From Consultation to Shared Decision‐Making: Youth Engagement Strategies for Promoting School and Community Wellbeing

ABSTRACT BACKGROUND The benefits of youth engagement are well documented. In this paper, we examine youth engagement in America's Promise Alliance's Every School Healthy initiative, a part of the Robert Wood Johnson Foundation's Together for Healthy and Successful Schools Initiative (THSS). METHODS Six community acceleration sites were selected through a competitive grant‐making process. Sites were required to describe youth engagement strategies. A case study design was employed to examine how sites conceptualize youth engagement as well as youth engagement strategies employed across 6 sites. Data sources included observations, team member debriefs, and document review. RESULTS There was variation in how youth engagement and youth voice are conceptualized in educational settings, and readiness for youth engagement. Sites actively solicited and implemented youth engagement resources and strategies. CONCLUSIONS By failing to engage young people, well‐intentioned adults miss important opportunities. Youth engagement presents an exciting opportunity for school leaders, policymakers, and program planners to gain a deeper understanding of the factors that influence individual and community health and wellbeing and, in turn, helps them to develop responsive policies and programs.

health through an illustrative case study of the America's Promise Alliance, Every School Healthy (ESH) initiative. ESH, by design, was intended to center young people employing the Whole School Whole Community Whole Child model (WSCC) 19 and more specifically to promote authentic youth participation. Recognizing the value of young people's perspectives and wisdom, the initiative called for youth voice in decision-making. This paper contributes to the school health literature by describing youth authentic participation as an important strategy for centering youth as part of the WSCC. 19 How participation was conceptualized across local sites is explored. In addition, strategies partnerships can employ to both prepare for meaningful youth participation and assess their readiness for youth-adult partnerships are presented.
A brief background on youth participation and voice is provided followed by an overview of the ESH initiative. The case study methodology employed is outlined and the results are presented and then discussed in the context of the extant literature. We conclude by discussing the limitations as well as the youth participation implications for school health.
Youth participation in schools has been defined as a partnership or collaboration between students and diverse adult stakeholders in the school setting. 13 In the context of youth participation, young people, in this case students, are centered as assets who hold important knowledge and expertise needed to inform decision-making. 20,21 The benefits of centering young people as leaders are many and have been documented for both youth and adults as well as organizations and institutions. 13,18 Youth develop sociopolitical awareness and increases in motivation, civic participation, professional development, skills, and competencies have been observed. 9,13,14,22 Adults meanwhile, see improvement in the quality of their relationships with youth as well as their understanding of youth. 13 Organizations and institutions yield relevant policies and programs and improvements in organizational culture have been seen. 13 Given the benefits of the youth participation and its alignment with the mission and values of America's Promise Alliance (APA), the organization sought to infuse youth voice in the ESH initiative in addition to community stakeholder engagement. Youth participation has been referred in the education literature as student or youth voice. Like youth participation and engagement, it is not consistently defined in practice. For example, it is not merely the collection of youth priorities or opinions by adults. More so, it refers to meaningful engagement in decision-making and goal-setting that leads to changes in school programs and policies that reflect youth priorities. 23 Moreover, like other participatory approaches, initiatives to harness youth voice are rooted in critical pedagogy, and recognize the need for the redistribution of power in school settings, whereby students are driving change and decision-making in partnership with supportive, caring adults. 23 In 2017, with funding from the Robert Wood Johnson Foundation, APA launched ESH. ESH is a multi-year, multisector initiative that was designed to catalyze a national movement advancing school health. The initiative included 3 primary objectives and was grounded in the notion that all schools can be healthy schools. The first objective was focused on local action to advance health equity. The team recognized solutions to pronounced inequities in both health and education demand investment in local knowledge and decision-making. As such, 6 unique school-community partnerships from across the country were selected through a competitive application process. The second objective was to promote bidirectional capacity building and cross-site learning, whereby practitioners from local sites as well as youth and partners, researchers, and school leaders were learning from one another-both informing and adopting best practices. The learning laboratory, as it was developed, was then extended across sites to form a multisite learning community. Finally, broad dissemination was employed to further contextualize and amplify learnings. Real-time sharing occurred with APA partners across the nation through webinar and local dialogues as well as, traditional earned media, listservs, and social media. At the center of this initiative were young people, students. As part of the application, process sites were asked to describe their plans for ensuring youth voice in their efforts. The level of youth engagement at each site was assessed. Using instrumental case study design, we describe the ranking process, and explore how youth engagement was conceptualized across sites. Youth engagement strategies and perceived technical assistance needs related to youth engagement are also examined. What emerged was a story about the promises and challenges associated with youth engagement as well as the need to explore organizational readiness for youth engagement.

