Implementation contextual factors related to youth advocacy for healthy eating and active living

Implementation contextual factors related to youth advocacy for healthy eating and active living Abstract Healthy eating and active living are critical to youth health and development. Youth advocacy can improve health-related behaviors and environments by empowering youth to act as change agents in their community. This mixed-method study examined implementation contextual factors in relation to implementation success in high school youth advocacy projects targeting healthy eating and active living. Semi-structured interviews were conducted with key informants from each of the 21 participating youth groups. Interviews gathered information on implementation processes, barriers and facilitators, and Implementation Outcomes (Progress, Penetration, Health Impact, Sustainability, and an overall Implementation Success Composite). Interview responses were coded using the Consolidated Framework for Implementation Research (CFIR). Each identified construct was rated for its impact on implementation and ratings were tested for their association with the Implementation Outcomes. Cosmopolitanism (leveraging connections within the community; rated in 20 groups) and Internal Intervention Source (rated in 9 groups) showed consistent moderate/large associations with the Implementation Outcomes and Implementation Success Composite. Other moderate/large associations were outcome specific, with Student Group Leader Engagement, External Change Agents, and Student and Community Needs and Resources also being associated with the Implementation Success Composite. Implementation contextual factors, particularly community-connectedness, group functioning, and internal project idea development are important factors for implementing youth advocacy projects that will reach large numbers of people and be likely to lead to sustained health improvements. Implementation strategies that target these factors need to be developed and tested in partnership with community organizations to maximize success of youth advocacy efforts. Implications Practice: Supporting project selection autonomy, connectedness with community organizations, and group functioning can improve effectiveness of youth advocacy programs to support healthy eating and active living. Policy: Youth have an important voice for affecting local-level policy changes, but evidence-based implementation strategies are needed to improve effectiveness of youth advocacy efforts. Research: Specific implementation strategies that target participant autonomy, group function, and community-connectedness need to be developed and tested for increasing effectiveness of youth advocacy programs. INTRODUCTION Rates of overweight/obesity in youth have been increasing over the past several decades [1]. Although some evidence suggests stabilization, current rates indicate that 20.6% of adolescents of ages 12–19 are obese and 16.2% are overweight [2], and overweight/obesity and related problems are shown to continue into adulthood [3, 4]. Obesity in youth is associated with poor mental health outcomes, such as decreased quality of life and self-esteem, and adverse physical health outcomes, such as type 2 diabetes and cardiovascular disease [5, 6]. Overweight/obesity is attributed to longstanding unhealthy eating and physical inactivity [6]. About 40% of children and adolescents’ daily caloric intake comes from empty calories (e.g., added sugars and solid fats) [7]. About 8% of adolescents meet the 60-min/day physical activity guideline based on objective data, and gender and racial/ethnic disparities exist [8–10]. Ecological models suggest that healthy eating and active living in youth are influenced by individual- (e.g., motivation, skills), interpersonal- (e.g., social support), and environmental-level (e.g., access to health foods and safe places for walking) factors [11]. Leading public health organizations recommend interventions based on ecological models [12–14]. Environmental strategies are often targeted because they can reach large portions of the population and remove barriers to healthy eating and active living. One strategy that has promise for improving healthy eating and active living is advocacy. Advocacy generally refers to the process of increasing support for a cause or policy [15] and has been targeted in “youth advocacy” programs by training and engaging youth to advocate for improved health within a community [16]. Youth advocacy has been an effective intervention for health promotion, including for reducing tobacco use [17] and improving environments to foster healthy eating and active living [18–20]. There are many benefits when youth serve as advocates, such as that decision makers may be more open to requests made by youth, the process can strengthen youth development (e.g., mastery, knowledge, character, self-esteem), the outcomes can create lasting changes in the community, and the participants can become sustained advocates for a lifetime [16]. Youth advocacy programs targeting health behavior change are gaining popularity and being implemented by community organizations across the U.S. However, little evidence exists regarding best practices for and barriers and facilitators to implementation (i.e., implementation contextual factors). These factors are important to understand because they can be targeted to promote positive program outcomes and guide future efforts [21]. Thus, the purpose of this study was to evaluate implementation contextual factors in relation to implementation outcomes/success in youth advocacy projects that were embedded in and facilitated by an existing community- based leadership program in high schools. METHODS Evaluation participants Evaluation participants were key informants from 21 high school-based youth advocacy groups/projects, facilitated by a community-based organization. One youth key informant from each of the 21 youth groups was identified by the community-based organization based on his/her leadership role in the group’s project. About 57% of the key informants were the leader or coleader of their group based on group elections. Another group member was selected as the key informant when the group leader was not available or not deemed as the best person to participate in the interview by the community-based organization. The 21 evaluation participants were from 16 high schools and represented groups of 2–30 students (Median = 10) at the beginning of the program and 2–13 students (Median = 5) at the end of the program, due to drop outs, differences in interest levels across schools, and students from some schools splitting into multiple groups. Approximately 90% of the interview participants were girls. The community-based organization requested demographic information from all group members in an online survey (115/224 students across the 21 groups responded): 74% were girls, 39.1% were Hispanic nonWhite, 35.7% were Black, 15.7% were nonHispanic White, 3.5% were Asian, and 6.1% were multiracial. Free or reduced-price lunch eligibility at the attending schools ranged from 20% to 100% (M = 77.2%; SD = 21.5%) [22, 23]. The study was approved by the sponsoring institution’s human subject’s protection committee. Description of program The youth advocacy projects were embedded in an ongoing youth leadership program led by a community-based organization. The broad objective of the leadership program was to foster leadership skills and community involvement. The 10-month leadership program “blends academically, socially, economically, racially and geographically diverse students in learning the importance of earning an education and taking personal and social responsibility. Program content includes: college and career exploration, local and state government, media, law, entrepreneurship, finance, personal and leadership development, the arts and social service” [24]. Juniors and seniors from 16 high schools in the Kansas City metropolitan area were eligible to participate in the leadership program during the 2015–2016 school year. Together, the 21 groups attended three trainings specific to youth advocacy in Fall 2015. The trainings were developed specifically for this program and led by staff from a community health initiative sponsored by the local children’s hospital. The trainings focused on educating youth on healthy eating and active living, the role of the school and community environment in health, framing and communicating the advocacy message to decision makers (led by a marketing organization), and the 12345 Fit-Tastic! message (1 hr or more of physical activity, 2 hr maximum of screen time, three servings of low or nonfat milk or yogurt, four servings of water not sugary drinks, and five servings or more of fruits and vegetables) [25]. Two videos of successful youth advocacy projects from across the USA were presented as examples, one involved a school garden and the other involved creation of a new trail. Each group of youth was required to develop and implement a youth advocacy project at their high school during the Spring 2016 semester targeting healthy eating and/or active living and incorporate the 12345 Fit-Tastic! message where appropriate. Each group received $1,000 USD to support their project and ongoing technical assistance around the planning and facilitation of projects from one of two staff members from the community-based organization. Data collection Semi-structured interviews were conducted with key informants at the end of or directly following the Spring 2016 semester. Each interview lasted approximately 25 min (range = 17–47 min) and was completed by one of two interviewers in-person or by phone. The interview script included broad open-ended questions covering the five domains of the Consolidated Framework for Implementation Research (CFIR): Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Process [26]. Descriptions of the CFIR framework and constructs can be found on the CFIR website [27]. CFIR is widely used to evaluate contextual factors that support or inhibit effective implementation (e.g., [28]). The interview script also captured Implementation Outcomes including Progress, Penetration, Health Impact, and Sustainability [29]. Interviews were audio recorded and transcribed verbatim. Interview coding The CFIR codebook available through the CFIR Technical Assistance Website [30] was used to facilitate coding of CFIR constructs, with slight adaptations made to the codebook to create specificity to the intervention. Of the 39 constructs captured across the five domains of CFIR, 24 were selected for inclusion in the present study based on their perceived importance to youth advocacy and their ability to be captured from the key informant interviews. Constructs such as Evidence Strength and Quality, Trialability, and Design Quality and Packaging were excluded because we did not expect to observe variation in these constructs across youth groups. Other constructs (e.g., Knowledge and Beliefs) were not captured by the broad questions used in the interview and thus were not coded. Definitions and coding criteria for the Implementation Outcomes are presented in Table 1, and definitions and coding criteria for the CFIR-related Implementation Contextual Factors are presented in Table 2. Table 1 | Implementation outcome descriptions and mean ratings by key informants (N = 21) Implementation Outcomes  Brief description  Rating M(SD)  Progress  Higher ratings were given to groups that successfully accomplished/completed their project goals.  2.05(1.20)  Penetration  Higher ratings given to projects that reached a larger number of people.  0.62(0.67)  Health Impact  Higher ratings were given to projects that were more likely to impact health.  1.86(0.79)  Sustainability  Higher ratings were given to projects that were more likely to have sustained impacts.  .19(.40)  Implementation Outcome Composite  Sum of Penetration, Health Impact, and Sustainability.  2.67(1.20)  Implementation Outcomes  Brief description  Rating M(SD)  Progress  Higher ratings were given to groups that successfully accomplished/completed their project goals.  2.05(1.20)  Penetration  Higher ratings given to projects that reached a larger number of people.  0.62(0.67)  Health Impact  Higher ratings were given to projects that were more likely to impact health.  1.86(0.79)  Sustainability  Higher ratings were given to projects that were more likely to have sustained impacts.  .19(.40)  Implementation Outcome Composite  Sum of Penetration, Health Impact, and Sustainability.  2.67(1.20)  Ratings were on a 0–3 scale, with the exception of Sustainability which was rated as yes = 1, no = 0. Composite is a sum score which excludes Progress (possible range = 0–7). View Large Table 1 | Implementation outcome descriptions and mean ratings by key informants (N = 21) Implementation Outcomes  Brief description  Rating M(SD)  Progress  Higher ratings were given to groups that successfully accomplished/completed their project goals.  2.05(1.20)  Penetration  Higher ratings given to projects that reached a larger number of people.  0.62(0.67)  Health Impact  Higher ratings were given to projects that were more likely to impact health.  1.86(0.79)  Sustainability  Higher ratings were given to projects that were more likely to have sustained impacts.  .19(.40)  Implementation Outcome Composite  Sum of Penetration, Health Impact, and Sustainability.  2.67(1.20)  Implementation Outcomes  Brief description  Rating M(SD)  Progress  Higher ratings were given to groups that successfully accomplished/completed their project goals.  2.05(1.20)  Penetration  Higher ratings given to projects that reached a larger number of people.  0.62(0.67)  Health Impact  Higher ratings were given to projects that were more likely to impact health.  1.86(0.79)  Sustainability  Higher ratings were given to projects that were more likely to have sustained impacts.  .19(.40)  Implementation Outcome Composite  Sum of Penetration, Health Impact, and Sustainability.  2.67(1.20)  Ratings were on a 0–3 scale, with the exception of Sustainability which was rated as yes = 1, no = 0. Composite is a sum score which excludes Progress (possible range = 0–7). View Large Table 2 | Description, mean ratings, and frequency of constructs reported by key informants (N = 21) CFIR constructs  Higher scoring groups had the following characteristics  Rating M(SD)  N  I. Intervention Characteristics  Intervention Source  Project idea developed within group rather than based on external influence.  +0.89(0.33)  9  Relative Advantage  Project improved upon existing programs/facilities in the school and/ or community.  Missing  4  Perceived Complexity  Less reported complexity and difficulty during implementation.  −1.08(0.29)  12  Cost  Stayed within budget and/or fund raised through grants or donations.  +0.42(1.16)  12  II. Outer Setting  Student and Community Needs and Resources  Considered the needs of the students and/or community members when planning the project.  +1.20(0.41)  20  Cosmopolitanism  Leveraged more external connections in the community.  +0.25(1.07)  20  Peer Pressure  Engaged in competition with other groups (within or outside of the school).  Missing  3  III. Inner Setting  Group Characteristics  Worked as a cohesive group to accomplish project goals.  −0.29(1.35)  21  Networks and Communications   Within the school  Had productive, open communication with school staff and teachers.  +0.67(0.91)  21   Within the youth group  Communicated well, met often, and had strategies in place for ongoing communication.  +0.38(1.20)  21   Within the leadership program  Reported beneficial communication and relationships with the leadership program staff.  +0.88(0.81)  16  Implementation climate   Tension for change  Leveraged an existing tension within the school to support change.  +1.08(0.28)  13   Compatibility  Project appeared to fit with the setting and elicited less pushback.  +1.13(0.35)  8   Priority  Project was prioritized highly by the school.  Missing  2  Readiness for implementation     Leadership engagement  Leadership program staff played a large role in facilitating implementation.  +1.06(0.64)  18   Available resources  Group had access to necessary resources.  +1.00(0.65)  15  IV. Characteristics of Individuals  Identification with Project  Interviewees felt positively about the project.  +0.71(1.06)  21  V. Process  Planning  Group included pre-implementation planning and refinements as needed.  +0.29(1.01)  21  Engaging   Student Group Leader  Group leader was engaged and assigned roles to other group members based on strengths.  +0.25(1.06)  12   Inner Stakeholders  Group had greater involvement from school staff.  +0.76(0.83)  21   External Change Agents  (outer stakeholders)  Group leveraged external resources and support.  +0.60(1.14)  20  Executing  Group followed a clear plan of action to accomplish their project.  −0.27(1.16)  15  Reflecting and Evaluating  Group used feedback from stakeholders to refine their efforts.  +0.48(1.08)  21  CFIR constructs  Higher scoring groups had the following characteristics  Rating M(SD)  N  I. Intervention Characteristics  Intervention Source  Project idea developed within group rather than based on external influence.  +0.89(0.33)  9  Relative Advantage  Project improved upon existing programs/facilities in the school and/ or community.  Missing  4  Perceived Complexity  Less reported complexity and difficulty during implementation.  −1.08(0.29)  12  Cost  Stayed within budget and/or fund raised through grants or donations.  +0.42(1.16)  12  II. Outer Setting  Student and Community Needs and Resources  Considered the needs of the students and/or community members when planning the project.  +1.20(0.41)  20  Cosmopolitanism  Leveraged more external connections in the community.  +0.25(1.07)  20  Peer Pressure  Engaged in competition with other groups (within or outside of the school).  Missing  3  III. Inner Setting  Group Characteristics  Worked as a cohesive group to accomplish project goals.  −0.29(1.35)  21  Networks and Communications   Within the school  Had productive, open communication with school staff and teachers.  +0.67(0.91)  21   Within the youth group  Communicated well, met often, and had strategies in place for ongoing communication.  +0.38(1.20)  21   Within the leadership program  Reported beneficial communication and relationships with the leadership program staff.  +0.88(0.81)  16  Implementation climate   Tension for change  Leveraged an existing tension within the school to support change.  +1.08(0.28)  13   Compatibility  Project appeared to fit with the setting and elicited less pushback.  +1.13(0.35)  8   Priority  Project was prioritized highly by the school.  Missing  2  Readiness for implementation     Leadership engagement  Leadership program staff played a large role in facilitating implementation.  +1.06(0.64)  18   Available resources  Group had access to necessary resources.  +1.00(0.65)  15  IV. Characteristics of Individuals  Identification with Project  Interviewees felt positively about the project.  +0.71(1.06)  21  V. Process  Planning  Group included pre-implementation planning and refinements as needed.  +0.29(1.01)  21  Engaging   Student Group Leader  Group leader was engaged and assigned roles to other group members based on strengths.  +0.25(1.06)  12   Inner Stakeholders  Group had greater involvement from school staff.  +0.76(0.83)  21   External Change Agents  (outer stakeholders)  Group leveraged external resources and support.  +0.60(1.14)  20  Executing  Group followed a clear plan of action to accomplish their project.  −0.27(1.16)  15  Reflecting and Evaluating  Group used feedback from stakeholders to refine their efforts.  +0.48(1.08)  21  Ratings of −2 through +2 were possible. Valence (+,−) indicated whether or not the construct helped or hindered the implementation process. Strength indicated how much the construct helped or hindered the implementation process. View Large Table 2 | Description, mean ratings, and frequency of constructs reported by key informants (N = 21) CFIR constructs  Higher scoring groups had the following characteristics  Rating M(SD)  N  I. Intervention Characteristics  Intervention Source  Project idea developed within group rather than based on external influence.  +0.89(0.33)  9  Relative Advantage  Project improved upon existing programs/facilities in the school and/ or community.  Missing  4  Perceived Complexity  Less reported complexity and difficulty during implementation.  −1.08(0.29)  12  Cost  Stayed within budget and/or fund raised through grants or donations.  +0.42(1.16)  12  II. Outer Setting  Student and Community Needs and Resources  Considered the needs of the students and/or community members when planning the project.  +1.20(0.41)  20  Cosmopolitanism  Leveraged more external connections in the community.  +0.25(1.07)  20  Peer Pressure  Engaged in competition with other groups (within or outside of the school).  Missing  3  III. Inner Setting  Group Characteristics  Worked as a cohesive group to accomplish project goals.  −0.29(1.35)  21  Networks and Communications   Within the school  Had productive, open communication with school staff and teachers.  +0.67(0.91)  21   Within the youth group  Communicated well, met often, and had strategies in place for ongoing communication.  +0.38(1.20)  21   Within the leadership program  Reported beneficial communication and relationships with the leadership program staff.  +0.88(0.81)  16  Implementation climate   Tension for change  Leveraged an existing tension within the school to support change.  +1.08(0.28)  13   Compatibility  Project appeared to fit with the setting and elicited less pushback.  +1.13(0.35)  8   Priority  Project was prioritized highly by the school.  Missing  2  Readiness for implementation     Leadership engagement  Leadership program staff played a large role in facilitating implementation.  +1.06(0.64)  18   Available resources  Group had access to necessary resources.  +1.00(0.65)  15  IV. Characteristics of Individuals  Identification with Project  Interviewees felt positively about the project.  +0.71(1.06)  21  V. Process  Planning  Group included pre-implementation planning and refinements as needed.  +0.29(1.01)  21  Engaging   Student Group Leader  Group leader was engaged and assigned roles to other group members based on strengths.  +0.25(1.06)  12   Inner Stakeholders  Group had greater involvement from school staff.  +0.76(0.83)  21   External Change Agents  (outer stakeholders)  Group leveraged external resources and support.  +0.60(1.14)  20  Executing  Group followed a clear plan of action to accomplish their project.  −0.27(1.16)  15  Reflecting and Evaluating  Group used feedback from stakeholders to refine their efforts.  +0.48(1.08)  21  CFIR constructs  Higher scoring groups had the following characteristics  Rating M(SD)  N  I. Intervention Characteristics  Intervention Source  Project idea developed within group rather than based on external influence.  +0.89(0.33)  9  Relative Advantage  Project improved upon existing programs/facilities in the school and/ or community.  Missing  4  Perceived Complexity  Less reported complexity and difficulty during implementation.  −1.08(0.29)  12  Cost  Stayed within budget and/or fund raised through grants or donations.  +0.42(1.16)  12  II. Outer Setting  Student and Community Needs and Resources  Considered the needs of the students and/or community members when planning the project.  +1.20(0.41)  20  Cosmopolitanism  Leveraged more external connections in the community.  +0.25(1.07)  20  Peer Pressure  Engaged in competition with other groups (within or outside of the school).  Missing  3  III. Inner Setting  Group Characteristics  Worked as a cohesive group to accomplish project goals.  −0.29(1.35)  21  Networks and Communications   Within the school  Had productive, open communication with school staff and teachers.  +0.67(0.91)  21   Within the youth group  Communicated well, met often, and had strategies in place for ongoing communication.  +0.38(1.20)  21   Within the leadership program  Reported beneficial communication and relationships with the leadership program staff.  +0.88(0.81)  16  Implementation climate   Tension for change  Leveraged an existing tension within the school to support change.  +1.08(0.28)  13   Compatibility  Project appeared to fit with the setting and elicited less pushback.  +1.13(0.35)  8   Priority  Project was prioritized highly by the school.  Missing  2  Readiness for implementation     Leadership engagement  Leadership program staff played a large role in facilitating implementation.  +1.06(0.64)  18   Available resources  Group had access to necessary resources.  +1.00(0.65)  15  IV. Characteristics of Individuals  Identification with Project  Interviewees felt positively about the project.  +0.71(1.06)  21  V. Process  Planning  Group included pre-implementation planning and refinements as needed.  +0.29(1.01)  21  Engaging   Student Group Leader  Group leader was engaged and assigned roles to other group members based on strengths.  +0.25(1.06)  12   Inner Stakeholders  Group had greater involvement from school staff.  +0.76(0.83)  21   External Change Agents  (outer stakeholders)  Group leveraged external resources and support.  +0.60(1.14)  20  Executing  Group followed a clear plan of action to accomplish their project.  −0.27(1.16)  15  Reflecting and Evaluating  Group used feedback from stakeholders to refine their efforts.  +0.48(1.08)  21  Ratings of −2 through +2 were possible. Valence (+,−) indicated whether or not the construct helped or hindered the implementation process. Strength indicated how much the construct helped or hindered the implementation process. View Large Two trained staff independently coded each transcribed interview using QSR International’s NVivo 11 Software [31]. The CFIR rating guide [32] was used to rate the valance and impact of each construct, with scores ranging from −2 to +2. Valence indicated whether the coded material functioned as a facilitator (+) or barrier (−) to implementation. The magnitude of the score (1 or 2) indicated the extent to which the construct helped or hindered implementation. Higher positive scores indicated that the construct functioned as a facilitator. A score of zero indicated that the construct was present but did not appear to have an impact on project implementation. If the construct was not ratable in at least eight interviews, it was considered to be missing. The Implementation Outcomes Progress, Penetration, and Health Impact were rated using a 0–3 scale, with higher scores indicating greater presence of that outcome. The Implementation Outcome Sustainability was rated as 0 (no) or 1 (yes) due to low variability. Three Implementation Outcomes (Penetration, Health Impact, and Sustainability) were combined into an overall Implementation Success Composite score by taking a sum of the three items (possible range = 0–7). Progress was excluded to prevent unfairly biasing against more challenging environmental projects. The two coders compared all ratings and reconciled discrepancies through discussion. In cases where an agreement could not be reached, a third adjudicator determined the final rating. Data analysis Means and standard deviations were calculated for the Implementation Contextual Factors (i.e., CFIR constructs) and Implementation Outcomes. Next, Pearson correlations were calculated to quantitatively assess the relation of each Implementation Contextual Factor to each Implementation Outcome and overall Implementation Success. Correlations of .30 to .49 were considered moderate, and correlations ≥.50 were considered large, based on criteria developed by Cohen [33]. Constructs with correlations <.30 were interpreted as being of less importance. The analyses were conducted in SPSS version 23. RESULTS Of the 21 groups, 5 targeted a built environment improvement in or around their school (outdoor classroom; garden; sport facility; lighting for sport facility; changes to school library), 2 targeted an ongoing outreach effort (e.g., teaching younger students about health), and 14 targeted a one-time event (e.g., health fair, fitness event). Table 1 shows the mean and standard deviation rating for each Implementation Outcome and the Implementation Outcome Composite. For Progress, completed projects received higher ratings, projects where groups made substantial progress but had not yet completed the project (e.g., some environmental projects) received moderate-to-high ratings, and projects that made little traction received lower ratings. For Penetration, projects that targeted health-related environmental improvements that would affect a large number of people received higher ratings, whereas one-time and outreach events received lower ratings, based on the number of attendees. For Health Impact, environmental improvements were generally rated as having the highest potential to impact health, with ratings of events being lower and distinguished by the level at which health was incorporated. For Sustainability, environmental projects received a yes and events received a no because none had plans for being sustained. Table 2 shows the number of interviews in which each CFIR construct was captured and the mean and standard deviation rating for each construct. The constructs that most consistently emerged across the groups were Group Characteristics (N = 21), Networks and Communication Within the School (N = 21) and Within the Group (N = 21), Leader Identification with Project (N = 21), Planning (N = 21), Engaging Inner Stakeholders (N = 21), Reflecting and Evaluating (N = 21), Student and Community Needs and Resources (N = 20), Cosmopolitanism, defined as leveraging connections within the community (N = 20), External Change Agents (N = 20), and Leadership Engagement (N = 18). Student and Community Needs and Resources (Mean = 1.20, SD = 0.41), Compatibility (Mean = 1.13, SD = 0.35), Tension for Change (Mean = 1.08, SD = 0.28), and Leadership Engagement (Mean = 1.06, SD = 0.64) had the highest ratings with regards to supporting implementation. Perceived Complexity (Mean = −1.08, SD = 0.29), Group Characteristics (Mean = −0.29, SD = 1.35), and Executing (Mean = −0.27, SD = 1.16) had the lowest ratings. Associations between the CFIR constructs and Implementation Outcomes are presented in Table 3. Progress (7 associations in the expected direction) was positively related to Group Characteristics, Networks and Communication Within the Youth Group, Reflecting and Evaluating, Perceived Complexity, Executing, Networks and Communication Within the School, and Inner Stakeholders (r = .31–.56). Penetration (six associations in the expected direction) was positively related to Compatibility, Student Group Leader Engagement, External Change Agents, Cosmopolitanism, and Intervention Source (r = .40–.75), and negatively related to the Number of Dropouts and Planning (r = −.52 and −.35, respectively). Health Impact (three associations in the expected direction) was positively related to Intervention Source, Student and Community Needs and Resources, and Cosmopolitanism (r = .35–.43), and negatively related to Planning (r = −.57). Sustainability (four associations in the expected direction) was positively related to Group Characteristics, Executing, Cosmopolitanism, and Reflecting and Evaluating (r = .36–.47), and negatively related to Available Resources and Intervention Source (r = −.53 and −.50, respectively). Table 3 | Relationship between CFIR constructs and implementation outcomes (Pearson r)   Implementation outcomes  CFIR constructs  Progress  Penetration  Health Impact  Sustainability  Composite  I. Intervention Characteristics  Intervention Source (Internal)  −.23  .40b  .43b  −.50a  .30b  Relative Advantage  Missing  Missing  Missing  Missing  Missing  Perceived Complexity  .36b  −.07  .09  .14  .05  Cost  .15  −.04  −.19  −.11  −.17  II. Outer Setting  Student and Community Needs and Resources  .16  .27  .41b  .06  .44b  Cosmopolitanism  .14  .43b  .35b  .36b  .59a  Peer Pressure  Missing  Missing  Missing  Missing  Missing  III. Inner Setting  Group Characteristics  .56a  .21  −.09  .47b  .22  Number of dropouts  −.21  −.52a  −.04  −.02  −.31b  Group size  .26  .29  .23  .25  .40b  Networks and Communications   Within the school  .33b  −.14  −.21  .18  −.15   Within the youth group  .51a  .19  .01  .26  .20   Within the leadership program  .07  .26  .09  .28  .29  Implementation climate   Tension for Change  .26  .10  −.07  −.16  −.04   Compatibility  −.05  .75a  −.06  −.22  .27   Priority  Missing  Missing  Missing  Missing  Missing  Readiness for implementation   Leadership Engagement  −.11  .18  .23  .20  .31b   Available Resources  −.13  .15  .27  −.53a  .09  IV. Characteristics of Individuals  Identification with Project  .09  .12  .19  .25  .27  V. Process  Planning  .20  −.35b  −.57a  .11  −.54a  Engaging   Student group leader  .13  .55a  .23  .11  .63a   Inner (school) Stakeholders  .31b  −.26  .10  .29  .02   External Change Agents (outer stakeholders)  .18  .53a  .27  .18  .53a  Executing  .34b  .21  −.02  .41b  .26  Reflecting and Evaluating  .41b  .06  .14  .36b  .25    Implementation outcomes  CFIR constructs  Progress  Penetration  Health Impact  Sustainability  Composite  I. Intervention Characteristics  Intervention Source (Internal)  −.23  .40b  .43b  −.50a  .30b  Relative Advantage  Missing  Missing  Missing  Missing  Missing  Perceived Complexity  .36b  −.07  .09  .14  .05  Cost  .15  −.04  −.19  −.11  −.17  II. Outer Setting  Student and Community Needs and Resources  .16  .27  .41b  .06  .44b  Cosmopolitanism  .14  .43b  .35b  .36b  .59a  Peer Pressure  Missing  Missing  Missing  Missing  Missing  III. Inner Setting  Group Characteristics  .56a  .21  −.09  .47b  .22  Number of dropouts  −.21  −.52a  −.04  −.02  −.31b  Group size  .26  .29  .23  .25  .40b  Networks and Communications   Within the school  .33b  −.14  −.21  .18  −.15   Within the youth group  .51a  .19  .01  .26  .20   Within the leadership program  .07  .26  .09  .28  .29  Implementation climate   Tension for Change  .26  .10  −.07  −.16  −.04   Compatibility  −.05  .75a  −.06  −.22  .27   Priority  Missing  Missing  Missing  Missing  Missing  Readiness for implementation   Leadership Engagement  −.11  .18  .23  .20  .31b   Available Resources  −.13  .15  .27  −.53a  .09  IV. Characteristics of Individuals  Identification with Project  .09  .12  .19  .25  .27  V. Process  Planning  .20  −.35b  −.57a  .11  −.54a  Engaging   Student group leader  .13  .55a  .23  .11  .63a   Inner (school) Stakeholders  .31b  −.26  .10  .29  .02   External Change Agents (outer stakeholders)  .18  .53a  .27  .18  .53a  Executing  .34b  .21  −.02  .41b  .26  Reflecting and Evaluating  .41b  .06  .14  .36b  .25  alarge correlation (r ≥ .50); bmoderate correlation (r = .30–.49); Composite = sum score including Penetration, Sustainability, and Health Impact. View Large Table 3 | Relationship between CFIR constructs and implementation outcomes (Pearson r)   Implementation outcomes  CFIR constructs  Progress  Penetration  Health Impact  Sustainability  Composite  I. Intervention Characteristics  Intervention Source (Internal)  −.23  .40b  .43b  −.50a  .30b  Relative Advantage  Missing  Missing  Missing  Missing  Missing  Perceived Complexity  .36b  −.07  .09  .14  .05  Cost  .15  −.04  −.19  −.11  −.17  II. Outer Setting  Student and Community Needs and Resources  .16  .27  .41b  .06  .44b  Cosmopolitanism  .14  .43b  .35b  .36b  .59a  Peer Pressure  Missing  Missing  Missing  Missing  Missing  III. Inner Setting  Group Characteristics  .56a  .21  −.09  .47b  .22  Number of dropouts  −.21  −.52a  −.04  −.02  −.31b  Group size  .26  .29  .23  .25  .40b  Networks and Communications   Within the school  .33b  −.14  −.21  .18  −.15   Within the youth group  .51a  .19  .01  .26  .20   Within the leadership program  .07  .26  .09  .28  .29  Implementation climate   Tension for Change  .26  .10  −.07  −.16  −.04   Compatibility  −.05  .75a  −.06  −.22  .27   Priority  Missing  Missing  Missing  Missing  Missing  Readiness for implementation   Leadership Engagement  −.11  .18  .23  .20  .31b   Available Resources  −.13  .15  .27  −.53a  .09  IV. Characteristics of Individuals  Identification with Project  .09  .12  .19  .25  .27  V. Process  Planning  .20  −.35b  −.57a  .11  −.54a  Engaging   Student group leader  .13  .55a  .23  .11  .63a   Inner (school) Stakeholders  .31b  −.26  .10  .29  .02   External Change Agents (outer stakeholders)  .18  .53a  .27  .18  .53a  Executing  .34b  .21  −.02  .41b  .26  Reflecting and Evaluating  .41b  .06  .14  .36b  .25    Implementation outcomes  CFIR constructs  Progress  Penetration  Health Impact  Sustainability  Composite  I. Intervention Characteristics  Intervention Source (Internal)  −.23  .40b  .43b  −.50a  .30b  Relative Advantage  Missing  Missing  Missing  Missing  Missing  Perceived Complexity  .36b  −.07  .09  .14  .05  Cost  .15  −.04  −.19  −.11  −.17  II. Outer Setting  Student and Community Needs and Resources  .16  .27  .41b  .06  .44b  Cosmopolitanism  .14  .43b  .35b  .36b  .59a  Peer Pressure  Missing  Missing  Missing  Missing  Missing  III. Inner Setting  Group Characteristics  .56a  .21  −.09  .47b  .22  Number of dropouts  −.21  −.52a  −.04  −.02  −.31b  Group size  .26  .29  .23  .25  .40b  Networks and Communications   Within the school  .33b  −.14  −.21  .18  −.15   Within the youth group  .51a  .19  .01  .26  .20   Within the leadership program  .07  .26  .09  .28  .29  Implementation climate   Tension for Change  .26  .10  −.07  −.16  −.04   Compatibility  −.05  .75a  −.06  −.22  .27   Priority  Missing  Missing  Missing  Missing  Missing  Readiness for implementation   Leadership Engagement  −.11  .18  .23  .20  .31b   Available Resources  −.13  .15  .27  −.53a  .09  IV. Characteristics of Individuals  Identification with Project  .09  .12  .19  .25  .27  V. Process  Planning  .20  −.35b  −.57a  .11  −.54a  Engaging   Student group leader  .13  .55a  .23  .11  .63a   Inner (school) Stakeholders  .31b  −.26  .10  .29  .02   External Change Agents (outer stakeholders)  .18  .53a  .27  .18  .53a  Executing  .34b  .21  −.02  .41b  .26  Reflecting and Evaluating  .41b  .06  .14  .36b  .25  alarge correlation (r ≥ .50); bmoderate correlation (r = .30–.49); Composite = sum score including Penetration, Sustainability, and Health Impact. View Large The factors that were positively related to the Implementation Success Composite (eight in the expected direction) were Student Group Leader Engagement, Cosmopolitanism, External Change Agents, Student and Community Needs and Resources, Group Size, Leadership Engagement, and Intervention Source (r = .30–.63). The factors that were negatively related to the Implementation Success Composite score were Planning and Number of Dropouts (r = −.54 and −.31, respectively). Table 4 presents summaries and example responses from the qualitative interviews for CFIR constructs that were positively associated with ≥2 Implementation Outcomes, and Table 5 presents two case examples showing the impacts of constructs related to group function and community-connectedness on implementation success. This information provides more detail on how the constructs manifested in the advocacy projects and how they led to or inhibited success. Table 4 | Summary and example interviewee responses for key constructs identified CFIR construct  Summary and example response(s)  Intervention Source (internal)  Summary: Groups with high scores on Intervention Source noted that the group developed the project idea internally and expressed confidence in their idea. Some groups also offered a rationale for why their project would be unique. Example: “The easiest parts were probably thinking of the project idea because the first day that we got introduced to the [leadership program], we were like, ‘Okay, we got this.’ and we knew what we were going to do all along...”  Student and Community Needs and Resources  Summary: Groups with high scores on Student and Community Needs and Resources noted areas that were lacking in their school or community and tailored their projects to fit those needs. Example: “We had a survey like for the whole school, for teachers and students, and over half of our students at our school liked the idea of having an outdoor classroom. I think it would motivate them to come to school and do better in school, as well as teaching the stuff that they would, it would be a really nice idea and a good thing for their classroom as well to have.” Example: “Our goal was to like incorporate like the food grown in our garden into like different classes so our biology class can learn about the photosynthesis and how plant life works and they can incorporate it into their experiments. Also we have a business house so people who want to do something business related they can work that in and see how to start their own companies or how to start selling and how to balance things so that can be incorporated into that whole area. Also our funding was cut for our wellness class so they did not get to do a lot of cooking this year.”  Cosmopolitanism  Summary: Groups with high scores on Cosmopolitanism reported that they had support in the form of resources, information, and/or assistance from community partners with regards to planning and implementation. Example: “We had a bunch of people come in and we presented our idea to our commissioner and she thought it was a good idea. She supported us in it (.…) and then there was another guy who came in to talk to us. He scheduled like community sand volleyball meets. He would go from community to community and help us or help the people make it like an affair, like something to be excited about, how to set up teams, how do people pay for it if they do.”  Group Characteristics  Summary: Favorable Group Characteristics included utilizing all members’ strengths during project implementation, group member investment (e.g., attending meetings, completing assigned responsibilities, contributing ideas, willingness to help), setting a plan at the beginning of the project and staying on track with the plan, collaboration, and strong communication. Example: “The strategies we used were respect for one because we had to respect each other in order to get the project done. In order to get ideas off the ground we had to respect that your idea may not be used or this idea is good. Time management was one of our biggest strategies because we knew we had months to prepare for it. (.…) We met with each other a lot and I’m pretty sure they’re sick of me because we met with each other so much. Having fun—we had a lot of fun doing this (.…) there were some points where we just wanted to give up, but overall we kind of stuck by each other’s side and just pushed through it.”  Student Group Leader Engagement  Summary: Groups with high scores on Student Group Leader Engagement had leaders that felt personal responsibility for making sure the project was completed, and made changes (i.e., increased frequency of meetings) to meet this goal. They also worked with the strengths of each group member to delegate tasks. Example: “As soon as we figured out what people were best at we took their strengths and were able to kind of hand out what they would do. (…) It took a lot of us having to talk to each other and figure out what one person is best at and maybe this person is not so good at putting presentations together but they are really great at public speaking, so we had to work something out and figure out what everyone was good at.”  External Change Agents (outer stakeholders)  Summary: Groups with high scores on External Change Agents worked with organizations outside of their school to learn a skill or information related to their projects, or to secure resources or event space that would support the project or event. Example: “They donate supplies for us and at a cheaper cost, so different things we need, like shovels and different tools we need within the garden they give them to us at a lower price. So it is affordable and they work with many schools and so we asked them if they would work with our school.”  Executing  Summary: Groups with high scores on Executing divided the project into steps and worked through them to complete their project goals. Example: “We tried to break it up in sections so we did like the filming section. Well, we did the brainstorming section, the filming section, and the editing section. (…) We all knew that we were going to do some type of video or something because we thought that would be funny. So we did that. We sat down and we got to filming and we had to cut some of our ideas out because we were kind of working on a time constraint...”  Reflecting and Evaluating  Summary: Groups with high scores on Reflecting and Evaluating solicited and received feedback from participants and administration. Example: “Everyone felt like it was a good idea because we already talked about what we wanted to do and we voted on it. Also even afterwards they thought it was a great idea. Even we had fun doing it. A lot of people came out and they said they enjoyed it. Our administration said we did a great job with hosting it and making sure everything was cleaned up.”  CFIR construct  Summary and example response(s)  Intervention Source (internal)  Summary: Groups with high scores on Intervention Source noted that the group developed the project idea internally and expressed confidence in their idea. Some groups also offered a rationale for why their project would be unique. Example: “The easiest parts were probably thinking of the project idea because the first day that we got introduced to the [leadership program], we were like, ‘Okay, we got this.’ and we knew what we were going to do all along...”  Student and Community Needs and Resources  Summary: Groups with high scores on Student and Community Needs and Resources noted areas that were lacking in their school or community and tailored their projects to fit those needs. Example: “We had a survey like for the whole school, for teachers and students, and over half of our students at our school liked the idea of having an outdoor classroom. I think it would motivate them to come to school and do better in school, as well as teaching the stuff that they would, it would be a really nice idea and a good thing for their classroom as well to have.” Example: “Our goal was to like incorporate like the food grown in our garden into like different classes so our biology class can learn about the photosynthesis and how plant life works and they can incorporate it into their experiments. Also we have a business house so people who want to do something business related they can work that in and see how to start their own companies or how to start selling and how to balance things so that can be incorporated into that whole area. Also our funding was cut for our wellness class so they did not get to do a lot of cooking this year.”  Cosmopolitanism  Summary: Groups with high scores on Cosmopolitanism reported that they had support in the form of resources, information, and/or assistance from community partners with regards to planning and implementation. Example: “We had a bunch of people come in and we presented our idea to our commissioner and she thought it was a good idea. She supported us in it (.…) and then there was another guy who came in to talk to us. He scheduled like community sand volleyball meets. He would go from community to community and help us or help the people make it like an affair, like something to be excited about, how to set up teams, how do people pay for it if they do.”  Group Characteristics  Summary: Favorable Group Characteristics included utilizing all members’ strengths during project implementation, group member investment (e.g., attending meetings, completing assigned responsibilities, contributing ideas, willingness to help), setting a plan at the beginning of the project and staying on track with the plan, collaboration, and strong communication. Example: “The strategies we used were respect for one because we had to respect each other in order to get the project done. In order to get ideas off the ground we had to respect that your idea may not be used or this idea is good. Time management was one of our biggest strategies because we knew we had months to prepare for it. (.