Engaging Emerging Voices: Training Minority Young Adults as Change Agents in the Battle against COVID-19

Background: Affected by the pathophysiologic effects of COVID-19 and non-medical issues, many young adults expressed that they felt left out of the discussions surrounding the virus. Training young adults to champion their health priorities enhances the impact of health promotions. This article presents the outcomes of the Young Ambassador Program, a brief training to develop change agents addressing COVID-19 matters among their peers. Methods: Mississippi Individuals ages 18 to 29 years participated in a 45-minute training framed by the classical change theory. The level of participant satisfaction and outreach activities were assessed. Results: Ten individuals completed the training. Performance metrics included posting approximately 134 social media messages on Instagram, Facebook


Introduction
During the COVID-19 pandemic, some primary responsibilities of public health officials were to encourage people to protect themselves and others and to teach them prevention and mitigation measures to slow the spread of the virus [1]. This was a daunting task, as many people were opposed to the safety measures instituted, such as the shelter-in-place directives, mask mandates, and, after they were discovered, the vaccine mandates [2]. Another issue that became rampant during the pandemic was the misinformation that was publicly available and widely spread over the internet. This further increased the already present skepticism [3]. The abundance of online misinformation coupled with relaxed adherence to social distancing and mask-wearing had serious repercussions, particularly for young adults. Reliable health sources such as the World Health Organization (WHO) and the Center for Disease Control and Prevention (CDC) utilized their major social media platforms to spread verified and accurate information. Though young people were spending a significant amount of their time on various social media platforms [4], many young people felt unable to fully engage with and relate to these sources and sometimes felt overwhelmed by the amount of information presented [5]. This suggests that simply giving information to young people is not enough. For maximum benefit, information should be presented in ways that are relevant to the priority population, and in ways to which they can relate.
One important way some public health organizations and officials sought to promote the spread of accurate information and encourage buy-in from the public in adhering to recommendations was to engage the help of change agents [6,7]. Change agents are people who lead and facilitate change and serve as agents or catalysts for promoting new understanding and outcomes [8]. To successfully function in this role, the change agent must have a high degree of trust and credibility within their target audience, be able to connect with and engage people, and have considerable knowledge of the information they are promoting [9,10]. These individuals are empowered to ask questions and drive activities to produce outcomes. They use data effectively, and rally around common goals and performance improvements [11]. Change agents must be able to effectively address questions and concerns by leveraging multiple channels and platforms and seeking expertise from varied sources. Researchers [7,12] suggest that greater attention be given to the selection and preparation of persons who will serve as these agents of change. Selection should be given based on factors such as a desire to help, personality qualities, affiliation with the community and its experts, and their positions in salient social networks. Assigning a young person who possesses these attributes may increase other young adults' interest and participation in the project. Young people serving as change agents can be a resource that motivates the community to act and promotes growth and optimism among the age group [13]. The study relied upon 37 young people ages 10-21 years from an American Indian community to create relevant, sociocultural health promotion information that was disseminated via broadcast radio [13]. The authors acknowledged the need to ensure fun along with a focus on education and skill-building when conducting such non-school-based training for young people. Harrigan and colleagues [14] noted that young people are more likely to engage with their peers online and believe information from people with whom they can relate. A study among young adults with cancer by Lazard et al. [15] showed that the patients valued connecting with peers outside their personal networks who also had similar health challenges. They discovered that this connection allowed the young adults to feel validated about their concerns. Enke & Borchers [16] presented the significance of social media influencers (SMIs) as change agents. The SMIs use the internet and the SM platforms to share life experiences and promote content that builds relationships with the people who follow them, and establish themselves as a reliable and trustworthy entity. The SMIs as change agents accepted their main duties of carefully selecting and curating the kind of content they share. They used a variety of ways to engage with their followers online, such as webinars, live videos, and live chats [16]. The SMIs working as change agents to spread health-related information to the public has recently been increasing. The COVID-19 pandemic has bolstered the interest among some young adults to become involved in the identification and dissemination of relevant and trustworthy health information to share with their family, friends, and community for the purpose of maintaining and improving their well-being. Public health practitioners may find that collaborating with and training young adults to champion their health priorities can enhance the impact of health education initiatives. This article presents the outcomes of the Young Ambassador Program (YAP), a brief training that sought to prepare young adults to be change agents in the battle against COVID-19.