METHODS
Instrumental case study design was employed to qualitatively examine how ESH sites conceptualize youth engagement as well as youth engagement strategies employed across 6 sites. 24,25 This social science research is designed for the study of a case in a real-life, present-day setting. 24,25 Data sources included meeting and site observations; team member debriefs as well as document review (Table 1). Procedures associated with each source of data are described in detail below. This study was determined to be non-human subjects research data collected through debriefs were focused on program processes and were not designed to be generalizable but more so to inform our work with the sites.

Procedures
The overall goal of observations was to explore youth engagement strategies as well as conceptualization of youth engagement and perceived technical assistance needs. Observations were planned and conducted by the youth engagement specialist at in-person site visits, in addition, conference calls and remote meetings were observed. Comprehensive notes were taken during and at the culmination of each observation. Observation notes were typed and then analyzed thematically.
Similar to the observations, document review was designed to explore how sites conceptualized youth engagement as well as strategies and technical assistant requests. Project documents included: ESH program descriptions developed by APA, applications and applicant narratives, evaluation reports, and learning agenda reports and grant reports from sites as well as materials released via websites, newsletters, and social media.
Finally, themes were captured from debriefs with APA staff over the course of the project. In addition, debriefs with sites about their youth engagement technical assistance needs were conducted. The data collection and analysis, were continuous and emergent themes were shared with APA staff over the course of the initiative. Similarly, site-specific themes were shared with sites after meetings and observations.

Data Analysis
Two types of data analysis were employed, holistic analysis of the whole case and embedded analysis of specific parts of the case. 24 A chronology of events was examined in addition to key themes to assess the complexity of the case. 24 Each data source was coded inductively, focusing on the data itself without preconceived categories. 26,27 Documents as well as notes from direct observation and debriefs were reviewed and analyzed thematically.
Each document was read multiple times to search for meaningful patterns, 26 and to reflect on questions and reactions to the codes. 28 Themes were discussed with APA staff over the course of the project to ensure consistency in the analytic approach. 29 Codes were developed by labeling and naming selected text and then sorted into possible themes. Relationships were explored between themes across levels and refined to ensure the data within each was cohesive and distinct. 26,27 The larger story within the data was then identified and illustrative examples of engagement, as well as text, was selected to produce a coherent story within and across the identified themes from each data source. 26

RESULTS
How youth engagement was assessed across the site application process is presented accompanied by youth engagement levels. We then highlight the approach to technical assistance strategies used by APA and its core partner organizations as well as youth engagement activities employed across the selected sites. The section concludes with an overview of the challenges of youth engagement as described by sites.
Six acceleration sites were selected from a total of 138 eligible applications from 20 states. Figure 1 illustrates the geographic spread of the applicants. The application responses were coded thematically to explore themes across applicant sites. The most commonly mentioned health and educational challenges cited by the 138 applicants included: poverty; race, racism and racialization; transportation; food insecurity; trauma; obesity; health care access; mental health; and low graduation rates. Applications were scored by a group of reviewers including youth, APA staff, and core partners. Each application was scored by 4 individuals.