…) We met with each other a lot and I’m pretty sure they’re sick of me because we met with each other so much. Having fun—we had a lot of fun doing this (.…) there were some points where we just wanted to give up, but overall we kind of stuck by each other’s side and just pushed through it.”  Student Group Leader Engagement  Summary: Groups with high scores on Student Group Leader Engagement had leaders that felt personal responsibility for making sure the project was completed, and made changes (i.e., increased frequency of meetings) to meet this goal. They also worked with the strengths of each group member to delegate tasks. Example: “As soon as we figured out what people were best at we took their strengths and were able to kind of hand out what they would do. (…) It took a lot of us having to talk to each other and figure out what one person is best at and maybe this person is not so good at putting presentations together but they are really great at public speaking, so we had to work something out and figure out what everyone was good at.”  External Change Agents (outer stakeholders)  Summary: Groups with high scores on External Change Agents worked with organizations outside of their school to learn a skill or information related to their projects, or to secure resources or event space that would support the project or event. Example: “They donate supplies for us and at a cheaper cost, so different things we need, like shovels and different tools we need within the garden they give them to us at a lower price. So it is affordable and they work with many schools and so we asked them if they would work with our school.”  Executing  Summary: Groups with high scores on Executing divided the project into steps and worked through them to complete their project goals. Example: “We tried to break it up in sections so we did like the filming section. Well, we did the brainstorming section, the filming section, and the editing section. (…) We all knew that we were going to do some type of video or something because we thought that would be funny. So we did that. We sat down and we got to filming and we had to cut some of our ideas out because we were kind of working on a time constraint...”  Reflecting and Evaluating  Summary: Groups with high scores on Reflecting and Evaluating solicited and received feedback from participants and administration. Example: “Everyone felt like it was a good idea because we already talked about what we wanted to do and we voted on it. Also even afterwards they thought it was a great idea. Even we had fun doing it. A lot of people came out and they said they enjoyed it. Our administration said we did a great job with hosting it and making sure everything was cleaned up.”  Example responses are provided for constructs that had a moderate or large positive correlation with ≥2 Implementation Outcomes (including the Composite). View Large Table 4 | Summary and example interviewee responses for key constructs identified CFIR construct  Summary and example response(s)  Intervention Source (internal)  Summary: Groups with high scores on Intervention Source noted that the group developed the project idea internally and expressed confidence in their idea. Some groups also offered a rationale for why their project would be unique. Example: “The easiest parts were probably thinking of the project idea because the first day that we got introduced to the [leadership program], we were like, ‘Okay, we got this.’ and we knew what we were going to do all along...”  Student and Community Needs and Resources  Summary: Groups with high scores on Student and Community Needs and Resources noted areas that were lacking in their school or community and tailored their projects to fit those needs. Example: “We had a survey like for the whole school, for teachers and students, and over half of our students at our school liked the idea of having an outdoor classroom. I think it would motivate them to come to school and do better in school, as well as teaching the stuff that they would, it would be a really nice idea and a good thing for their classroom as well to have.” Example: “Our goal was to like incorporate like the food grown in our garden into like different classes so our biology class can learn about the photosynthesis and how plant life works and they can incorporate it into their experiments. Also we have a business house so people who want to do something business related they can work that in and see how to start their own companies or how to start selling and how to balance things so that can be incorporated into that whole area. Also our funding was cut for our wellness class so they did not get to do a lot of cooking this year.”  Cosmopolitanism  Summary: Groups with high scores on Cosmopolitanism reported that they had support in the form of resources, information, and/or assistance from community partners with regards to planning and implementation. Example: “We had a bunch of people come in and we presented our idea to our commissioner and she thought it was a good idea. She supported us in it (.…) and then there was another guy who came in to talk to us. He scheduled like community sand volleyball meets. He would go from community to community and help us or help the people make it like an affair, like something to be excited about, how to set up teams, how do people pay for it if they do.”  Group Characteristics  Summary: Favorable Group Characteristics included utilizing all members’ strengths during project implementation, group member investment (e.g., attending meetings, completing assigned responsibilities, contributing ideas, willingness to help), setting a plan at the beginning of the project and staying on track with the plan, collaboration, and strong communication. Example: “The strategies we used were respect for one because we had to respect each other in order to get the project done. In order to get ideas off the ground we had to respect that your idea may not be used or this idea is good. Time management was one of our biggest strategies because we knew we had months to prepare for it. (.…) We met with each other a lot and I’m pretty sure they’re sick of me because we met with each other so much. Having fun—we had a lot of fun doing this (.…) there were some points where we just wanted to give up, but overall we kind of stuck by each other’s side and just pushed through it.”  Student Group Leader Engagement  Summary: Groups with high scores on Student Group Leader Engagement had leaders that felt personal responsibility for making sure the project was completed, and made changes (i.e., increased frequency of meetings) to meet this goal. They also worked with the strengths of each group member to delegate tasks. Example: “As soon as we figured out what people were best at we took their strengths and were able to kind of hand out what they would do. (…) It took a lot of us having to talk to each other and figure out what one person is best at and maybe this person is not so good at putting presentations together but they are really great at public speaking, so we had to work something out and figure out what everyone was good at.”  External Change Agents (outer stakeholders)  Summary: Groups with high scores on External Change Agents worked with organizations outside of their school to learn a skill or information related to their projects, or to secure resources or event space that would support the project or event. Example: “They donate supplies for us and at a cheaper cost, so different things we need, like shovels and different tools we need within the garden they give them to us at a lower price. So it is affordable and they work with many schools and so we asked them if they would work with our school.”  Executing  Summary: Groups with high scores on Executing divided the project into steps and worked through them to complete their project goals. Example: “We tried to break it up in sections so we did like the filming section. Well, we did the brainstorming section, the filming section, and the editing section. (…) We all knew that we were going to do some type of video or something because we thought that would be funny. So we did that. We sat down and we got to filming and we had to cut some of our ideas out because we were kind of working on a time constraint...”  Reflecting and Evaluating  Summary: Groups with high scores on Reflecting and Evaluating solicited and received feedback from participants and administration. Example: “Everyone felt like it was a good idea because we already talked about what we wanted to do and we voted on it. Also even afterwards they thought it was a great idea. Even we had fun doing it. A lot of people came out and they said they enjoyed it. Our administration said we did a great job with hosting it and making sure everything was cleaned up.”  CFIR construct  Summary and example response(s)  Intervention Source (internal)  Summary: Groups with high scores on Intervention Source noted that the group developed the project idea internally and expressed confidence in their idea. Some groups also offered a rationale for why their project would be unique. Example: “The easiest parts were probably thinking of the project idea because the first day that we got introduced to the [leadership program], we were like, ‘Okay, we got this.’ and we knew what we were going to do all along...”  Student and Community Needs and Resources  Summary: Groups with high scores on Student and Community Needs and Resources noted areas that were lacking in their school or community and tailored their projects to fit those needs. Example: “We had a survey like for the whole school, for teachers and students, and over half of our students at our school liked the idea of having an outdoor classroom. I think it would motivate them to come to school and do better in school, as well as teaching the stuff that they would, it would be a really nice idea and a good thing for their classroom as well to have.” Example: “Our goal was to like incorporate like the food grown in our garden into like different classes so our biology class can learn about the photosynthesis and how plant life works and they can incorporate it into their experiments. Also we have a business house so people who want to do something business related they can work that in and see how to start their own companies or how to start selling and how to balance things so that can be incorporated into that whole area. Also our funding was cut for our wellness class so they did not get to do a lot of cooking this year.”  Cosmopolitanism  Summary: Groups with high scores on Cosmopolitanism reported that they had support in the form of resources, information, and/or assistance from community partners with regards to planning and implementation. Example: “We had a bunch of people come in and we presented our idea to our commissioner and she thought it was a good idea. She supported us in it (.…) and then there was another guy who came in to talk to us. He scheduled like community sand volleyball meets. He would go from community to community and help us or help the people make it like an affair, like something to be excited about, how to set up teams, how do people pay for it if they do.”  Group Characteristics  Summary: Favorable Group Characteristics included utilizing all members’ strengths during project implementation, group member investment (e.g., attending meetings, completing assigned responsibilities, contributing ideas, willingness to help), setting a plan at the beginning of the project and staying on track with the plan, collaboration, and strong communication. Example: “The strategies we used were respect for one because we had to respect each other in order to get the project done. In order to get ideas off the ground we had to respect that your idea may not be used or this idea is good. Time management was one of our biggest strategies because we knew we had months to prepare for it. (.…) We met with each other a lot and I’m pretty sure they’re sick of me because we met with each other so much. Having fun—we had a lot of fun doing this (.…) there were some points where we just wanted to give up, but overall we kind of stuck by each other’s side and just pushed through it.”  Student Group Leader Engagement  Summary: Groups with high scores on Student Group Leader Engagement had leaders that felt personal responsibility for making sure the project was completed, and made changes (i.e., increased frequency of meetings) to meet this goal. They also worked with the strengths of each group member to delegate tasks. Example: “As soon as we figured out what people were best at we took their strengths and were able to kind of hand out what they would do. (…) It took a lot of us having to talk to each other and figure out what one person is best at and maybe this person is not so good at putting presentations together but they are really great at public speaking, so we had to work something out and figure out what everyone was good at.”  External Change Agents (outer stakeholders)  Summary: Groups with high scores on External Change Agents worked with organizations outside of their school to learn a skill or information related to their projects, or to secure resources or event space that would support the project or event. Example: “They donate supplies for us and at a cheaper cost, so different things we need, like shovels and different tools we need within the garden they give them to us at a lower price. So it is affordable and they work with many schools and so we asked them if they would work with our school.”  Executing  Summary: Groups with high scores on Executing divided the project into steps and worked through them to complete their project goals. Example: “We tried to break it up in sections so we did like the filming section. Well, we did the brainstorming section, the filming section, and the editing section. (…) We all knew that we were going to do some type of video or something because we thought that would be funny. So we did that. We sat down and we got to filming and we had to cut some of our ideas out because we were kind of working on a time constraint...”  Reflecting and Evaluating  Summary: Groups with high scores on Reflecting and Evaluating solicited and received feedback from participants and administration. Example: “Everyone felt like it was a good idea because we already talked about what we wanted to do and we voted on it. Also even afterwards they thought it was a great idea. Even we had fun doing it. A lot of people came out and they said they enjoyed it. Our administration said we did a great job with hosting it and making sure everything was cleaned up.”  Example responses are provided for constructs that had a moderate or large positive correlation with ≥2 Implementation Outcomes (including the Composite). View Large Table 5 | Case examples showing the impacts of constructs related to group function and community-connectedness on implementation success Project description  Implementation Outcome scoresa  How primary driving implementation factors manifested in the group  Scores for primary driving implementation factorsb  Case 1: This group project included adding an outdoor sand volleyball court to a public neighborhood park. The court was not created during the study timeline, but the group made significant progress including obtaining a design, cost estimate, and approval from the city commissioner and parks and recreation department.  Progress: 2 Penetration: 1 Health Impact: 3 Sustainability: 1 Composite: 5  Group worked with and received support from the city commissioner, parks and recreation staff, and a community member who organizes and schedules sand volleyball meets.  Cosmopolitanism: 2  Group members enjoyed each other’s presence, were friendly towards each other, showed concern about the project outcome, participated equally, were organized, worked together towards group goals, cooperated, and helped immediately when asked.  Group Characteristics: 2  Parks and recreation staff provided consent to complete project and the city commissioner provided support.  External Change Agents: 2  Case 2: This group planned to host a field day event to promote physical activity among elementary school students. They also planned to provide healthy food for students during this event to model healthy eating. The project was not completed and little progress was made due to internal (i.e., follow through) rather than external (e.g., obtaining approval) factors.  Progress: 0 Penetration: 0 Health Impact: 2 Sustainability: 0 Composite: 2  Group members had difficulty with time management and prioritizing the project. One member left the group because of negative interactions (teasing) with other members of the group.  Group Characteristics: −2  Group members were often not able to find/agree on meeting times. They frequently cancelled meetings because of school fieldtrips or assignments/ tests. Member attendance was low and inconsistent when meetings were held.  Networks and Communications— Within the Youth Group: −2  Group acknowledged that they needed the help of area elementary school principals to complete their project, but did not connect with them.  Cosmopolitanism: −1  Group talked to school administration about reaching out to principals in the community; however, the group did not follow up with the administration’s suggestions following this conversation.  External Change Agents: −1  Project description  Implementation Outcome scoresa  How primary driving implementation factors manifested in the group  Scores for primary driving implementation factorsb  Case 1: This group project included adding an outdoor sand volleyball court to a public neighborhood park. The court was not created during the study timeline, but the group made significant progress including obtaining a design, cost estimate, and approval from the city commissioner and parks and recreation department.  Progress: 2 Penetration: 1 Health Impact: 3 Sustainability: 1 Composite: 5  Group worked with and received support from the city commissioner, parks and recreation staff, and a community member who organizes and schedules sand volleyball meets.  Cosmopolitanism: 2  Group members enjoyed each other’s presence, were friendly towards each other, showed concern about the project outcome, participated equally, were organized, worked together towards group goals, cooperated, and helped immediately when asked.  Group Characteristics: 2  Parks and recreation staff provided consent to complete project and the city commissioner provided support.  External Change Agents: 2  Case 2: This group planned to host a field day event to promote physical activity among elementary school students. They also planned to provide healthy food for students during this event to model healthy eating. The project was not completed and little progress was made due to internal (i.e., follow through) rather than external (e.g., obtaining approval) factors.  Progress: 0 Penetration: 0 Health Impact: 2 Sustainability: 0 Composite: 2  Group members had difficulty with time management and prioritizing the project. One member left the group because of negative interactions (teasing) with other members of the group.  Group Characteristics: −2  Group members were often not able to find/agree on meeting times. They frequently cancelled meetings because of school fieldtrips or assignments/ tests. Member attendance was low and inconsistent when meetings were held.  Networks and Communications— Within the Youth Group: −2  Group acknowledged that they needed the help of area elementary school principals to complete their project, but did not connect with them.  Cosmopolitanism: −1  Group talked to school administration about reaching out to principals in the community; however, the group did not follow up with the administration’s suggestions following this conversation.  External Change Agents: −1  aPossible range: Progress = 0–3, Penetration = 0–3, Health Impact = 0–3, Sustainability = 0–1, Composite (excludes Progress) = 0–7; bPossible range = −2 to 2 View Large Table 5 | Case examples showing the impacts of constructs related to group function and community-connectedness on implementation success Project description  Implementation Outcome scoresa  How primary driving implementation factors manifested in the group  Scores for primary driving implementation factorsb  Case 1: This group project included adding an outdoor sand volleyball court to a public neighborhood park. The court was not created during the study timeline, but the group made significant progress including obtaining a design, cost estimate, and approval from the city commissioner and parks and recreation department.  Progress: 2 Penetration: 1 Health Impact: 3 Sustainability: 1 Composite: 5  Group worked with and received support from the city commissioner, parks and recreation staff, and a community member who organizes and schedules sand volleyball meets.  Cosmopolitanism: 2  Group members enjoyed each other’s presence, were friendly towards each other, showed concern about the project outcome, participated equally, were organized, worked together towards group goals, cooperated, and helped immediately when asked.  Group Characteristics: 2  Parks and recreation staff provided consent to complete project and the city commissioner provided support.  External Change Agents: 2  Case 2: This group planned to host a field day event to promote physical activity among elementary school students. They also planned to provide healthy food for students during this event to model healthy eating. The project was not completed and little progress was made due to internal (i.e., follow through) rather than external (e.g., obtaining approval) factors.  Progress: 0 Penetration: 0 Health Impact: 2 Sustainability: 0 Composite: 2  Group members had difficulty with time management and prioritizing the project. One member left the group because of negative interactions (teasing) with other members of the group.  Group Characteristics: −2  Group members were often not able to find/agree on meeting times. They frequently cancelled meetings because of school fieldtrips or assignments/ tests. Member attendance was low and inconsistent when meetings were held.  Networks and Communications— Within the Youth Group: −2  Group acknowledged that they needed the help of area elementary school principals to complete their project, but did not connect with them.  Cosmopolitanism: −1  Group talked to school administration about reaching out to principals in the community; however, the group did not follow up with the administration’s suggestions following this conversation.  External Change Agents: −1  Project description  Implementation Outcome scoresa  How primary driving implementation factors manifested in the group  Scores for primary driving implementation factorsb  Case 1: This group project included adding an outdoor sand volleyball court to a public neighborhood park. The court was not created during the study timeline, but the group made significant progress including obtaining a design, cost estimate, and approval from the city commissioner and parks and recreation department.  Progress: 2 Penetration: 1 Health Impact: 3 Sustainability: 1 Composite: 5  Group worked with and received support from the city commissioner, parks and recreation staff, and a community member who organizes and schedules sand volleyball meets.  Cosmopolitanism: 2  Group members enjoyed each other’s presence, were friendly towards each other, showed concern about the project outcome, participated equally, were organized, worked together towards group goals, cooperated, and helped immediately when asked.  Group Characteristics: 2  Parks and recreation staff provided consent to complete project and the city commissioner provided support.  External Change Agents: 2  Case 2: This group planned to host a field day event to promote physical activity among elementary school students. They also planned to provide healthy food for students during this event to model healthy eating. The project was not completed and little progress was made due to internal (i.e., follow through) rather than external (e.g., obtaining approval) factors.  