributes to personal development and self-efficacy among young people by prompting them to reflect on their lives and take shared action. 25 The aim of this article was to understand the perceptions of health and health-promotion strategies among adolescent boys from disadvantaged neighbourhoods in Amsterdam, the Netherlands, in order to identify opportunities for health promotion that is better tailored to their needs.

| ME THODS
The article presents a participatory study conducted between The PAR approach is particularly useful in studying and involving hard-to-reach groups, such as adolescents with a low SEP and/ or poor literacy, and emphasizes understanding and listening to the voices of groups that are seldom-heard. 26,27 PAR involves data collection, reflection and taking action to achieve public improvements in close collaboration with the participants. 26,27 PAR is an iterative and flexible process, which makes it possible to make changes in order to adjust to the participants' needs and preferences. 27,28 To gain insights into the perceptions and ideas for health promotion of adolescent boys with a low SEP, we organized several participatory research activities. In total, 63 adolescent boys (aged [12][13][14][15][16][17][18] from two disadvantaged neighbourhoods in Amsterdam joined. The following activities were performed: 1. Nine individual interviews and three duo interviews with boys (n = 15) to gain insight into their perceptions of health and their ideas for health promotion in order to advise health policymakers.

Participant observations (30 hours) at existing social and
health-promotion activities organized by youth welfare centres (cooking evenings) and a school (workshops about food during a lifestyle-themed week), aiming to gain insight into boys' (n = 27) behaviours/attitudes during health-promotion activities.
3. Two preparatory co-creation sessions (n = 11) and six co-creation sessions (n = 10) as part of a small pilot intervention ('The Healthy Lifestyle Project') at a youth welfare centre, designed with boys and local youth workers. Sports and cooking activities were combined in six co-creation sessions over a 3-month period of time, aiming to challenge boys to reflect on their own lifestyles and advise policymakers and other professionals about health promotion that fit their daily realities. All research activities were performed by the first author (EL), who has experience in the field of public health and youth participation. The project was supervised by a senior researcher (CD) who is an expert in PAR/ethnography, especially with children and adolescents.

| Recruitment
Participants were recruited from two secondary schools (practical training level or vocational education secondary school level) and three youth welfare organizations in two disadvantaged neighbourhoods in Amsterdam. These neighbourhoods were selected because they have many low-income families and there is a high rate of overweight and obesity. 7 Besides education level and living in a disadvantaged neighbourhood, age between 12 and 18 was a selection criterion. To ensure inclusiveness, avoid stigmatization 29 and have a diverse group of participants, body size and current lifestyle were not selection criteria.
Generally, recruitment of hard-to-reach groups (including adolescents with a low SEP) is difficult; therefore, multiple recruitment strategies were used to maximize recruitment success 29 :

| Participants
Most participants joined school at the practical training level or vocational education secondary school level and were of a non-Western background. Most seemed to have a healthy weight based on the estimation of the researcher. Table 1 provides a description of the boys participating in interviews and co-creation sessions. It was not possible to collect full background characteristics of boys consulted during observations.

| Semi-structured interviews
Semi-structured interviews took, on average, around 45 minutes.
Topics and sample questions are shown in Table 2. Boys from school were allowed to miss part of their lessons and received a small gift (eg deodorant). Boys from welfare organizations received a voucher for 7.50 Euros as compensation for their time. Interviews were held individually (n = 9) or with a friend (n = 6). The interview design was adjusted to the boys' age and low health literacy. Visual tools and creative exercises (eg responding to provocative statements by means of red/green-coloured cards and placing pictures in order of importance) were used to make it easier for the boys to express themselves. There were always opportunities during the interviews for boys to introduce topics (see Table 3 for themes brought up by the participants). Interviews were recorded. Two boys did not wish to be recorded, so extensive notes were made.

| Co-creation sessions
First, two preparatory co-creation sessions (on average about 1.5 hours) were held to identify health-promotion strategies. In a session at a practical training school, participants (n = 4) were challenged to create leaflets aimed at motivating peers to participate in after-school sports activities. During a session at a youth centre, participants (n = 7) were asked to advise the municipality of Amsterdam about measures to improve the lifestyles of adolescents. Girls joined in these preparatory sessions, but only issues related to boys were used in the preparation of the final co-creation session.
Six final co-creation sessions were held during the 'Healthy Lifestyle project'. Sessions were led by researcher EL together with a youth worker. Although the researcher directed the project, boys were involved as partners, deciding on activities (eg which sports and what to cook) and themes to discuss (eg protein shakes). In total, ten boys joined; some (n = 2) joined all of these sessions, others (n = 8) once or twice. On average, four boys per session joined.
Scripts for the sessions were based on the research questions and input of boys during earlier sessions (see Tables 2 and 3). During every session, advice and ideas were collected by the researcher.