Assessing Youth Engagement
Youth engagement was scored separately from the overall application and did not impact the overall scoring. According to project documents, opportunities for youth involvement at both the national and local levels were intentionally built in. The goal was to work with sites to build their capacity for youth engagement throughout the process:  According to project notes, the level of youth engagement was ranked for each application using content analysis and scoring. The content was coded based on the nature of the activities using the levels described in Table 1. These activities were informed by the literature on youth engagement, community research engagement, and community readiness. [30][31][32] The review process involved scanning application content to determine the presence of youth engagement activities described in the criteria outlined in Table 2. Once the numeric value of level associated with each content code was applied, average scores were generated for each application. Final scores were rounded, ranging from 1 to 3. The mean score among sites was 1.9; 38% of sites scored 1; 34% score 2 and 28% scored 3. Of the sites scoring 1, the majority of conceptualized youth voice as surveying youth or exploring youth thinking. However, in these cases, youth were not engaged in decision-making. Adults were interpreting survey results, interviews, and focus group findings as a strategy to harness youth voice. Strategies have been developed to inform youth of activities and to solicit their feedback. Youth have been identified to be part of the process. This might include a youth board. The process to engage young people is not clear. Youth engaged in past and present efforts have been the ''usual suspects'', perhaps the group ''skims off the top''. There is no training or capacity building in place for youth, they are decorative and not necessarily involved in the decision-making process. 3 Groups have procedures in place for recruiting diverse segments of the youth population. Youth are compensated for their role. They are part of the decision-making process. There is team-building training in place for youth and adults designed to enhance communication, coordination, and trust relationships and reduce adultism. Youth are engaged across all aspects of the work, which reflects their priorities.
Of the 138 sites, 16 finalists were selected. Youth engagement scores varied among the 16 sites. The mean score was 1.6. Half of the 16 (50%), scored 1, 37.5% scored 2, and 12.5% scored 3. The APA team and core partners met to narrow the 16 applications to 6. All applicants were discussed and finalists were selected using a consensus decision-making process with the group, that involved dot polling followed by group discussion. The process continued until the pool was narrowed to 6.
The 6 finalists participated in telephone interviews with APA staff. Sites were asked a number of clarification questions associated with their youth engagement plans in an effort to further hone their level. For example, one site was asked: • How will youth be engaged in the decision-making process? • Will [youth] teams only provide feedback or will they be encouraged to lead the way? • How will you ensure those [youth] most impacted will be at the [decision-making]  Interview responses were reviewed and coded using the process previously described. Scores were then adjusted. The 6 selected sites participated in telephone meetings with technical assistance (TA) providers including the youth engagement specialist.

Youth Engagement Technical Assistance
Technical assistance (TA) began with an introduction to youth engagement. Hart's ladder 30 was used to illustrate the spectrum of youth engagement. Youth engagement TA by level can be seen in Table 2. The training was intended to create a shared understanding of youth engagement across sites. As noted in project documents: There are many terms that get used interchangeably when referring to how young people are involved with a program-eg, Youth Engagement, Youth Participation, Youth Voice, Youth Leadership, Youth Empowerment.
[project report] Planning notes indicate that after the initial training individualized plans were developed based on level goals and TA activities outlined in Table 2. For those at level 3, the youth engagement specialist served as a thought partner to help site staff develop strategies to maintain and perhaps expand the site's reach in their communities. For level 2 sites, the goal was to advance their existing work (Table 3).

Some acceleration sites have strong programming in other areas (eg, parent engagement). In this instance the youth engagement consultant [specialist] offers them support to modify the existing materials and curriculum so that it is appropriate for young people and the goals associated therewith. [internal initiative report]
. . . provided a 2-day youth assessment training to young people from 2 high schools as well as a train-the-trainer workshop for site staff to provide these trainings in the future. [external initiative report]  Youth groups are referred to as action groups, ambassadors, councils, and advisors. The structure and function of youth leadership collectives vary across sites. Activities, for example, range from service and peer education to research and policy advocacy. Youth engagement activities are shown in Table 4 illustrate examples of the role youth are playing across each of the 6 sites.