Progress: 0 Penetration: 0 Health Impact: 2 Sustainability: 0 Composite: 2  Group members had difficulty with time management and prioritizing the project. One member left the group because of negative interactions (teasing) with other members of the group.  Group Characteristics: −2  Group members were often not able to find/agree on meeting times. They frequently cancelled meetings because of school fieldtrips or assignments/ tests. Member attendance was low and inconsistent when meetings were held.  Networks and Communications— Within the Youth Group: −2  Group acknowledged that they needed the help of area elementary school principals to complete their project, but did not connect with them.  Cosmopolitanism: −1  Group talked to school administration about reaching out to principals in the community; however, the group did not follow up with the administration’s suggestions following this conversation.  External Change Agents: −1  aPossible range: Progress = 0–3, Penetration = 0–3, Health Impact = 0–3, Sustainability = 0–1, Composite (excludes Progress) = 0–7; bPossible range = −2 to 2 View Large DISCUSSION Youth advocacy programs are promising for increasing community capacity for improving healthy eating and active living [17–20]. Such programs support youth to have a voice in their community and stimulate health-related behavioral and environmental improvements through participatory approaches. However, little evidence exists on contextual factors related to implementing youth advocacy programs, such as barriers and facilitators of successful implementation. The present study used a comprehensive implementation science framework (CFIR) [30] to identify factors related to implementation success. Several key factors emerged as being important to implementation, with Cosmopolitanism (leveraging connections within the community) and Internal Intervention Source (student autonomy in selecting a project) having the most consistent associations with Implementation Success. Leaders of youth advocacy programs should target these implementation factors to maximize success of their programs. In addition to Cosmopolitanism and Internal Intervention Source, six other Implementation Factors were related to the Implementation Success Composite in the expected direction, and four of these factors were also related to Penetration or Health Impact, suggesting that these are also important factors to consider when developing implementation strategies. The six factors were either generally related to the involvement of stakeholders (constructs: External Change Agents, Leadership Engagement) or the function of the group (constructs: Student Group Leader Engagement, Group Size, Number of Dropouts [negative]), with the exception of Student and Community Needs and Resources. This suggests that strategies that engage stakeholders and improve group function should be targeted to increase the success of youth advocacy programs. A key aspect of stakeholder engagement is community-connectedness, which can be supported by linking youth to local community organizations that support their mission. Many of the projects were not accomplishable without identifying linkages in the community and working with those individuals. This was highlighted in the case studies, in which one group made significant progress towards their project by working with the parks and recreation department and city commissioner, whereas another group did not make much progress towards their project partly because no contact was made with the primary stakeholders (elementary school principals). Identifying and establishing contact with community stakeholders can be difficult for youth and in some cases may need to be facilitated by an intervention leader or school staff member. Further training on this topic, one-on-one support, and implementing a requirement for groups to work with an outside community stakeholder may increase the likelihood of groups making such connections. Groups with favorable group characteristics were more organized, communicated regularly, stuck together, and got along. This was also highlighted in the case studies, in which one group was highly organized and enjoyed working together, whereas the other group was disorganized, did not meet regularly, and had interpersonal conflicts. Group function can be supported through a number of strategies such as setting group goals at the outset [34], establishing written group expectations and repercussions for not abiding by them, using a team name [35], and encouraging the group to reflect on their performance at regular intervals [36]. Many of the groups with favorable group characteristics appeared to have a strong leader that kept the group together, as shown in Table 4 under the Student Group Leader Engagement construct. Youth advocacy intervention leaders could support group function by encouraging natural formation of groups and working directly with group leaders on how to support positive group interactions and organization. The findings related to Student and Community Needs and Resources suggest that it is important for the project to fit well within the school or target community, which should be considered when identifying a project. It is likely that groups who took the needs of their community or setting into account were more likely to elicit support from community or school stakeholders (e.g., students, administrators). Gaining stakeholder inclusion during both conceptualization and implementation is likely to be beneficial. This could be accomplished through polls or interviews with stakeholders (e.g., students, staff, and community members), which was done by at least one group in this study. Some of the Implementation Factor–Implementation Outcome associations were outcome specific. In particular, four of the seven factors that were associated with Progress were not associated with any of the other Implementation Outcomes or the Implementation Success Composite (constructs: Perceived Complexity, Networks and Communication Within the School, and Within the Youth Group, and Engaging Inner Stakeholders). Although these factors appear important to supporting projects to be completed within the timeframe of the program, the balance between progress and impact should be considered. Some projects with high ratings on Penetration, Health Impact, and Sustainability (e.g., multilevel or environmental projects) were not accomplished during the timeframe of the program, although substantial progress was made (e.g., commitment and/or funding was obtained). Since the leadership program was ongoing, the next cohort of students could complete the projects, although this may not be feasible in programs that are not ongoing. Program leaders should support students to identify projects that will maximize Penetration, Health Impact, and Sustainability while maintaining feasibility, and not discourage complex projects that are likely to have large impacts. Compatibility was also related to only one Implementation Factor (Penetration). This suggests that projects that were compatible with the needs of other students in the schools or members of the community were more likely to engage a larger number of people. This is similar to the findings related to Student and Community Needs and Resources and further suggests the importance of considering student and/or community member input when selecting a project. A few Implementation Factors were related to the Implementation Outcomes in the opposite direction as expected. Having an Internal Intervention Source and lower availability of resources were negatively related to Sustainability. This was likely because many groups may have opted for projects that were perceived as less difficult and requiring fewer resources. It is unclear why Planning was negatively related to Penetration, Health Impact, and the Composite. In comparison to other evaluations of youth advocacy programs (e.g., [19, 20]), the present program included fewer environmental improvement projects and more health-related outreach and event projects. Both types of projects can have health benefits and are represented in ecological models [11–14]. However, the environmental projects were generally rated as having higher Penetration, Health Impacts, and Sustainability, and thus should be a focus of youth advocacy programs. The large number of outreach and event projects in the present program likely occurred because these types of projects were viewed as more feasible to accomplish and the youth were not guided by an evidence-based curriculum. Evidence-based youth advocacy curriculums exist, such as from the Healthy Young People Empowerment Project (HYPE) [20] and Youth Engagement and Action for Health (Yeah!) [19]. More structured support from program staff, resources, and accountability are also likely needed to increase the number of groups that target high-impact projects. One lesson learned in the present study was that groups who had contact with older peers who had previously completed the leadership program were more likely to propose a project that targeted the built environment. Thus, program leaders should support carry-over of projects and/or ideas from year-to-year when ongoing programs as in place. Strengths, limitations, and future directions Study strengths included use of mixed-methods and a sample of mostly low socioeconomic status schools and youth, which are common settings for youth advocacy interventions. A study limitation is that the interview questions broadly asked about CFIR domains, not specific CFIR constructs, so we could not gauge whether certain constructs (e.g., Relative Advantage) were irrelevant or whether they were not captured in the interviews as a result of the general questions. Some constructs, such as Knowledge, were not assessed but have been associated with implementation success in other studies [18] and thus warrant incorporation into implementation strategies. Interviewing only one group member may have resulted in missed or biased information, particularly because the interviewee was not always the group leader. A large number of schools was included, but findings are from only one youth advocacy program and may not generalize to other programs such as those with different formats (e.g., adhering to an evidence-based curriculum) or structure (e.g., community-based rather than school-based, ongoing vs. one-time). Another limitation to this evaluation was that the data were observational and cross-sectional, so it is not clear whether targeting one of the emerging Implementation Factors (e.g., Cosmopolitanism) would result in improved implementation success. CONCLUSIONS The present study found that youth groups who had autonomy in selecting their projects, were supported by outer stakeholders, and had well-functioning groups were more successful in their implementation efforts. To maximize success of youth advocacy efforts, evidence-based curriculums [19, 20] should be used and intervention leaders should support group idea formation using strategies such as encouraging group brainstorming early in the process, team-building exercises to strengthen relationships, modeling positive communication, and acting as a mediator when necessary. Multiple community linkages should also be supported to maximize project success. Youth advocacy has promise for improving healthy eating and active living in underserved communities and understanding how to best implement these programs will maximize impacts on health. Compliance with Ethical Standards Conflict of interest: All co-authors have reviewed the final version of this manuscript and there are no conflicts of interest to report. Ethical Approval: Institutional Review Board approval was obtained from Children’s Mercy Kansas City prior to the administration of the study. Informed Consent: All participants either signed or provided verbal informed consent. Acknowledgments: This project was funded by the Health Care Foundation of Greater Kansas City (grant number 133-FY15-4038). Thank you to the outstanding staff at 2020 Leadership, including Marilyn Alstrom, Crystal Nance, and Sally Dannov, for their support with this evaluation study and hard work in the arena of youth leadership and advocacy. This manuscript has not been previously published, data have not been previously reported, nor is it under review by another journal. Authors have full control of primary data and agree to allow this journal to review data if requested. References 1. Fryar CD, Carroll MD, Ogden CL. Prevalence of obesity among children and adolescents: United States, trends 1963–1965 through 2009–2010. National Center for Health Statistics . 2012; 1– 6. 2. CDC. Prevalence of overweight and obesity among children and adolescents aged 2–19 years: United States, 1963–1965 through 2013–2014 . Available at https://www.cdc.gov/nchs/data/hestat/obesity_child_13_14/obesity_child_13_14.htm. Updated June 13, 2016. Accessed December 20, 2016. 3. Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa heart study. Pediatrics . 2001; 108( 3): 712– 718. Google Scholar CrossRef Search ADS PubMed  4. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med . 1997; 337( 13): 869– 873. Google Scholar CrossRef Search ADS PubMed  5. Juonala M, Magnussen CG, Berenson GSet al.   Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med . 2011; 365( 20): 1876– 1885. Google Scholar CrossRef Search ADS PubMed  6. Canoy D, Bundred P. Obesity in children. BMJ Clinical Evidence . 2011; 2011: 0325. Google Scholar PubMed  7. CDC. Nutrition and the health of young people. Available at http://www.cdc.gov/healthyschools/nutrition/facts.htm. Updated August 28, 2015. Accessibility verified October 26, 2016. 8. Office of Disease Prevention and Health Promotion. DPHP. 2008 Physical Activity Guidelines for Americans. Available at https://health.gov/paguidelines/guidelines/ Updated May 15, 2017. Accessibility verified May 18, 2017. 9. Whitt-Glover MC, Taylor WC, Floyd MF, Yore MM, Yancey AK, Matthews CE. Disparities in physical activity and sedentary behaviors among US children and adolescents: prevalence, correlates, and intervention implications. J Public Health Policy . 2009; 30( 1): S309– S334. Google Scholar CrossRef Search ADS PubMed  10. Troiano RP, Berrigan D, Dodd KW, Masse LC, McDowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc . 2008; 40( 1): 181– 188. Google Scholar CrossRef Search ADS PubMed  11. Sallis JF, Owen N, Fisher EB. Ecological models of health behavior. In: Glanz K, Rimer BK, Viswanath K. eds. Health behavior and health education: theory, research, and practice . 4th ed. San Francisco, CA: Jossey-Bass; 2008. Available at http://riskybusiness.web.unc.edu/files/2015/01/Health-Behavior-and-Health-Education.pdf#page=503. Accessibility verified December 20, 2016. 12. CDC. A guide for community action. Available at http://www.cdc.gov/physicalactivity/strategies/communityguide.html. Updated May 16, 2017. Accessibility verified May 18, 2017. 13. US National Physical Activity Plan. Available at http://www.physicalactivityplan.org/. Updated April, 2016. Accessibility verified May 18, 2017. 14. Office of Disease Prevention and Health Promotion. Physical activity. Available at https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity/objectives. Updated May 18, 2017. Accessibility verified May 18, 2017. 15. Martin J. The role of advocacy. In: Waters E, Swinburn B, Seidell J, Uauy R, eds. Preventing childhood obesity: evidence policy and practice . Hoboken, NJ: Blackwell Publishing Ltd.; 2010: 192– 199. Google Scholar CrossRef Search ADS   16. Millstein RA, Sallis JF. Youth advocacy for obesity prevention: the next wave of social change for health. Transl Behav Med . 2011; 1( 3): 497– 505. Google Scholar CrossRef Search ADS PubMed  17. CDC. Best practices user guide: youth engagement—state and community interventions, 2010 . Atlanta, Georgia: U.S. Department of Health and Human Services Centers for Disease Control and Prevention; 2010. 18. Millstein RA, Woodruff SI, Linton LS, Edwards CC, Sallis JF. A pilot study evaluating the effects of a youth advocacy program on youth readiness to advocate for environment and policy changes for obesity prevention. Transl Behav Med . 2016; 6( 4): 648– 658. Google Scholar CrossRef Search ADS PubMed  19. Linton LS, Edwards CC, Woodruff SI, Millstein RA, Moder C. Youth advocacy as a tool for environmental and policy changes that support physical activity and nutrition: an evaluation study in San Diego County. Prev Chronic Dis . 2014; 11: E46 Google Scholar CrossRef Search ADS PubMed  20. Besenyi G, Carter T, Pope AW, Gordon K, Freeman B, Kaczynski AT. Healthy young people empowerment (HYPE) project: facilitator’s guid  e. Paper presented at American Public Health Association Meeting; November 15–19, 2014; New Orleans, LA. 21. Durlak JA, DuPre EP. Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. Am J Community Psychol . 2008; 41( 3–4): 327– 350. Google Scholar CrossRef Search ADS PubMed  22. Missouri Department of Elementary and Secondary Education. Food and nutrition services statistics. Available at https://dese.mo.gov/financial-admin-services/food-nutrition-services/statistics. Accessibility verified December 6, 2016. 23. Kansas State Department of Education. School finance publications. Available at http://www.ksde.org/Agency/Fiscal-and-Administrative-Services/School-Finance/Reports-and-Publications#Free%20and%20Reduced. Accessibility verified December 6, 2016. 24. 20/20 Leadership. What is 20/20 Leadership? Available at http://www.2020leadership.org/. Accessibility vereified May 18, 2017. 25. Healthy Lifestyles Initiative. 12345 Fit-Tastic! Available at http://fittastic.org/. Accessibility verified December 20, 2016. 26. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci . 2009; 4( 1): 50. Google Scholar CrossRef Search ADS PubMed  27. Consolidated Framework for Implementation Research. CFIR constructs. Available at http://www.cfirguide.org/constructs.html. Updated October 29, 2014. Accessibility verified January 13, 2016. 28. Damschroder LJ, Lowery, JC. Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR). Implement Sci . 2013; 8: 51. Google Scholar CrossRef Search ADS PubMed  29. Proctor E, Silmere H, Raghavan Ret al.   Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health . 2011; 38( 2): 65– 76. Google Scholar CrossRef Search ADS PubMed  30. Consolidated Framework for Implementation Research. Welcome to the CFIR Technical Assistance Website. Available at http://www.cfirguide.org/. Updated October 29, 2014. Accessibility verified November 18, 2016. 31. NVivo qualitative data analysis Software; QSR International Pty Ltd. Version 11, 2012. Available at https://www.qsrinternational.com/nvivo/home 32. Consolidated Framework for Implementation Research. CFIR Rating Rules. Available at http://www.cfirguide.org/RatingRules10.29.14.pdf. Accessibility verified December 20, 2016. 33. Cohen J. Statistical power analysis for the behavioral sciences . 2nd ed. New York, NY: Lawrence Erlbaum Associates; 1988. 34. Roseth CJ, Johnson DW, Johnson RT. Promoting early adolescents’ achievement and peer relationships: the effects of cooperative, competitive, and individualistic goal structures. Psychol Bull . 2008; 134( 2): 223– 246. Google Scholar CrossRef Search ADS PubMed  35. Oakley B, Felder RM, Brent R, Elhajj I. Turning student groups into effective teams. J Student Centered Learn . 2004; 2( 1): 9– 34. 36. Keavney A. Team building strategies. Train Dev J . 2016; 43( 2): 26– 28. APPENDIX. INTERVIEW CONTENT What is your project goal? Why did you choose that project idea?  Tell me about how you planned for and coordinated meetings? How often did they occur?  How were group members designated or assigned to roles? How did they interact with each other? How did group interactions impact project goals? How did group members view the project?  How were administrators and teachers involved throughout the project? How did others in the school view the project?  Who did you work with outside of the school to accomplish the project? How were they involved?  What strategies and/or steps did you take to accomplish your project goals?  What were the hardest parts of your project? Did you face any major problems?  What were the key things that helped you accomplish your project?  Was your project accomplished? What were your outcomes? Did you accomplish your project goals?  What types of supports would have made it easier to accomplish your project? What kind of feedback did you receive from those outside of your group about accomplishing your project?  Were you exposed to the 12345 Fit-Tastic! Message? Did you use it in your project or share it with others?  What is your project goal? Why did you choose that project idea?  Tell me about how you planned for and coordinated meetings? How often did they occur?  How were group members designated or assigned to roles? How did they interact with each other? How did group interactions impact project goals? How did group members view the project?  How were administrators and teachers involved throughout the project? How did others in the school view the project?  Who did you work with outside of the school to accomplish the project? How were they involved?  What strategies and/or steps did you take to accomplish your project goals?  What were the hardest parts of your project? Did you face any major problems?  What were the key things that helped you accomplish your project?  Was your project accomplished? What were your outcomes? Did you accomplish your project goals?  What types of supports would have made it easier to accomplish your project? What kind of feedback did you receive from those outside of your group about accomplishing your project?  Were you exposed to the 12345 Fit-Tastic! Message? Did you use it in your project or share it with others?  View Large What is your project goal? Why did you choose that project idea?  Tell me about how you planned for and coordinated meetings? How often did they occur?  How were group members designated or assigned to roles? How did they interact with each other? How did group interactions impact project goals? How did group members view the project?  How were administrators and teachers involved throughout the project? How did others in the school view the project?  Who did you work with outside of the school to accomplish the project? How were they involved?  What strategies and/or steps did you take to accomplish your project goals?  What were the hardest parts of your project? Did you face any major problems?  What were the key things that helped you accomplish your project?  Was your project accomplished? What were your outcomes? Did you accomplish your project goals?  What types of supports would have made it easier to accomplish your project? What kind of feedback did you receive from those outside of your group about accomplishing your project?  Were you exposed to the 12345 Fit-Tastic! Message? Did you use it in your project or share it with others?  What is your project goal? Why did you choose that project idea?  Tell me about how you planned for and coordinated meetings? How often did they occur?  How were group members designated or assigned to roles? How did they interact with each other? How did group interactions impact project goals? How did group members view the project?  How were administrators and teachers involved throughout the project? How did others in the school view the project?  Who did you work with outside of the school to accomplish the project? How were they involved?  What strategies and/or steps did you take to accomplish your project goals?  What were the hardest parts of your project? Did you face any major problems?  What were the key things that helped you accomplish your project?  Was your project accomplished? What were your outcomes? Did you accomplish your project goals?  What types of supports would have made it easier to accomplish your project? What kind of feedback did you receive from those outside of your group about accomplishing your project?  Were you exposed to the 12345 Fit-Tastic! Message? Did you use it in your project or share it with others?  View Large © Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Translational Behavioral Medicine Oxford University Press