| Data analysis
Interviews were transcribed verbatim. All transcripts, notes and created content from the co-creation sessions were imported into MAXQDA2007 qualitative data-analysis software. Ethnographic content analysis was used to identify and understand the relevance, significance and meaning of the data. 31 Analyses were conducted during and after data collection. The use of a log, repeated review of the data, and seeking feedback from researcher colleagues and involved youth workers on content as well as possible projections and blind spots of the researcher enlarged reflexivity and reduced researcher bias. 32 During the study, data were coded by researchers EL and CD.
First, transcripts and field notes were read to become familiar with the data and code for recurring themes (inductive). Then, codes were discussed by the research team, refined and organized into overarching (sub)themes by looking for emergent patterns and themes.
The codebook was revised and refined during the project until data saturation was reached (no new themes emerged from the analysis). Once data saturation was reached, we stopped recruiting participants. Midway through the analyses, the main outcomes were checked with participants ('Tell me what I may be missing') to deepen our understanding and enhance the credibility and trustworthiness of our findings (Berger, 2015). 32 Table 3 shows the final main themes brought up by the participants.   Table 4. These profiles mainly differ in their interest in sports and the importance of appearance.

| Barriers
Boys experienced several barriers and motives in relation to living healthily, which are summarized in Tables 5 and 6

| Motives
Most motives related to wanting to be attractive to girls. This means not being fat, being muscular and having good skin without pimples.
Boys with visibly (serious) overweight suffered from bullying, which was their main motive for losing weight. George, aged 14, who recently lost a lot of weight, said that he just wanted to be 'normally skinny' before going to high school. Other important motives were the direct effects on mental and physical well-being and improved sports performance. Overweight boys, in particular, wanted to know how to lose weight.

| Opportunities boys see for health promotion
Some boys also mentioned a need for information about the deceitful practices of the food industry (for instance, saying that orange juice is healthy even though it is full of sugar).
Third, all boys emphasized that developing a healthy lifestyle app for adolescents would be a waste of money. Nobody would use it.
Ayoup tried a weight-management app: 'I used it for two days, but then I stopped, it was too boring.' Making an app fun like a game is not recommended, because then the boys would only play for fun and would not learn anything from it. In contrast, many boys thought short (at most 2.5 minutes) vlogs via Facebook and YouTube have potential for health promotion, because this fits their daily activities and does not require much effort from them. These vlogs should be funny and recognizable. The vloggers do not have to be famouslocal role models can work just as well or better than celebrities.
Fourth, the boys often said that it is important to not push healthy choices and use fun activities. Not all boys like sport-related activities; however, all of them enjoyed cooking activities (which were combined with food education and discussion/reflection). Mike says: 'The cooking part is most fun; you learn and you eat together.' Many boys thought that free cooking classes are a suitable way to convey food education. Most essential for boys is that they have a say in the activity, for instance, that they can choose recipes themselves and play their own music. Some boys did not want to join a vegetarian-burger cooking workshop, so there should be an opportunity to cook with meat.

| D ISCUSS I ON
This study is one of the first to consider the perspectives of adolescent boys from disadvantaged neighbourhoods on health promotion and to explicitly ask them for their input on how to provide it. adult men with a low SEP eat more meat 35 and less healthily 9 than men with a high SEP. It is important that health promotion addresses the contradiction between the beauty ideal and strong social norms, since this makes it complicated for boys to eat healthily. Field and colleagues 36 showed that almost 20% of adolescent boys have concerns about muscularity, possibly leading to psychosocial problems.
A possible explanation might be that taking direct action to improve your health is still seen as a 'women's thing,' 14 while there is growing pressure on young men to be perfectly shaped because of the depiction of 'perfect' male bodies in (social) media. 16

| Strengths and limitations
The key strength of this study is the qualitative participatory approach in which we focused on the perspectives of adolescent boys with low SEP. By using this approach, we succeeded in talking to a broad group of boys about a subject that is not of immediate interest to them. Results were used to improve health policy of the municipality of Amsterdam. Engaging this vulnerable group in public health research is important. 10,17,43 However, similar to other studies, 29,[43][44][45] it proved difficult to recruit and retain these boys, so it was important to adjust research activities to their interests and collaborate with youth workers and teachers. The use of different methods (triangulation) increased the validity of the results, but the disadvantage of using different methods and groups/ sites is the relatively low number of participants per group/site. This could make generalization of the results difficult. A few girls joined in some activities, which might have influenced the results.
Another limitation of the study is that the weight of the boys was not measured, but estimated by the researcher. Although this prevented stigmatization, it is possible that some boys were overweight while this was not recognized by the researcher (and vice versa). The fact that the main researcher is a woman had both advantages and disadvantages. Although a male researcher might have found it easier to connect with boys, 46 boys often talk more openly with female researchers because male researchers might induce stereotypical masculine behaviour. 47 This research has important implications for adolescent health promotion. Our findings offer insights into the perspectives of a seldom-heard group and suggest better tailored interventions and directions for future research. For health promotion, it is vital to connect with who the boys are/want to be in relation to their peers.
Boys mentioned that current health promotion, often provided by slender white women, does not correspond to their daily lives. The solution is to listen more to boys and tailor interventions to their specific needs and maybe also to invite more men into this field.

ACK N OWLED G EM ENTS
We would like to thank Carina Pittens for critical feedback on earlier versions of this article. Throughout the study, we approached informed consent as a process; consent (especially anonymity, voluntariness) was frequently discussed with the boys in addition to initial, formal written consent.

E TH I C A L
We emphasized that participation was voluntary and that they had the opportunity to withdraw at any moment without giving any reason. Parents were informed by letter and asked for informed con-

DATA AVA I L A B I L I T Y
The data that support the findings of this study are available from the corresponding author upon reasonable request.