The Challenges of Youth Engagement
Youth engagement was not without its challenges. Sites described a number of impediments to establishing partnerships with young people and engaging them in meaningful ways. These challenges varied but in most cases were structural. Namely, community-level factors such as transportation and organizational factors related to interagency collaboration, resource scale-up, and staffing issues. Individual factors related to behavior, capacity, and life circumstances were also noted. Table 5 provides a snapshot of challenges by theme.

DISCUSSION
Consistent with the literature, we found there is a great deal of variation in how youth voice and youth engagement are conceptualized. 23 Youth engagement spanned the spectrum of Hart's Ladder 30 ; however, this was not always black and white. Engagement levels varied within programs and across activities. Even in cases where sites had youth-initiated activities and programs, there were instances when youth engagement was characterized as tokenism or assigned and informed. 30 This was likely associated with having youth engagement champions in settings with little overall infrastructure for youth engagement. This points to the importance of organizational readiness for youth engagement.
There are multiple elements that comprise an organization. For example, McKinley lays out 7 organizational elements: structure, systems, strategy, skill, staffing, style, and shared values. 33 As such, even organizations with youth engagement embedded in their values, may not have the structures or skills to support authentic youth engagement. 33 External factors to the organization, such as transportation and interorganizational collaborations also served as barriers to readiness for youth engagement. Systematically assessing readiness for youth engagement across organizational elements, as well as planning tools such as Strengths Weaknesses Opportunities and Threats (SWOT) analysis may be important strategies for identifying both external and internal factors that may influence engagement. Overall, sites found Hart's Ladder to be a framework by which to understand engagement and provided clear goals to target. Some sites used the graphic of the Ladder with youth to reflect on where they were with respect to programming. Exploring the rungs of the ladder together, youth and adults evaluated their engagement and were able to collaboratively generate partnership goals as well as strategies for arriving at their desired destination. Similarly, sites benefited from resources and TA activities aimed at examining how adultism operates within systems. Authentic youth engagement calls for adults ready to tackle ideology, systems and structures that proliferate adultism and impede engagement. At the end of the day, this work takes both time and intentionality. Organization readiness assessments may facilitate efforts to engage youth authentically.

Limitations
This work is not without limitation. We present an analysis of observational data and program documents coded by a single reviewer, which may have introduced bias. To compensate for this limitation study, findings have been reviewed by and discussed with APA staff to explore the extent to which finding reflect their lived experience. In addition, the triangulation of multiple data sources has helped to ensure validation. 34 Despite limitations, future studies exploring changes in youth engagement over time through both observational and interview data may provide important insight. Similarly, implementation studies may help to discern practices and strategies most effective in facilitating meaningful youth engagement.

Conclusions
As we strive to implement WSCC strategies for improving outcomes, 19 failing to meaningfully engage young people we, well-intentioned adults, miss important opportunities. Youth engagement presents an exciting prospect for school leaders, policymakers, and program planners to gain a deeper understanding of the factors that influence individual and community health and wellbeing and, in turn, helps them to develop responsive policies and programs. It also helps to cultivate the next generation of leaders. However, getting there requires intentionality and incremental systems change.

IMPLICATIONS FOR SCHOOL HEALTH
Consistent with the literature, we found efforts to create healthy environments for students that fail to meaningfully engage them to run the risk of employing adult-centric approaches. 35 All sites noted, engaging those who are most marginalized in the decisionmaking process can help to ensure the relevance of practices and policies to promote health for everyone. Youth engagement presents a promising strategy for school health education and health promotion efforts. Moreover, youth engagement is associated with positive health and developmental outcomes for youth. 18 In the context of COVID-19, we, adults, need to be particularly mindful of what it means to authentically engage young people. The goal of any social system is to maintain equilibrium. Youth engagement is complicated because it challenges norms within social systems, including schools. Today, systems are in crisis and having to adapt to a new landscape. As such, we run the risk of setbacks if we do not continue to both think and act intentionally about how we collaborate, partner, and engage with youth.