Implementation contextual factors related to youth advocacy for healthy eating and active living

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Abstract

Abstract Healthy eating and active living are critical to youth health and development. Youth advocacy can improve health-related behaviors and environments by empowering youth to act as change agents in their community. This mixed-method study examined implementation contextual factors in relation to implementation success in high school youth advocacy projects targeting healthy eating and active living. Semi-structured interviews were conducted with key informants from each of the 21 participating youth groups. Interviews gathered information on implementation processes, barriers and facilitators, and Implementation Outcomes (Progress, Penetration, Health Impact, Sustainability, and an overall Implementation Success Composite). Interview responses were coded using the Consolidated Framework for Implementation Research (CFIR). Each identified construct was rated for its impact on implementation and ratings were tested for their association with the Implementation Outcomes. Cosmopolitanism (leveraging connections within the community; rated in 20 groups) and Internal Intervention Source (rated in 9 groups) showed consistent moderate/large associations with the Implementation Outcomes and Implementation Success Composite. Other moderate/large associations were outcome specific, with Student Group Leader Engagement, External Change Agents, and Student and Community Needs and Resources also being associated with the Implementation Success Composite. Implementation contextual factors, particularly community-connectedness, group functioning, and internal project idea development are important factors for implementing youth advocacy projects that will reach large numbers of people and be likely to lead to sustained health improvements. Implementation strategies that target these factors need to be developed and tested in partnership with community organizations to maximize success of youth advocacy efforts. Implications Practice: Supporting project selection autonomy, connectedness with community organizations, and group functioning can improve effectiveness of youth advocacy programs to support healthy eating and active living. Policy: Youth have an important voice for affecting local-level policy changes, but evidence-based implementation strategies are needed to improve effectiveness of youth advocacy efforts. Research: Specific implementation strategies that target participant autonomy, group function, and community-connectedness need to be developed and tested for increasing effectiveness of youth advocacy programs. INTRODUCTION Rates of overweight/obesity in youth have been increasing over the past several decades [1]. Although some evidence suggests stabilization, current rates indicate that 20.6% of adolescents of ages 12–19 are obese and 16.2% are overweight [2], and overweight/obesity and related problems are shown to continue into adulthood [3, 4]. Obesity in youth is associated with poor mental health outcomes, such as decreased quality of life and self-esteem, and adverse physical health outcomes, such as type 2 diabetes and cardiovascular disease [5, 6]. Overweight/obesity is attributed to longstanding unhealthy eating and physical inactivity [6]. About 40% of children and adolescents’ daily caloric intake comes from empty calories (e.g., added sugars and solid fats) [7]. About 8% of adolescents meet the 60-min/day physical activity guideline based on objective data, and gender and racial/ethnic disparities exist [8–10]. Ecological models suggest that healthy eating and active living in youth are influenced by individual- (e.g., motivation, skills), interpersonal- (e.g., social support), and environmental-level (e.g., access to health foods and safe places for walking) factors [11]. Leading public health organizations recommend interventions based on ecological models [12–14]. Environmental strategies are often targeted because they can reach large portions of the population and remove barriers to healthy eating and active living. One strategy that has promise for improving healthy eating and active living is advocacy. Advocacy generally refers to the process of increasing support for a cause or policy [15] and has been targeted in “youth advocacy” programs by training and engaging youth to advocate for improved health within a community [16]. Youth advocacy has been an effective intervention for health promotion, including for reducing tobacco use [17] and improving environments to foster healthy eating and active living [18–20]. There are many benefits when youth serve as advocates, such as that decision makers may be more open to requests made by youth, the process can strengthen youth development (e.g., mastery, knowledge, character, self-esteem), the outcomes can create lasting changes in the community, and the participants can become sustained advocates for a lifetime [16]. Youth advocacy programs targeting health behavior change are gaining popularity and being implemented by community organizations across the U.S. However, little evidence exists regarding best practices for and barriers and facilitators to implementation (i.e., implementation contextual factors). These factors are important to understand because they can be targeted to promote positive program outcomes and guide future efforts [21]. Thus, the purpose of this study was to evaluate implementation contextual factors in relation to implementation outcomes/success in youth advocacy projects that were embedded in and facilitated by an existing community- based leadership program in high schools. METHODS Evaluation participants Evaluation participants were key informants from 21 high school-based youth advocacy groups/projects, facilitated by a community-based organization. One youth key informant from each of the 21 youth groups was identified by the community-based organization based on his/her leadership role in the group’s project. About 57% of the key informants were the leader or coleader of their group based on group elections. Another group member was selected as the key informant when the group leader was not available or not deemed as the best person to participate in the interview by the community-based organization. The 21 evaluation participants were from 16 high schools and represented groups of 2–30 students (Median = 10) at the beginning of the program and 2–13 students (Median = 5) at the end of the program, due to drop outs, differences in interest levels across schools, and students from some schools splitting into multiple groups. Approximately 90% of the interview participants were girls. The community-based organization requested demographic information from all group members in an online survey (115/224 students across the 21 groups responded): 74% were girls, 39.1% were Hispanic nonWhite, 35.7% were Black, 15.7% were nonHispanic White, 3.5% were Asian, and 6.1% were multiracial. Free or reduced-price lunch eligibility at the attending schools ranged from 20% to 100% (M = 77.2%; SD = 21.5%) [22, 23]. The study was approved by the sponsoring institution’s human subject’s protection committee. Description of program The youth advocacy projects were embedded in an ongoing youth leadership program led by a community-based organization. The broad objective of the leadership program was to foster leadership skills and community involvement. The 10-month leadership program “blends academically, socially, economically, racially and geographically diverse students in learning the importance of earning an education and taking personal and social responsibility. Program content includes: college and career exploration, local and state government, media, law, entrepreneurship, finance, personal and leadership development, the arts and social service” [24]. Juniors and seniors from 16 high schools in the Kansas City metropolitan area were eligible to participate in the leadership program during the 2015–2016 school year. Together, the 21 groups attended three trainings specific to youth advocacy in Fall 2015. The trainings were developed specifically for this program and led by staff from a community health initiative sponsored by the local children’s hospital. The trainings focused on educating youth on healthy eating and active living, the role of the school and community environment in health, framing and communicating the advocacy message to decision makers (led by a marketing organization), and the 12345 Fit-Tastic! message (1 hr or more of physical activity, 2 hr maximum of screen time, three servings of low or nonfat milk or yogurt, four servings of water not sugary drinks, and five servings or more of fruits and vegetables) [25]. Two videos of successful youth advocacy projects from across the USA were presented as examples, one involved a school garden and the other involved creation of a new trail. Each group of youth was required to develop and implement a youth advocacy project at their high school during the Spring 2016 semester targeting healthy eating and/or active living and incorporate the 12345 Fit-Tastic! message where appropriate. Each group received $1,000 USD to support their project and ongoing technical assistance around the planning and facilitation of projects from one of two staff members from the community-based organization. Data collection Semi-structured interviews were conducted with key informants at the end of or directly following the Spring 2016 semester. Each interview lasted approximately 25 min (range = 17–47 min) and was completed by one of two interviewers in-person or by phone. The interview script included broad open-ended questions covering the five domains of the Consolidated Framework for Implementation Research (CFIR): Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Process [26]. Descriptions of the CFIR framework and constructs can be found on the CFIR website [27]. CFIR is widely used to evaluate contextual factors that support or inhibit effective implementation (e.g., [28]). The interview script also captured Implementation Outcomes including Progress, Penetration, Health Impact, and Sustainability [29]. Interviews were audio recorded and transcribed verbatim. Interview coding The CFIR codebook available through the CFIR Technical Assistance Website [30] was used to facilitate coding of CFIR constructs, with slight adaptations made to the codebook to create specificity to the intervention. Of the 39 constructs captured across the five domains of CFIR, 24 were selected for inclusion in the present study based on their perceived importance to youth advocacy and their ability to be captured from the key informant interviews. Constructs such as Evidence Strength and Quality, Trialability, and Design Quality and Packaging were excluded because we did not expect to observe variation in these constructs across youth groups. Other constructs (e.g., Knowledge and Beliefs) were not captured by the broad questions used in the interview and thus were not coded. Definitions and coding criteria for the Implementation Outcomes are presented in Table 1, and definitions and coding criteria for the CFIR-related Implementation Contextual Factors are presented in Table 2. Table 1 | Implementation outcome descriptions and mean ratings by key informants (N = 21) Implementation Outcomes  Brief description  Rating M(SD)  Progress  Higher ratings were given to groups that successfully accomplished/completed their project goals.  2.05(1.20)  Penetration  Higher ratings given to projects that reached a larger number of people.  0.62(0.67)  Health Impact  Higher ratings were given to projects that were more likely to impact health.  1.86(0.79)  Sustainability  Higher ratings were given to projects that were more likely to have sustained impacts.  .19(.40)  Implementation Outcome Composite  Sum of Penetration, Health Impact, and Sustainability.  2.67(1.20)  Implementation Outcomes  Brief description  Rating M(SD)  Progress  Higher ratings were given to groups that successfully accomplished/completed their project goals.  2.05(1.20)  Penetration  Higher ratings given to projects that reached a larger number of people.  0.62(0.67)  Health Impact  Higher ratings were given to projects that were more likely to impact health.  1.86(0.79)  Sustainability  Higher ratings were given to projects that were more likely to have sustained impacts.  .19(.40)  Implementation Outcome Composite  Sum of Penetration, Health Impact, and Sustainability.  2.67(1.20)  Ratings were on a 0–3 scale, with the exception of Sustainability which was rated as yes = 1, no = 0. Composite is a sum score which excludes Progress (possible range = 0–7). View Large Table 1 | Implementation outcome descriptions and mean ratings by key informants (N = 21) Implementation Outcomes  Brief description  Rating M(SD)  Progress  Higher ratings were given to groups that successfully accomplished/completed their project goals.  2.05(1.20)  Penetration  Higher ratings given to projects that reached a larger number of people.  0.62(0.67)  Health Impact  Higher ratings were given to projects that were more likely to impact health.  1.86(0.79)  Sustainability  Higher ratings were given to projects that were more likely to have sustained impacts.  .19(.40)  Implementation Outcome Composite  Sum of Penetration, Health Impact, and Sustainability.  2.67(1.20)  Implementation Outcomes  Brief description  Rating M(SD)  Progress  Higher ratings were given to groups that successfully accomplished/completed their project goals.  2.05(1.20)  Penetration  Higher ratings given to projects that reached a larger number of people.  0.62(0.67)  Health Impact  Higher ratings were given to projects that were more likely to impact health.  1.86(0.79)  Sustainability  Higher ratings were given to projects that were more likely to have sustained impacts.  .19(.40)  Implementation Outcome Composite  Sum of Penetration, Health Impact, and Sustainability.  2.67(1.20)  Ratings were on a 0–3 scale, with the exception of Sustainability which was rated as yes = 1, no = 0. Composite is a sum score which excludes Progress (possible range = 0–7). View Large Table 2 | Description, mean ratings, and frequency of constructs reported by key informants (N = 21) CFIR constructs  Higher scoring groups had the following characteristics  Rating M(SD)  N  I. Intervention Characteristics  Intervention Source  Project idea developed within group rather than based on external influence.  +0.89(0.33)  9  Relative Advantage  Project improved upon existing programs/facilities in the school and/ or community.  Missing  4  Perceived Complexity  Less reported complexity and difficulty during implementation.  −1.08(0.29)  12  Cost  Stayed within budget and/or fund raised through grants or donations.  +0.42(1.16)  12  II. Outer Setting  Student and Community Needs and Resources  Considered the needs of the students and/or community members when planning the project.  +1.20(0.41)  20  Cosmopolitanism  Leveraged more external connections in the community.  +0.25(1.07)  20  Peer Pressure  Engaged in competition with other groups (within or outside of the school).  Missing  3  III. Inner Setting  Group Characteristics  Worked as a cohesive group to accomplish project goals.  −0.29(1.35)  21  Networks and Communications   Within the school  Had productive, open communication with school staff and teachers.  +0.67(0.91)  21   Within the youth group  Communicated well, met often, and had strategies in place for ongoing communication.  +0.38(1.20)  21   Within the leadership program  Reported beneficial communication and relationships with the leadership program staff.  +0.88(0.81)  16  Implementation climate   Tension for change  Leveraged an existing tension within the school to support change.  +1.08(0.28)  13   Compatibility  Project appeared to fit with the setting and elicited less pushback.  +1.13(0.35)  8   Priority  Project was prioritized highly by the school.  Missing  2  Readiness for implementation     Leadership engagement  Leadership program staff played a large role in facilitating implementation.  +1.06(0.64)  18   Available resources  Group had access to necessary resources.  +1.00(0.65)  15  IV. Characteristics of Individuals  Identification with Project  Interviewees felt positively about the project.  +0.71(1.06)  21  V. Process  Planning  Group included pre-implementation planning and refinements as needed.  +0.29(1.01)  21  Engaging   Student Group Leader  Group leader was engaged and assigned roles to other group members based on strengths.  +0.25(1.06)  12   Inner Stakeholders  Group had greater involvement from school staff.  +0.76(0.83)  21   External Change Agents  (outer stakeholders)  Group leveraged external resources and support.  +0.60(1.14)  20  Executing  Group followed a clear plan of action to accomplish their project.  −0.27(1.16)  15  Reflecting and Evaluating  Group used feedback from stakeholders to refine their efforts.  +0.48(1.08)  21  CFIR constructs  Higher scoring groups had the following characteristics  Rating M(SD)  N  I. Intervention Characteristics  Intervention Source  Project idea developed within group rather than based on external influence.  +0.89(0.33)  9  Relative Advantage  Project improved upon existing programs/facilities in the school and/ or community.  Missing  4  Perceived Complexity  Less reported complexity and difficulty during implementation.  −1.08(0.29)  12  Cost  Stayed within budget and/or fund raised through grants or donations.  +0.42(1.16)  12  II. Outer Setting  Student and Community Needs and Resources  Considered the needs of the students and/or community members when planning the project.  +1.20(0.41)  20  Cosmopolitanism  Leveraged more external connections in the community.  +0.25(1.07)  20  Peer Pressure  Engaged in competition with other groups (within or outside of the school).  Missing  3  III. Inner Setting  Group Characteristics  Worked as a cohesive group to accomplish project goals.  −0.29(1.35)  21  Networks and Communications   Within the school  Had productive, open communication with school staff and teachers.  +0.67(0.91)  21   Within the youth group  Communicated well, met often, and had strategies in place for ongoing communication.  +0.38(1.20)  21   Within the leadership program  Reported beneficial communication and relationships with the leadership program staff.  +0.88(0.81)  16  Implementation climate   Tension for change  Leveraged an existing tension within the school to support change.  +1.08(0.28)  13   Compatibility  Project appeared to fit with the setting and elicited less pushback.  +1.13(0.35)  8   Priority  Project was prioritized highly by the school.  Missing  2  Readiness for implementation     Leadership engagement  Leadership program staff played a large role in facilitating implementation.  +1.06(0.64)  18   Available resources  Group had access to necessary resources.  +1.00(0.65)  15  IV. Characteristics of Individuals  Identification with Project  Interviewees felt positively about the project.  +0.71(1.06)  21  V. Process  Planning  Group included pre-implementation planning and refinements as needed.  +0.29(1.01)  21  Engaging   Student Group Leader  Group leader was engaged and assigned roles to other group members based on strengths.  +0.25(1.06)  12   Inner Stakeholders  Group had greater involvement from school staff.  +0.76(0.83)  21   External Change Agents  (outer stakeholders)  Group leveraged external resources and support.  +0.60(1.14)  20  Executing  Group followed a clear plan of action to accomplish their project.  −0.27(1.16)  15  Reflecting and Evaluating  Group used feedback from stakeholders to refine their efforts.  +0.48(1.08)  21  Ratings of −2 through +2 were possible. Valence (+,−) indicated whether or not the construct helped or hindered the implementation process. Strength indicated how much the construct helped or hindered the implementation process. View Large Table 2 | Description, mean ratings, and frequency of constructs reported by key informants (N = 21) CFIR constructs  Higher scoring groups had the following characteristics  Rating M(SD)  N  I. Intervention Characteristics  Intervention Source  Project idea developed within group rather than based on external influence.  +0.89(0.33)  9  Relative Advantage  Project improved upon existing programs/facilities in the school and/ or community.  Missing  4  Perceived Complexity  Less reported complexity and difficulty during implementation.  −1.08(0.29)  12  Cost  Stayed within budget and/or fund raised through grants or donations.  +0.42(1.16)  12  II. Outer Setting  Student and Community Needs and Resources  Considered the needs of the students and/or community members when planning the project.  +1.20(0.41)  20  Cosmopolitanism  Leveraged more external connections in the community.  +0.25(1.07)  20  Peer Pressure  Engaged in competition with other groups (within or outside of the school).  Missing  3  III. Inner Setting  Group Characteristics  Worked as a cohesive group to accomplish project goals.  −0.29(1.35)  21  Networks and Communications   Within the school  Had productive, open communication with school staff and teachers.  +0.67(0.91)  21   Within the youth group  Communicated well, met often, and had strategies in place for ongoing communication.  +0.38(1.20)  21   Within the leadership program  Reported beneficial communication and relationships with the leadership program staff.  +0.88(0.81)  16  Implementation climate   Tension for change  Leveraged an existing tension within the school to support change.  +1.08(0.28)  13   Compatibility  Project appeared to fit with the setting and elicited less pushback.  +1.13(0.35)  8   Priority  Project was prioritized highly by the school.  Missing  2  Readiness for implementation     Leadership engagement  Leadership program staff played a large role in facilitating implementation.  +1.06(0.64)  18   Available resources  Group had access to necessary resources.  +1.00(0.65)  15  IV. Characteristics of Individuals  Identification with Project  Interviewees felt positively about the project.  +0.71(1.06)  21  V. Process  Planning  Group included pre-implementation planning and refinements as needed.  +0.29(1.01)  21  Engaging   Student Group Leader  Group leader was engaged and assigned roles to other group members based on strengths.  +0.25(1.06)  12   Inner Stakeholders  Group had greater involvement from school staff.  +0.76(0.83)  21   External Change Agents  (outer stakeholders)  Group leveraged external resources and support.  +0.60(1.14)  20  Executing  Group followed a clear plan of action to accomplish their project.  −0.27(1.16)  15  Reflecting and Evaluating  Group used feedback from stakeholders to refine their efforts.  +0.48(1.08)  21  CFIR constructs  Higher scoring groups had the following characteristics  Rating M(SD)  N  I. Intervention Characteristics  Intervention Source  Project idea developed within group rather than based on external influence.  +0.89(0.33)  9  Relative Advantage  Project improved upon existing programs/facilities in the school and/ or community.  Missing  4  Perceived Complexity  Less reported complexity and difficulty during implementation.  −1.08(0.29)  12  Cost  Stayed within budget and/or fund raised through grants or donations.  +0.42(1.16)  12  II. Outer Setting  Student and Community Needs and Resources  Considered the needs of the students and/or community members when planning the project.  +1.20(0.41)  20  Cosmopolitanism  Leveraged more external connections in the community.  +0.25(1.07)  20  Peer Pressure  Engaged in competition with other groups (within or outside of the school).  Missing  3  III. Inner Setting  Group Characteristics  Worked as a cohesive group to accomplish project goals.  −0.29(1.35)  21  Networks and Communications   Within the school  Had productive, open communication with school staff and teachers.  +0.67(0.91)  21   Within the youth group  Communicated well, met often, and had strategies in place for ongoing communication.  +0.38(1.20)  21   Within the leadership program  Reported beneficial communication and relationships with the leadership program staff.  +0.88(0.81)  16  Implementation climate   Tension for change  Leveraged an existing tension within the school to support change.  +1.08(0.28)  13   Compatibility  Project appeared to fit with the setting and elicited less pushback.  +1.13(0.35)  8   Priority  Project was prioritized highly by the school.  Missing  2  Readiness for implementation     Leadership engagement  Leadership program staff played a large role in facilitating implementation.  +1.06(0.64)  18   Available resources  Group had access to necessary resources.  +1.00(0.65)  15  IV. Characteristics of Individuals  Identification with Project  Interviewees felt positively about the project.  +0.71(1.06)  21  V. Process  Planning  Group included pre-implementation planning and refinements as needed.  +0.29(1.01)  21  Engaging   Student Group Leader  Group leader was engaged and assigned roles to other group members based on strengths.  +0.25(1.06)  12   Inner Stakeholders  Group had greater involvement from school staff.  +0.76(0.83)  21   External Change Agents  (outer stakeholders)  Group leveraged external resources and support.  +0.60(1.14)  20  Executing  Group followed a clear plan of action to accomplish their project.  −0.27(1.16)  15  Reflecting and Evaluating  Group used feedback from stakeholders to refine their efforts.  +0.48(1.08)  21  Ratings of −2 through +2 were possible. Valence (+,−) indicated whether or not the construct helped or hindered the implementation process. Strength indicated how much the construct helped or hindered the implementation process. View Large Two trained staff independently coded each transcribed interview using QSR International’s NVivo 11 Software [31]. The CFIR rating guide [32] was used to rate the valance and impact of each construct, with scores ranging from −2 to +2. Valence indicated whether the coded material functioned as a facilitator (+) or barrier (−) to implementation. The magnitude of the score (1 or 2) indicated the extent to which the construct helped or hindered implementation. Higher positive scores indicated that the construct functioned as a facilitator. A score of zero indicated that the construct was present but did not appear to have an impact on project implementation. If the construct was not ratable in at least eight interviews, it was considered to be missing. The Implementation Outcomes Progress, Penetration, and Health Impact were rated using a 0–3 scale, with higher scores indicating greater presence of that outcome. The Implementation Outcome Sustainability was rated as 0 (no) or 1 (yes) due to low variability. Three Implementation Outcomes (Penetration, Health Impact, and Sustainability) were combined into an overall Implementation Success Composite score by taking a sum of the three items (possible range = 0–7). Progress was excluded to prevent unfairly biasing against more challenging environmental projects. The two coders compared all ratings and reconciled discrepancies through discussion. In cases where an agreement could not be reached, a third adjudicator determined the final rating. Data analysis Means and standard deviations were calculated for the Implementation Contextual Factors (i.e., CFIR constructs) and Implementation Outcomes. Next, Pearson correlations were calculated to quantitatively assess the relation of each Implementation Contextual Factor to each Implementation Outcome and overall Implementation Success. Correlations of .30 to .49 were considered moderate, and correlations ≥.50 were considered large, based on criteria developed by Cohen [33]. Constructs with correlations <.30 were interpreted as being of less importance. The analyses were conducted in SPSS version 23. RESULTS Of the 21 groups, 5 targeted a built environment improvement in or around their school (outdoor classroom; garden; sport facility; lighting for sport facility; changes to school library), 2 targeted an ongoing outreach effort (e.g., teaching younger students about health), and 14 targeted a one-time event (e.g., health fair, fitness event). Table 1 shows the mean and standard deviation rating for each Implementation Outcome and the Implementation Outcome Composite. For Progress, completed projects received higher ratings, projects where groups made substantial progress but had not yet completed the project (e.g., some environmental projects) received moderate-to-high ratings, and projects that made little traction received lower ratings. For Penetration, projects that targeted health-related environmental improvements that would affect a large number of people received higher ratings, whereas one-time and outreach events received lower ratings, based on the number of attendees. For Health Impact, environmental improvements were generally rated as having the highest potential to impact health, with ratings of events being lower and distinguished by the level at which health was incorporated. For Sustainability, environmental projects received a yes and events received a no because none had plans for being sustained. Table 2 shows the number of interviews in which each CFIR construct was captured and the mean and standard deviation rating for each construct. The constructs that most consistently emerged across the groups were Group Characteristics (N = 21), Networks and Communication Within the School (N = 21) and Within the Group (N = 21), Leader Identification with Project (N = 21), Planning (N = 21), Engaging Inner Stakeholders (N = 21), Reflecting and Evaluating (N = 21), Student and Community Needs and Resources (N = 20), Cosmopolitanism, defined as leveraging connections within the community (N = 20), External Change Agents (N = 20), and Leadership Engagement (N = 18). Student and Community Needs and Resources (Mean = 1.20, SD = 0.41), Compatibility (Mean = 1.13, SD = 0.35), Tension for Change (Mean = 1.08, SD = 0.28), and Leadership Engagement (Mean = 1.06, SD = 0.64) had the highest ratings with regards to supporting implementation. Perceived Complexity (Mean = −1.08, SD = 0.29), Group Characteristics (Mean = −0.29, SD = 1.35), and Executing (Mean = −0.27, SD = 1.16) had the lowest ratings. Associations between the CFIR constructs and Implementation Outcomes are presented in Table 3. Progress (7 associations in the expected direction) was positively related to Group Characteristics, Networks and Communication Within the Youth Group, Reflecting and Evaluating, Perceived Complexity, Executing, Networks and Communication Within the School, and Inner Stakeholders (r = .31–.56). Penetration (six associations in the expected direction) was positively related to Compatibility, Student Group Leader Engagement, External Change Agents, Cosmopolitanism, and Intervention Source (r = .40–.75), and negatively related to the Number of Dropouts and Planning (r = −.52 and −.35, respectively). Health Impact (three associations in the expected direction) was positively related to Intervention Source, Student and Community Needs and Resources, and Cosmopolitanism (r = .35–.43), and negatively related to Planning (r = −.57). Sustainability (four associations in the expected direction) was positively related to Group Characteristics, Executing, Cosmopolitanism, and Reflecting and Evaluating (r = .36–.47), and negatively related to Available Resources and Intervention Source (r = −.53 and −.50, respectively). Table 3 | Relationship between CFIR constructs and implementation outcomes (Pearson r)   Implementation outcomes  CFIR constructs  Progress  Penetration  Health Impact  Sustainability  Composite  I. Intervention Characteristics  Intervention Source (Internal)  −.23  .40b  .43b  −.50a  .30b  Relative Advantage  Missing  Missing  Missing  Missing  Missing  Perceived Complexity  .36b  −.07  .09  .14  .05  Cost  .15  −.04  −.19  −.11  −.17  II. Outer Setting  Student and Community Needs and Resources  .16  .27  .41b  .06  .44b  Cosmopolitanism  .14  .43b  .35b  .36b  .59a  Peer Pressure  Missing  Missing  Missing  Missing  Missing  III. Inner Setting  Group Characteristics  .56a  .21  −.09  .47b  .22  Number of dropouts  −.21  −.52a  −.04  −.02  −.31b  Group size  .26  .29  .23  .25  .40b  Networks and Communications   Within the school  .33b  −.14  −.21  .18  −.15   Within the youth group  .51a  .19  .01  .26  .20   Within the leadership program  .07  .26  .09  .28  .29  Implementation climate   Tension for Change  .26  .10  −.07  −.16  −.04   Compatibility  −.05  .75a  −.06  −.22  .27   Priority  Missing  Missing  Missing  Missing  Missing  Readiness for implementation   Leadership Engagement  −.11  .18  .23  .20  .31b   Available Resources  −.13  .15  .27  −.53a  .09  IV. Characteristics of Individuals  Identification with Project  .09  .12  .19  .25  .27  V. Process  Planning  .20  −.35b  −.57a  .11  −.54a  Engaging   Student group leader  .13  .55a  .23  .11  .63a   Inner (school) Stakeholders  .31b  −.26  .10  .29  .02   External Change Agents (outer stakeholders)  .18  .53a  .27  .18  .53a  Executing  .34b  .21  −.02  .41b  .26  Reflecting and Evaluating  .41b  .06  .14  .36b  .25    Implementation outcomes  CFIR constructs  Progress  Penetration  Health Impact  Sustainability  Composite  I. Intervention Characteristics  Intervention Source (Internal)  −.23  .40b  .43b  −.50a  .30b  Relative Advantage  Missing  Missing  Missing  Missing  Missing  Perceived Complexity  .36b  −.07  .09  .14  .05  Cost  .15  −.04  −.19  −.11  −.17  II. Outer Setting  Student and Community Needs and Resources  .16  .27  .41b  .06  .44b  Cosmopolitanism  .14  .43b  .35b  .36b  .59a  Peer Pressure  Missing  Missing  Missing  Missing  Missing  III. Inner Setting  Group Characteristics  .56a  .21  −.09  .47b  .22  Number of dropouts  −.21  −.52a  −.04  −.02  −.31b  Group size  .26  .29  .23  .25  .40b  Networks and Communications   Within the school  .33b  −.14  −.21  .18  −.15   Within the youth group  .51a  .19  .01  .26  .20   Within the leadership program  .07  .26  .09  .28  .29  Implementation climate   Tension for Change  .26  .10  −.07  −.16  −.04   Compatibility  −.05  .75a  −.06  −.22  .27   Priority  Missing  Missing  Missing  Missing  Missing  Readiness for implementation   Leadership Engagement  −.11  .18  .23  .20  .31b   Available Resources  −.13  .15  .27  −.53a  .09  IV. Characteristics of Individuals  Identification with Project  .09  .12  .19  .25  .27  V. Process  Planning  .20  −.35b  −.57a  .11  −.54a  Engaging   Student group leader  .13  .55a  .23  .11  .63a   Inner (school) Stakeholders  .31b  −.26  .10  .29  .02   External Change Agents (outer stakeholders)  .18  .53a  .27  .18  .53a  Executing  .34b  .21  −.02  .41b  .26  Reflecting and Evaluating  .41b  .06  .14  .36b  .25  alarge correlation (r ≥ .50); bmoderate correlation (r = .30–.49); Composite = sum score including Penetration, Sustainability, and Health Impact. View Large Table 3 | Relationship between CFIR constructs and implementation outcomes (Pearson r)   Implementation outcomes  CFIR constructs  Progress  Penetration  Health Impact  Sustainability  Composite  I. Intervention Characteristics  Intervention Source (Internal)  −.23  .40b  .43b  −.50a  .30b  Relative Advantage  Missing  Missing  Missing  Missing  Missing  Perceived Complexity  .36b  −.07  .09  .14  .05  Cost  .15  −.04  −.19  −.11  −.17  II. Outer Setting  Student and Community Needs and Resources  .16  .27  .41b  .06  .44b  Cosmopolitanism  .14  .43b  .35b  .36b  .59a  Peer Pressure  Missing  Missing  Missing  Missing  Missing  III. Inner Setting  Group Characteristics  .56a  .21  −.09  .47b  .22  Number of dropouts  −.21  −.52a  −.04  −.02  −.31b  Group size  .26  .29  .23  .25  .40b  Networks and Communications   Within the school  .33b  −.14  −.21  .18  −.15   Within the youth group  .51a  .19  .01  .26  .20   Within the leadership program  .07  .26  .09  .28  .29  Implementation climate   Tension for Change  .26  .10  −.07  −.16  −.04   Compatibility  −.05  .75a  −.06  −.22  .27   Priority  Missing  Missing  Missing  Missing  Missing  Readiness for implementation   Leadership Engagement  −.11  .18  .23  .20  .31b   Available Resources  −.13  .15  .27  −.53a  .09  IV. Characteristics of Individuals  Identification with Project  .09  .12  .19  .25  .27  V. Process  Planning  .20  −.35b  −.57a  .11  −.54a  Engaging   Student group leader  .13  .55a  .23  .11  .63a   Inner (school) Stakeholders  .31b  −.26  .10  .29  .02   External Change Agents (outer stakeholders)  .18  .53a  .27  .18  .53a  Executing  .34b  .21  −.02  .41b  .26  Reflecting and Evaluating  .41b  .06  .14  .36b  .25    Implementation outcomes  CFIR constructs  Progress  Penetration  Health Impact  Sustainability  Composite  I. Intervention Characteristics  Intervention Source (Internal)  −.23  .40b  .43b  −.50a  .30b  Relative Advantage  Missing  Missing  Missing  Missing  Missing  Perceived Complexity  .36b  −.07  .09  .14  .05  Cost  .15  −.04  −.19  −.11  −.17  II. Outer Setting  Student and Community Needs and Resources  .16  .27  .41b  .06  .44b  Cosmopolitanism  .14  .43b  .35b  .36b  .59a  Peer Pressure  Missing  Missing  Missing  Missing  Missing  III. Inner Setting  Group Characteristics  .56a  .21  −.09  .47b  .22  Number of dropouts  −.21  −.52a  −.04  −.02  −.31b  Group size  .26  .29  .23  .25  .40b  Networks and Communications   Within the school  .33b  −.14  −.21  .18  −.15   Within the youth group  .51a  .19  .01  .26  .20   Within the leadership program  .07  .26  .09  .28  .29  Implementation climate   Tension for Change  .26  .10  −.07  −.16  −.04   Compatibility  −.05  .75a  −.06  −.22  .27   Priority  Missing  Missing  Missing  Missing  Missing  Readiness for implementation   Leadership Engagement  −.11  .18  .23  .20  .31b   Available Resources  −.13  .15  .27  −.53a  .09  IV. Characteristics of Individuals  Identification with Project  .09  .12  .19  .25  .27  V. Process  Planning  .20  −.35b  −.57a  .11  −.54a  Engaging   Student group leader  .13  .55a  .23  .11  .63a   Inner (school) Stakeholders  .31b  −.26  .10  .29  .02   External Change Agents (outer stakeholders)  .18  .53a  .27  .18  .53a  Executing  .34b  .21  −.02  .41b  .26  Reflecting and Evaluating  .41b  .06  .14  .36b  .25  alarge correlation (r ≥ .50); bmoderate correlation (r = .30–.49); Composite = sum score including Penetration, Sustainability, and Health Impact. View Large The factors that were positively related to the Implementation Success Composite (eight in the expected direction) were Student Group Leader Engagement, Cosmopolitanism, External Change Agents, Student and Community Needs and Resources, Group Size, Leadership Engagement, and Intervention Source (r = .30–.63). The factors that were negatively related to the Implementation Success Composite score were Planning and Number of Dropouts (r = −.54 and −.31, respectively). Table 4 presents summaries and example responses from the qualitative interviews for CFIR constructs that were positively associated with ≥2 Implementation Outcomes, and Table 5 presents two case examples showing the impacts of constructs related to group function and community-connectedness on implementation success. This information provides more detail on how the constructs manifested in the advocacy projects and how they led to or inhibited success. Table 4 | Summary and example interviewee responses for key constructs identified CFIR construct  Summary and example response(s)  Intervention Source (internal)  Summary: Groups with high scores on Intervention Source noted that the group developed the project idea internally and expressed confidence in their idea. Some groups also offered a rationale for why their project would be unique. Example: “The easiest parts were probably thinking of the project idea because the first day that we got introduced to the [leadership program], we were like, ‘Okay, we got this.’ and we knew what we were going to do all along...”  Student and Community Needs and Resources  Summary: Groups with high scores on Student and Community Needs and Resources noted areas that were lacking in their school or community and tailored their projects to fit those needs. Example: “We had a survey like for the whole school, for teachers and students, and over half of our students at our school liked the idea of having an outdoor classroom. I think it would motivate them to come to school and do better in school, as well as teaching the stuff that they would, it would be a really nice idea and a good thing for their classroom as well to have.” Example: “Our goal was to like incorporate like the food grown in our garden into like different classes so our biology class can learn about the photosynthesis and how plant life works and they can incorporate it into their experiments. Also we have a business house so people who want to do something business related they can work that in and see how to start their own companies or how to start selling and how to balance things so that can be incorporated into that whole area. Also our funding was cut for our wellness class so they did not get to do a lot of cooking this year.”  Cosmopolitanism  Summary: Groups with high scores on Cosmopolitanism reported that they had support in the form of resources, information, and/or assistance from community partners with regards to planning and implementation. Example: “We had a bunch of people come in and we presented our idea to our commissioner and she thought it was a good idea. She supported us in it (.…) and then there was another guy who came in to talk to us. He scheduled like community sand volleyball meets. He would go from community to community and help us or help the people make it like an affair, like something to be excited about, how to set up teams, how do people pay for it if they do.”  Group Characteristics  Summary: Favorable Group Characteristics included utilizing all members’ strengths during project implementation, group member investment (e.g., attending meetings, completing assigned responsibilities, contributing ideas, willingness to help), setting a plan at the beginning of the project and staying on track with the plan, collaboration, and strong communication. Example: “The strategies we used were respect for one because we had to respect each other in order to get the project done. In order to get ideas off the ground we had to respect that your idea may not be used or this idea is good. Time management was one of our biggest strategies because we knew we had months to prepare for it. (.…) We met with each other a lot and I’m pretty sure they’re sick of me because we met with each other so much. Having fun—we had a lot of fun doing this (.…) there were some points where we just wanted to give up, but overall we kind of stuck by each other’s side and just pushed through it.”  Student Group Leader Engagement  Summary: Groups with high scores on Student Group Leader Engagement had leaders that felt personal responsibility for making sure the project was completed, and made changes (i.e., increased frequency of meetings) to meet this goal. They also worked with the strengths of each group member to delegate tasks. Example: “As soon as we figured out what people were best at we took their strengths and were able to kind of hand out what they would do. (…) It took a lot of us having to talk to each other and figure out what one person is best at and maybe this person is not so good at putting presentations together but they are really great at public speaking, so we had to work something out and figure out what everyone was good at.”  External Change Agents (outer stakeholders)  Summary: Groups with high scores on External Change Agents worked with organizations outside of their school to learn a skill or information related to their projects, or to secure resources or event space that would support the project or event. Example: “They donate supplies for us and at a cheaper cost, so different things we need, like shovels and different tools we need within the garden they give them to us at a lower price. So it is affordable and they work with many schools and so we asked them if they would work with our school.”  Executing  Summary: Groups with high scores on Executing divided the project into steps and worked through them to complete their project goals. Example: “We tried to break it up in sections so we did like the filming section. Well, we did the brainstorming section, the filming section, and the editing section. (…) We all knew that we were going to do some type of video or something because we thought that would be funny. So we did that. We sat down and we got to filming and we had to cut some of our ideas out because we were kind of working on a time constraint...”  Reflecting and Evaluating  Summary: Groups with high scores on Reflecting and Evaluating solicited and received feedback from participants and administration. Example: “Everyone felt like it was a good idea because we already talked about what we wanted to do and we voted on it. Also even afterwards they thought it was a great idea. Even we had fun doing it. A lot of people came out and they said they enjoyed it. Our administration said we did a great job with hosting it and making sure everything was cleaned up.”  CFIR construct  Summary and example response(s)  Intervention Source (internal)  Summary: Groups with high scores on Intervention Source noted that the group developed the project idea internally and expressed confidence in their idea. Some groups also offered a rationale for why their project would be unique. Example: “The easiest parts were probably thinking of the project idea because the first day that we got introduced to the [leadership program], we were like, ‘Okay, we got this.’ and we knew what we were going to do all along...”  Student and Community Needs and Resources  Summary: Groups with high scores on Student and Community Needs and Resources noted areas that were lacking in their school or community and tailored their projects to fit those needs. Example: “We had a survey like for the whole school, for teachers and students, and over half of our students at our school liked the idea of having an outdoor classroom. I think it would motivate them to come to school and do better in school, as well as teaching the stuff that they would, it would be a really nice idea and a good thing for their classroom as well to have.” Example: “Our goal was to like incorporate like the food grown in our garden into like different classes so our biology class can learn about the photosynthesis and how plant life works and they can incorporate it into their experiments. Also we have a business house so people who want to do something business related they can work that in and see how to start their own companies or how to start selling and how to balance things so that can be incorporated into that whole area. Also our funding was cut for our wellness class so they did not get to do a lot of cooking this year.”  Cosmopolitanism  Summary: Groups with high scores on Cosmopolitanism reported that they had support in the form of resources, information, and/or assistance from community partners with regards to planning and implementation. Example: “We had a bunch of people come in and we presented our idea to our commissioner and she thought it was a good idea. She supported us in it (.…) and then there was another guy who came in to talk to us. He scheduled like community sand volleyball meets. He would go from community to community and help us or help the people make it like an affair, like something to be excited about, how to set up teams, how do people pay for it if they do.”  Group Characteristics  Summary: Favorable Group Characteristics included utilizing all members’ strengths during project implementation, group member investment (e.g., attending meetings, completing assigned responsibilities, contributing ideas, willingness to help), setting a plan at the beginning of the project and staying on track with the plan, collaboration, and strong communication. Example: “The strategies we used were respect for one because we had to respect each other in order to get the project done. In order to get ideas off the ground we had to respect that your idea may not be used or this idea is good. Time management was one of our biggest strategies because we knew we had months to prepare for it. (.…) We met with each other a lot and I’m pretty sure they’re sick of me because we met with each other so much. Having fun—we had a lot of fun doing this (.…) there were some points where we just wanted to give up, but overall we kind of stuck by each other’s side and just pushed through it.”  Student Group Leader Engagement  Summary: Groups with high scores on Student Group Leader Engagement had leaders that felt personal responsibility for making sure the project was completed, and made changes (i.e., increased frequency of meetings) to meet this goal. They also worked with the strengths of each group member to delegate tasks. Example: “As soon as we figured out what people were best at we took their strengths and were able to kind of hand out what they would do. (…) It took a lot of us having to talk to each other and figure out what one person is best at and maybe this person is not so good at putting presentations together but they are really great at public speaking, so we had to work something out and figure out what everyone was good at.”  External Change Agents (outer stakeholders)  Summary: Groups with high scores on External Change Agents worked with organizations outside of their school to learn a skill or information related to their projects, or to secure resources or event space that would support the project or event. Example: “They donate supplies for us and at a cheaper cost, so different things we need, like shovels and different tools we need within the garden they give them to us at a lower price. So it is affordable and they work with many schools and so we asked them if they would work with our school.”  Executing  Summary: Groups with high scores on Executing divided the project into steps and worked through them to complete their project goals. Example: “We tried to break it up in sections so we did like the filming section. Well, we did the brainstorming section, the filming section, and the editing section. (…) We all knew that we were going to do some type of video or something because we thought that would be funny. So we did that. We sat down and we got to filming and we had to cut some of our ideas out because we were kind of working on a time constraint...”  Reflecting and Evaluating  Summary: Groups with high scores on Reflecting and Evaluating solicited and received feedback from participants and administration. Example: “Everyone felt like it was a good idea because we already talked about what we wanted to do and we voted on it. Also even afterwards they thought it was a great idea. Even we had fun doing it. A lot of people came out and they said they enjoyed it. Our administration said we did a great job with hosting it and making sure everything was cleaned up.”  Example responses are provided for constructs that had a moderate or large positive correlation with ≥2 Implementation Outcomes (including the Composite). View Large Table 4 | Summary and example interviewee responses for key constructs identified CFIR construct  Summary and example response(s)  Intervention Source (internal)  Summary: Groups with high scores on Intervention Source noted that the group developed the project idea internally and expressed confidence in their idea. Some groups also offered a rationale for why their project would be unique. Example: “The easiest parts were probably thinking of the project idea because the first day that we got introduced to the [leadership program], we were like, ‘Okay, we got this.’ and we knew what we were going to do all along...”  Student and Community Needs and Resources  Summary: Groups with high scores on Student and Community Needs and Resources noted areas that were lacking in their school or community and tailored their projects to fit those needs. Example: “We had a survey like for the whole school, for teachers and students, and over half of our students at our school liked the idea of having an outdoor classroom. I think it would motivate them to come to school and do better in school, as well as teaching the stuff that they would, it would be a really nice idea and a good thing for their classroom as well to have.” Example: “Our goal was to like incorporate like the food grown in our garden into like different classes so our biology class can learn about the photosynthesis and how plant life works and they can incorporate it into their experiments. Also we have a business house so people who want to do something business related they can work that in and see how to start their own companies or how to start selling and how to balance things so that can be incorporated into that whole area. Also our funding was cut for our wellness class so they did not get to do a lot of cooking this year.”  Cosmopolitanism  Summary: Groups with high scores on Cosmopolitanism reported that they had support in the form of resources, information, and/or assistance from community partners with regards to planning and implementation. Example: “We had a bunch of people come in and we presented our idea to our commissioner and she thought it was a good idea. She supported us in it (.…) and then there was another guy who came in to talk to us. He scheduled like community sand volleyball meets. He would go from community to community and help us or help the people make it like an affair, like something to be excited about, how to set up teams, how do people pay for it if they do.”  Group Characteristics  Summary: Favorable Group Characteristics included utilizing all members’ strengths during project implementation, group member investment (e.g., attending meetings, completing assigned responsibilities, contributing ideas, willingness to help), setting a plan at the beginning of the project and staying on track with the plan, collaboration, and strong communication. Example: “The strategies we used were respect for one because we had to respect each other in order to get the project done. In order to get ideas off the ground we had to respect that your idea may not be used or this idea is good. Time management was one of our biggest strategies because we knew we had months to prepare for it. (.…) We met with each other a lot and I’m pretty sure they’re sick of me because we met with each other so much. Having fun—we had a lot of fun doing this (.…) there were some points where we just wanted to give up, but overall we kind of stuck by each other’s side and just pushed through it.”  Student Group Leader Engagement  Summary: Groups with high scores on Student Group Leader Engagement had leaders that felt personal responsibility for making sure the project was completed, and made changes (i.e., increased frequency of meetings) to meet this goal. They also worked with the strengths of each group member to delegate tasks. Example: “As soon as we figured out what people were best at we took their strengths and were able to kind of hand out what they would do. (…) It took a lot of us having to talk to each other and figure out what one person is best at and maybe this person is not so good at putting presentations together but they are really great at public speaking, so we had to work something out and figure out what everyone was good at.”  External Change Agents (outer stakeholders)  Summary: Groups with high scores on External Change Agents worked with organizations outside of their school to learn a skill or information related to their projects, or to secure resources or event space that would support the project or event. Example: “They donate supplies for us and at a cheaper cost, so different things we need, like shovels and different tools we need within the garden they give them to us at a lower price. So it is affordable and they work with many schools and so we asked them if they would work with our school.”  Executing  Summary: Groups with high scores on Executing divided the project into steps and worked through them to complete their project goals. Example: “We tried to break it up in sections so we did like the filming section. Well, we did the brainstorming section, the filming section, and the editing section. (…) We all knew that we were going to do some type of video or something because we thought that would be funny. So we did that. We sat down and we got to filming and we had to cut some of our ideas out because we were kind of working on a time constraint...”  Reflecting and Evaluating  Summary: Groups with high scores on Reflecting and Evaluating solicited and received feedback from participants and administration. Example: “Everyone felt like it was a good idea because we already talked about what we wanted to do and we voted on it. Also even afterwards they thought it was a great idea. Even we had fun doing it. A lot of people came out and they said they enjoyed it. Our administration said we did a great job with hosting it and making sure everything was cleaned up.”  CFIR construct  Summary and example response(s)  Intervention Source (internal)  Summary: Groups with high scores on Intervention Source noted that the group developed the project idea internally and expressed confidence in their idea. Some groups also offered a rationale for why their project would be unique. Example: “The easiest parts were probably thinking of the project idea because the first day that we got introduced to the [leadership program], we were like, ‘Okay, we got this.’ and we knew what we were going to do all along...”  Student and Community Needs and Resources  Summary: Groups with high scores on Student and Community Needs and Resources noted areas that were lacking in their school or community and tailored their projects to fit those needs. Example: “We had a survey like for the whole school, for teachers and students, and over half of our students at our school liked the idea of having an outdoor classroom. I think it would motivate them to come to school and do better in school, as well as teaching the stuff that they would, it would be a really nice idea and a good thing for their classroom as well to have.” Example: “Our goal was to like incorporate like the food grown in our garden into like different classes so our biology class can learn about the photosynthesis and how plant life works and they can incorporate it into their experiments. Also we have a business house so people who want to do something business related they can work that in and see how to start their own companies or how to start selling and how to balance things so that can be incorporated into that whole area. Also our funding was cut for our wellness class so they did not get to do a lot of cooking this year.”  Cosmopolitanism  Summary: Groups with high scores on Cosmopolitanism reported that they had support in the form of resources, information, and/or assistance from community partners with regards to planning and implementation. Example: “We had a bunch of people come in and we presented our idea to our commissioner and she thought it was a good idea. She supported us in it (.…) and then there was another guy who came in to talk to us. He scheduled like community sand volleyball meets. He would go from community to community and help us or help the people make it like an affair, like something to be excited about, how to set up teams, how do people pay for it if they do.”  Group Characteristics  Summary: Favorable Group Characteristics included utilizing all members’ strengths during project implementation, group member investment (e.g., attending meetings, completing assigned responsibilities, contributing ideas, willingness to help), setting a plan at the beginning of the project and staying on track with the plan, collaboration, and strong communication. Example: “The strategies we used were respect for one because we had to respect each other in order to get the project done. In order to get ideas off the ground we had to respect that your idea may not be used or this idea is good. Time management was one of our biggest strategies because we knew we had months to prepare for it. (.…) We met with each other a lot and I’m pretty sure they’re sick of me because we met with each other so much. Having fun—we had a lot of fun doing this (.…) there were some points where we just wanted to give up, but overall we kind of stuck by each other’s side and just pushed through it.”  Student Group Leader Engagement  Summary: Groups with high scores on Student Group Leader Engagement had leaders that felt personal responsibility for making sure the project was completed, and made changes (i.e., increased frequency of meetings) to meet this goal. They also worked with the strengths of each group member to delegate tasks. Example: “As soon as we figured out what people were best at we took their strengths and were able to kind of hand out what they would do. (…) It took a lot of us having to talk to each other and figure out what one person is best at and maybe this person is not so good at putting presentations together but they are really great at public speaking, so we had to work something out and figure out what everyone was good at.”  External Change Agents (outer stakeholders)  Summary: Groups with high scores on External Change Agents worked with organizations outside of their school to learn a skill or information related to their projects, or to secure resources or event space that would support the project or event. Example: “They donate supplies for us and at a cheaper cost, so different things we need, like shovels and different tools we need within the garden they give them to us at a lower price. So it is affordable and they work with many schools and so we asked them if they would work with our school.”  Executing  Summary: Groups with high scores on Executing divided the project into steps and worked through them to complete their project goals. Example: “We tried to break it up in sections so we did like the filming section. Well, we did the brainstorming section, the filming section, and the editing section. (…) We all knew that we were going to do some type of video or something because we thought that would be funny. So we did that. We sat down and we got to filming and we had to cut some of our ideas out because we were kind of working on a time constraint...”  Reflecting and Evaluating  Summary: Groups with high scores on Reflecting and Evaluating solicited and received feedback from participants and administration. Example: “Everyone felt like it was a good idea because we already talked about what we wanted to do and we voted on it. Also even afterwards they thought it was a great idea. Even we had fun doing it. A lot of people came out and they said they enjoyed it. Our administration said we did a great job with hosting it and making sure everything was cleaned up.”  Example responses are provided for constructs that had a moderate or large positive correlation with ≥2 Implementation Outcomes (including the Composite). View Large Table 5 | Case examples showing the impacts of constructs related to group function and community-connectedness on implementation success Project description  Implementation Outcome scoresa  How primary driving implementation factors manifested in the group  Scores for primary driving implementation factorsb  Case 1: This group project included adding an outdoor sand volleyball court to a public neighborhood park. The court was not created during the study timeline, but the group made significant progress including obtaining a design, cost estimate, and approval from the city commissioner and parks and recreation department.  Progress: 2 Penetration: 1 Health Impact: 3 Sustainability: 1 Composite: 5  Group worked with and received support from the city commissioner, parks and recreation staff, and a community member who organizes and schedules sand volleyball meets.  Cosmopolitanism: 2  Group members enjoyed each other’s presence, were friendly towards each other, showed concern about the project outcome, participated equally, were organized, worked together towards group goals, cooperated, and helped immediately when asked.  Group Characteristics: 2  Parks and recreation staff provided consent to complete project and the city commissioner provided support.  External Change Agents: 2  Case 2: This group planned to host a field day event to promote physical activity among elementary school students. They also planned to provide healthy food for students during this event to model healthy eating. The project was not completed and little progress was made due to internal (i.e., follow through) rather than external (e.g., obtaining approval) factors.  Progress: 0 Penetration: 0 Health Impact: 2 Sustainability: 0 Composite: 2  Group members had difficulty with time management and prioritizing the project. One member left the group because of negative interactions (teasing) with other members of the group.  Group Characteristics: −2  Group members were often not able to find/agree on meeting times. They frequently cancelled meetings because of school fieldtrips or assignments/ tests. Member attendance was low and inconsistent when meetings were held.  Networks and Communications— Within the Youth Group: −2  Group acknowledged that they needed the help of area elementary school principals to complete their project, but did not connect with them.  Cosmopolitanism: −1  Group talked to school administration about reaching out to principals in the community; however, the group did not follow up with the administration’s suggestions following this conversation.  External Change Agents: −1  Project description  Implementation Outcome scoresa  How primary driving implementation factors manifested in the group  Scores for primary driving implementation factorsb  Case 1: This group project included adding an outdoor sand volleyball court to a public neighborhood park. The court was not created during the study timeline, but the group made significant progress including obtaining a design, cost estimate, and approval from the city commissioner and parks and recreation department.  Progress: 2 Penetration: 1 Health Impact: 3 Sustainability: 1 Composite: 5  Group worked with and received support from the city commissioner, parks and recreation staff, and a community member who organizes and schedules sand volleyball meets.  Cosmopolitanism: 2  Group members enjoyed each other’s presence, were friendly towards each other, showed concern about the project outcome, participated equally, were organized, worked together towards group goals, cooperated, and helped immediately when asked.  Group Characteristics: 2  Parks and recreation staff provided consent to complete project and the city commissioner provided support.  External Change Agents: 2  Case 2: This group planned to host a field day event to promote physical activity among elementary school students. They also planned to provide healthy food for students during this event to model healthy eating. The project was not completed and little progress was made due to internal (i.e., follow through) rather than external (e.g., obtaining approval) factors.  Progress: 0 Penetration: 0 Health Impact: 2 Sustainability: 0 Composite: 2  Group members had difficulty with time management and prioritizing the project. One member left the group because of negative interactions (teasing) with other members of the group.  Group Characteristics: −2  Group members were often not able to find/agree on meeting times. They frequently cancelled meetings because of school fieldtrips or assignments/ tests. Member attendance was low and inconsistent when meetings were held.  Networks and Communications— Within the Youth Group: −2  Group acknowledged that they needed the help of area elementary school principals to complete their project, but did not connect with them.  Cosmopolitanism: −1  Group talked to school administration about reaching out to principals in the community; however, the group did not follow up with the administration’s suggestions following this conversation.  External Change Agents: −1  aPossible range: Progress = 0–3, Penetration = 0–3, Health Impact = 0–3, Sustainability = 0–1, Composite (excludes Progress) = 0–7; bPossible range = −2 to 2 View Large Table 5 | Case examples showing the impacts of constructs related to group function and community-connectedness on implementation success Project description  Implementation Outcome scoresa  How primary driving implementation factors manifested in the group  Scores for primary driving implementation factorsb  Case 1: This group project included adding an outdoor sand volleyball court to a public neighborhood park. The court was not created during the study timeline, but the group made significant progress including obtaining a design, cost estimate, and approval from the city commissioner and parks and recreation department.  Progress: 2 Penetration: 1 Health Impact: 3 Sustainability: 1 Composite: 5  Group worked with and received support from the city commissioner, parks and recreation staff, and a community member who organizes and schedules sand volleyball meets.  Cosmopolitanism: 2  Group members enjoyed each other’s presence, were friendly towards each other, showed concern about the project outcome, participated equally, were organized, worked together towards group goals, cooperated, and helped immediately when asked.  Group Characteristics: 2  Parks and recreation staff provided consent to complete project and the city commissioner provided support.  External Change Agents: 2  Case 2: This group planned to host a field day event to promote physical activity among elementary school students. They also planned to provide healthy food for students during this event to model healthy eating. The project was not completed and little progress was made due to internal (i.e., follow through) rather than external (e.g., obtaining approval) factors.  Progress: 0 Penetration: 0 Health Impact: 2 Sustainability: 0 Composite: 2  Group members had difficulty with time management and prioritizing the project. One member left the group because of negative interactions (teasing) with other members of the group.  Group Characteristics: −2  Group members were often not able to find/agree on meeting times. They frequently cancelled meetings because of school fieldtrips or assignments/ tests. Member attendance was low and inconsistent when meetings were held.  Networks and Communications— Within the Youth Group: −2  Group acknowledged that they needed the help of area elementary school principals to complete their project, but did not connect with them.  Cosmopolitanism: −1  Group talked to school administration about reaching out to principals in the community; however, the group did not follow up with the administration’s suggestions following this conversation.  External Change Agents: −1  Project description  Implementation Outcome scoresa  How primary driving implementation factors manifested in the group  Scores for primary driving implementation factorsb  Case 1: This group project included adding an outdoor sand volleyball court to a public neighborhood park. The court was not created during the study timeline, but the group made significant progress including obtaining a design, cost estimate, and approval from the city commissioner and parks and recreation department.  Progress: 2 Penetration: 1 Health Impact: 3 Sustainability: 1 Composite: 5  Group worked with and received support from the city commissioner, parks and recreation staff, and a community member who organizes and schedules sand volleyball meets.  Cosmopolitanism: 2  Group members enjoyed each other’s presence, were friendly towards each other, showed concern about the project outcome, participated equally, were organized, worked together towards group goals, cooperated, and helped immediately when asked.  Group Characteristics: 2  Parks and recreation staff provided consent to complete project and the city commissioner provided support.  External Change Agents: 2  Case 2: This group planned to host a field day event to promote physical activity among elementary school students. They also planned to provide healthy food for students during this event to model healthy eating. The project was not completed and little progress was made due to internal (i.e., follow through) rather than external (e.g., obtaining approval) factors.  Progress: 0 Penetration: 0 Health Impact: 2 Sustainability: 0 Composite: 2  Group members had difficulty with time management and prioritizing the project. One member left the group because of negative interactions (teasing) with other members of the group.  Group Characteristics: −2  Group members were often not able to find/agree on meeting times. They frequently cancelled meetings because of school fieldtrips or assignments/ tests. Member attendance was low and inconsistent when meetings were held.  Networks and Communications— Within the Youth Group: −2  Group acknowledged that they needed the help of area elementary school principals to complete their project, but did not connect with them.  Cosmopolitanism: −1  Group talked to school administration about reaching out to principals in the community; however, the group did not follow up with the administration’s suggestions following this conversation.  External Change Agents: −1  aPossible range: Progress = 0–3, Penetration = 0–3, Health Impact = 0–3, Sustainability = 0–1, Composite (excludes Progress) = 0–7; bPossible range = −2 to 2 View Large DISCUSSION Youth advocacy programs are promising for increasing community capacity for improving healthy eating and active living [17–20]. Such programs support youth to have a voice in their community and stimulate health-related behavioral and environmental improvements through participatory approaches. However, little evidence exists on contextual factors related to implementing youth advocacy programs, such as barriers and facilitators of successful implementation. The present study used a comprehensive implementation science framework (CFIR) [30] to identify factors related to implementation success. Several key factors emerged as being important to implementation, with Cosmopolitanism (leveraging connections within the community) and Internal Intervention Source (student autonomy in selecting a project) having the most consistent associations with Implementation Success. Leaders of youth advocacy programs should target these implementation factors to maximize success of their programs. In addition to Cosmopolitanism and Internal Intervention Source, six other Implementation Factors were related to the Implementation Success Composite in the expected direction, and four of these factors were also related to Penetration or Health Impact, suggesting that these are also important factors to consider when developing implementation strategies. The six factors were either generally related to the involvement of stakeholders (constructs: External Change Agents, Leadership Engagement) or the function of the group (constructs: Student Group Leader Engagement, Group Size, Number of Dropouts [negative]), with the exception of Student and Community Needs and Resources. This suggests that strategies that engage stakeholders and improve group function should be targeted to increase the success of youth advocacy programs. A key aspect of stakeholder engagement is community-connectedness, which can be supported by linking youth to local community organizations that support their mission. Many of the projects were not accomplishable without identifying linkages in the community and working with those individuals. This was highlighted in the case studies, in which one group made significant progress towards their project by working with the parks and recreation department and city commissioner, whereas another group did not make much progress towards their project partly because no contact was made with the primary stakeholders (elementary school principals). Identifying and establishing contact with community stakeholders can be difficult for youth and in some cases may need to be facilitated by an intervention leader or school staff member. Further training on this topic, one-on-one support, and implementing a requirement for groups to work with an outside community stakeholder may increase the likelihood of groups making such connections. Groups with favorable group characteristics were more organized, communicated regularly, stuck together, and got along. This was also highlighted in the case studies, in which one group was highly organized and enjoyed working together, whereas the other group was disorganized, did not meet regularly, and had interpersonal conflicts. Group function can be supported through a number of strategies such as setting group goals at the outset [34], establishing written group expectations and repercussions for not abiding by them, using a team name [35], and encouraging the group to reflect on their performance at regular intervals [36]. Many of the groups with favorable group characteristics appeared to have a strong leader that kept the group together, as shown in Table 4 under the Student Group Leader Engagement construct. Youth advocacy intervention leaders could support group function by encouraging natural formation of groups and working directly with group leaders on how to support positive group interactions and organization. The findings related to Student and Community Needs and Resources suggest that it is important for the project to fit well within the school or target community, which should be considered when identifying a project. It is likely that groups who took the needs of their community or setting into account were more likely to elicit support from community or school stakeholders (e.g., students, administrators). Gaining stakeholder inclusion during both conceptualization and implementation is likely to be beneficial. This could be accomplished through polls or interviews with stakeholders (e.g., students, staff, and community members), which was done by at least one group in this study. Some of the Implementation Factor–Implementation Outcome associations were outcome specific. In particular, four of the seven factors that were associated with Progress were not associated with any of the other Implementation Outcomes or the Implementation Success Composite (constructs: Perceived Complexity, Networks and Communication Within the School, and Within the Youth Group, and Engaging Inner Stakeholders). Although these factors appear important to supporting projects to be completed within the timeframe of the program, the balance between progress and impact should be considered. Some projects with high ratings on Penetration, Health Impact, and Sustainability (e.g., multilevel or environmental projects) were not accomplished during the timeframe of the program, although substantial progress was made (e.g., commitment and/or funding was obtained). Since the leadership program was ongoing, the next cohort of students could complete the projects, although this may not be feasible in programs that are not ongoing. Program leaders should support students to identify projects that will maximize Penetration, Health Impact, and Sustainability while maintaining feasibility, and not discourage complex projects that are likely to have large impacts. Compatibility was also related to only one Implementation Factor (Penetration). This suggests that projects that were compatible with the needs of other students in the schools or members of the community were more likely to engage a larger number of people. This is similar to the findings related to Student and Community Needs and Resources and further suggests the importance of considering student and/or community member input when selecting a project. A few Implementation Factors were related to the Implementation Outcomes in the opposite direction as expected. Having an Internal Intervention Source and lower availability of resources were negatively related to Sustainability. This was likely because many groups may have opted for projects that were perceived as less difficult and requiring fewer resources. It is unclear why Planning was negatively related to Penetration, Health Impact, and the Composite. In comparison to other evaluations of youth advocacy programs (e.g., [19, 20]), the present program included fewer environmental improvement projects and more health-related outreach and event projects. Both types of projects can have health benefits and are represented in ecological models [11–14]. However, the environmental projects were generally rated as having higher Penetration, Health Impacts, and Sustainability, and thus should be a focus of youth advocacy programs. The large number of outreach and event projects in the present program likely occurred because these types of projects were viewed as more feasible to accomplish and the youth were not guided by an evidence-based curriculum. Evidence-based youth advocacy curriculums exist, such as from the Healthy Young People Empowerment Project (HYPE) [20] and Youth Engagement and Action for Health (Yeah!) [19]. More structured support from program staff, resources, and accountability are also likely needed to increase the number of groups that target high-impact projects. One lesson learned in the present study was that groups who had contact with older peers who had previously completed the leadership program were more likely to propose a project that targeted the built environment. Thus, program leaders should support carry-over of projects and/or ideas from year-to-year when ongoing programs as in place. Strengths, limitations, and future directions Study strengths included use of mixed-methods and a sample of mostly low socioeconomic status schools and youth, which are common settings for youth advocacy interventions. A study limitation is that the interview questions broadly asked about CFIR domains, not specific CFIR constructs, so we could not gauge whether certain constructs (e.g., Relative Advantage) were irrelevant or whether they were not captured in the interviews as a result of the general questions. Some constructs, such as Knowledge, were not assessed but have been associated with implementation success in other studies [18] and thus warrant incorporation into implementation strategies. Interviewing only one group member may have resulted in missed or biased information, particularly because the interviewee was not always the group leader. A large number of schools was included, but findings are from only one youth advocacy program and may not generalize to other programs such as those with different formats (e.g., adhering to an evidence-based curriculum) or structure (e.g., community-based rather than school-based, ongoing vs. one-time). Another limitation to this evaluation was that the data were observational and cross-sectional, so it is not clear whether targeting one of the emerging Implementation Factors (e.g., Cosmopolitanism) would result in improved implementation success. CONCLUSIONS The present study found that youth groups who had autonomy in selecting their projects, were supported by outer stakeholders, and had well-functioning groups were more successful in their implementation efforts. To maximize success of youth advocacy efforts, evidence-based curriculums [19, 20] should be used and intervention leaders should support group idea formation using strategies such as encouraging group brainstorming early in the process, team-building exercises to strengthen relationships, modeling positive communication, and acting as a mediator when necessary. Multiple community linkages should also be supported to maximize project success. Youth advocacy has promise for improving healthy eating and active living in underserved communities and understanding how to best implement these programs will maximize impacts on health. Compliance with Ethical Standards Conflict of interest: All co-authors have reviewed the final version of this manuscript and there are no conflicts of interest to report. Ethical Approval: Institutional Review Board approval was obtained from Children’s Mercy Kansas City prior to the administration of the study. Informed Consent: All participants either signed or provided verbal informed consent. Acknowledgments: This project was funded by the Health Care Foundation of Greater Kansas City (grant number 133-FY15-4038). Thank you to the outstanding staff at 2020 Leadership, including Marilyn Alstrom, Crystal Nance, and Sally Dannov, for their support with this evaluation study and hard work in the arena of youth leadership and advocacy. This manuscript has not been previously published, data have not been previously reported, nor is it under review by another journal. Authors have full control of primary data and agree to allow this journal to review data if requested. References 1. Fryar CD, Carroll MD, Ogden CL. Prevalence of obesity among children and adolescents: United States, trends 1963–1965 through 2009–2010. National Center for Health Statistics . 2012; 1– 6. 2. CDC. Prevalence of overweight and obesity among children and adolescents aged 2–19 years: United States, 1963–1965 through 2013–2014 . Available at https://www.cdc.gov/nchs/data/hestat/obesity_child_13_14/obesity_child_13_14.htm. Updated June 13, 2016. Accessed December 20, 2016. 3. Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa heart study. Pediatrics . 2001; 108( 3): 712– 718. Google Scholar CrossRef Search ADS PubMed  4. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med . 1997; 337( 13): 869– 873. Google Scholar CrossRef Search ADS PubMed  5. Juonala M, Magnussen CG, Berenson GSet al.   Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med . 2011; 365( 20): 1876– 1885. Google Scholar CrossRef Search ADS PubMed  6. Canoy D, Bundred P. Obesity in children. BMJ Clinical Evidence . 2011; 2011: 0325. Google Scholar PubMed  7. CDC. Nutrition and the health of young people. Available at http://www.cdc.gov/healthyschools/nutrition/facts.htm. Updated August 28, 2015. Accessibility verified October 26, 2016. 8. Office of Disease Prevention and Health Promotion. DPHP. 2008 Physical Activity Guidelines for Americans. Available at https://health.gov/paguidelines/guidelines/ Updated May 15, 2017. Accessibility verified May 18, 2017. 9. Whitt-Glover MC, Taylor WC, Floyd MF, Yore MM, Yancey AK, Matthews CE. Disparities in physical activity and sedentary behaviors among US children and adolescents: prevalence, correlates, and intervention implications. J Public Health Policy . 2009; 30( 1): S309– S334. Google Scholar CrossRef Search ADS PubMed  10. Troiano RP, Berrigan D, Dodd KW, Masse LC, McDowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc . 2008; 40( 1): 181– 188. Google Scholar CrossRef Search ADS PubMed  11. Sallis JF, Owen N, Fisher EB. Ecological models of health behavior. In: Glanz K, Rimer BK, Viswanath K. eds. Health behavior and health education: theory, research, and practice . 4th ed. San Francisco, CA: Jossey-Bass; 2008. Available at http://riskybusiness.web.unc.edu/files/2015/01/Health-Behavior-and-Health-Education.pdf#page=503. Accessibility verified December 20, 2016. 12. CDC. A guide for community action. Available at http://www.cdc.gov/physicalactivity/strategies/communityguide.html. Updated May 16, 2017. Accessibility verified May 18, 2017. 13. US National Physical Activity Plan. Available at http://www.physicalactivityplan.org/. Updated April, 2016. Accessibility verified May 18, 2017. 14. Office of Disease Prevention and Health Promotion. Physical activity. Available at https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity/objectives. Updated May 18, 2017. Accessibility verified May 18, 2017. 15. Martin J. The role of advocacy. In: Waters E, Swinburn B, Seidell J, Uauy R, eds. Preventing childhood obesity: evidence policy and practice . Hoboken, NJ: Blackwell Publishing Ltd.; 2010: 192– 199. Google Scholar CrossRef Search ADS   16. Millstein RA, Sallis JF. Youth advocacy for obesity prevention: the next wave of social change for health. Transl Behav Med . 2011; 1( 3): 497– 505. Google Scholar CrossRef Search ADS PubMed  17. CDC. Best practices user guide: youth engagement—state and community interventions, 2010 . Atlanta, Georgia: U.S. Department of Health and Human Services Centers for Disease Control and Prevention; 2010. 18. Millstein RA, Woodruff SI, Linton LS, Edwards CC, Sallis JF. A pilot study evaluating the effects of a youth advocacy program on youth readiness to advocate for environment and policy changes for obesity prevention. Transl Behav Med . 2016; 6( 4): 648– 658. Google Scholar CrossRef Search ADS PubMed  19. Linton LS, Edwards CC, Woodruff SI, Millstein RA, Moder C. Youth advocacy as a tool for environmental and policy changes that support physical activity and nutrition: an evaluation study in San Diego County. Prev Chronic Dis . 2014; 11: E46 Google Scholar CrossRef Search ADS PubMed  20. Besenyi G, Carter T, Pope AW, Gordon K, Freeman B, Kaczynski AT. Healthy young people empowerment (HYPE) project: facilitator’s guid  e. Paper presented at American Public Health Association Meeting; November 15–19, 2014; New Orleans, LA. 21. Durlak JA, DuPre EP. Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. Am J Community Psychol . 2008; 41( 3–4): 327– 350. Google Scholar CrossRef Search ADS PubMed  22. Missouri Department of Elementary and Secondary Education. Food and nutrition services statistics. Available at https://dese.mo.gov/financial-admin-services/food-nutrition-services/statistics. Accessibility verified December 6, 2016. 23. Kansas State Department of Education. School finance publications. Available at http://www.ksde.org/Agency/Fiscal-and-Administrative-Services/School-Finance/Reports-and-Publications#Free%20and%20Reduced. Accessibility verified December 6, 2016. 24. 20/20 Leadership. What is 20/20 Leadership? Available at http://www.2020leadership.org/. Accessibility vereified May 18, 2017. 25. Healthy Lifestyles Initiative. 12345 Fit-Tastic! Available at http://fittastic.org/. Accessibility verified December 20, 2016. 26. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci . 2009; 4( 1): 50. Google Scholar CrossRef Search ADS PubMed  27. Consolidated Framework for Implementation Research. CFIR constructs. Available at http://www.cfirguide.org/constructs.html. Updated October 29, 2014. Accessibility verified January 13, 2016. 28. Damschroder LJ, Lowery, JC. Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR). Implement Sci . 2013; 8: 51. Google Scholar CrossRef Search ADS PubMed  29. Proctor E, Silmere H, Raghavan Ret al.   Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health . 2011; 38( 2): 65– 76. Google Scholar CrossRef Search ADS PubMed  30. Consolidated Framework for Implementation Research. Welcome to the CFIR Technical Assistance Website. Available at http://www.cfirguide.org/. Updated October 29, 2014. Accessibility verified November 18, 2016. 31. NVivo qualitative data analysis Software; QSR International Pty Ltd. Version 11, 2012. Available at https://www.qsrinternational.com/nvivo/home 32. Consolidated Framework for Implementation Research. CFIR Rating Rules. Available at http://www.cfirguide.org/RatingRules10.29.14.pdf. Accessibility verified December 20, 2016. 33. Cohen J. Statistical power analysis for the behavioral sciences . 2nd ed. New York, NY: Lawrence Erlbaum Associates; 1988. 34. Roseth CJ, Johnson DW, Johnson RT. Promoting early adolescents’ achievement and peer relationships: the effects of cooperative, competitive, and individualistic goal structures. Psychol Bull . 2008; 134( 2): 223– 246. Google Scholar CrossRef Search ADS PubMed  35. Oakley B, Felder RM, Brent R, Elhajj I. Turning student groups into effective teams. J Student Centered Learn . 2004; 2( 1): 9– 34. 36. Keavney A. Team building strategies. Train Dev J . 2016; 43( 2): 26– 28. APPENDIX. INTERVIEW CONTENT What is your project goal? Why did you choose that project idea?  Tell me about how you planned for and coordinated meetings? How often did they occur?  How were group members designated or assigned to roles? How did they interact with each other? How did group interactions impact project goals? How did group members view the project?  How were administrators and teachers involved throughout the project? How did others in the school view the project?  Who did you work with outside of the school to accomplish the project? How were they involved?  What strategies and/or steps did you take to accomplish your project goals?  What were the hardest parts of your project? Did you face any major problems?  What were the key things that helped you accomplish your project?  Was your project accomplished? What were your outcomes? Did you accomplish your project goals?  What types of supports would have made it easier to accomplish your project? What kind of feedback did you receive from those outside of your group about accomplishing your project?  Were you exposed to the 12345 Fit-Tastic! Message? Did you use it in your project or share it with others?  What is your project goal? Why did you choose that project idea?  Tell me about how you planned for and coordinated meetings? How often did they occur?  How were group members designated or assigned to roles? How did they interact with each other? How did group interactions impact project goals? How did group members view the project?  How were administrators and teachers involved throughout the project? How did others in the school view the project?  Who did you work with outside of the school to accomplish the project? How were they involved?  What strategies and/or steps did you take to accomplish your project goals?  What were the hardest parts of your project? Did you face any major problems?  What were the key things that helped you accomplish your project?  Was your project accomplished? What were your outcomes? Did you accomplish your project goals?  What types of supports would have made it easier to accomplish your project? What kind of feedback did you receive from those outside of your group about accomplishing your project?  Were you exposed to the 12345 Fit-Tastic! Message? Did you use it in your project or share it with others?  View Large What is your project goal? Why did you choose that project idea?  Tell me about how you planned for and coordinated meetings? How often did they occur?  How were group members designated or assigned to roles? How did they interact with each other? How did group interactions impact project goals? How did group members view the project?  How were administrators and teachers involved throughout the project? How did others in the school view the project?  Who did you work with outside of the school to accomplish the project? How were they involved?  What strategies and/or steps did you take to accomplish your project goals?  What were the hardest parts of your project? Did you face any major problems?  What were the key things that helped you accomplish your project?  Was your project accomplished? What were your outcomes? Did you accomplish your project goals?  What types of supports would have made it easier to accomplish your project? What kind of feedback did you receive from those outside of your group about accomplishing your project?  Were you exposed to the 12345 Fit-Tastic! Message? Did you use it in your project or share it with others?  What is your project goal? Why did you choose that project idea?  Tell me about how you planned for and coordinated meetings? How often did they occur?  How were group members designated or assigned to roles? How did they interact with each other? How did group interactions impact project goals? How did group members view the project?  How were administrators and teachers involved throughout the project? How did others in the school view the project?  Who did you work with outside of the school to accomplish the project? How were they involved?  What strategies and/or steps did you take to accomplish your project goals?  What were the hardest parts of your project? Did you face any major problems?  What were the key things that helped you accomplish your project?  Was your project accomplished? What were your outcomes? Did you accomplish your project goals?  What types of supports would have made it easier to accomplish your project? What kind of feedback did you receive from those outside of your group about accomplishing your project?  Were you exposed to the 12345 Fit-Tastic! Message? Did you use it in your project or share it with others?  View Large © Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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Translational Behavioral MedicineOxford University Press

Published: Jan 27, 2018

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