Introduction to the Young Ambassador Program
The Young Ambassador Program (YAP) was implemented as part of the Young Adults Against COVID-19 (YAACOV) study, a multi-phased, mixed-method study to explore Mississippi's African American young adults' knowledge and perceptions of Covid-19 and how they coped during the pandemic. The YAACOV study was approved by the University of Southern Mississippi Institutional Review Board (# 20-442) and was awarded in November 2020 through a partnership with the Mississippi Community Engagement Alliance Against COVID-19 Disparities (CEAL). The CEAL initiative, led by the National Institute on Minority Health and Health Disparities (NIMHD) and the National Heart, Lung, and Blood Institute (NHLBI), is a National Institutes of Health (NIH)-wide effort to address Covid health disparities among underrepresented and minority populations.
The YAACOV Young Ambassador Program (YAP) is a brief online training to prepare young adults to recruit their peers to participate in Covid-19 health education activities, engage their peers in bi-directional communication about Covid-19 health issues, and participate in the evaluation of Covid-19 health promotions. Implemented from February through May of 2022, during phase 2 of YAACOV, the YAP focused on engaging young adults, bestowed the title of "Young Ambassador (YA)", as change agents capable of identifying and disseminating accurate Covid-19 health information and establishing platforms for building trust and increasing engagement in efforts related to Covid-19. Young Ambassadors are people within the target age group who were recruited to assist with educating their peers about COVID- 19  rational strategies, providing knowledge is the most compelling prerequisite for change [17,18] and rational individuals acting in their own self-interest will adopt beneficial changes [18]. The Young Ambassadors acting as the agents of change will share information, address inadequate or incorrect beliefs with accurate and valid details, and provide psychological safety by establishing an environment of trust and acceptance of the change [18].

Selection and Recruitment of Young Ambassadors
The participation goal was to recruit ten individuals ages 18 -29 years living in Mississippi to complete the brief training to serve as Young Ambassadors for YAACOV. Given the available human and financial resources, a small group allowed for a manageable evaluation to determine the feasibility of the procedures for the recruitment and retention of participants and assess the usability of the technology employed for administering the health content [19]. Logie and colleagues [20] relied on eight youth participants to serve as peer leaders for their pilot, The Ngutulu Kagwero (Agents of change) project to test a contextually and age-tailored comic intervention addressing sensitive sexual topics. A minimum of 10 individuals should be used for a pilot [10,21]. Participants were considered eligible if they met the following criteria: 1) 18 -29 years of age, 2) identified as a person of color, 3) a resident of Mississippi, and, because the intervention emphasized social media as a communication tool, 5) had active accounts on Facebook, Instagram, and Twitter. Participants had to maintain a social media presence that had more than 200 "Peer" followers on each social media platform and be capable of posting content on all media platforms as well as capable of moderating/hosting webinars on web-based platforms (i.e., Zoom Technology). Other considerations included possessing a desire to help prevent the spread of Covid-19, personality qualities (i.e., outgoing, and willing to engage known and unknown individuals), affiliation with the community and its experts (i.e., association and/or organization members), and their positions in salient social networks (i.e., high activity and frequent posting online) [7].
The recruitment flyer was designed by a graphic artist with MS CEAL who was in the priority age group of 18 -29 years. The recruitment flyer was formatted for electronic distribution via e-mail and social media posting. Student assistants who were included in the priority age group reviewed the flyer and provided input on its clarity and appropriateness. The YAP announcements were e-mailed to contacts at colleges and universities in the state and to contacts at select youth-serving community-based organizations. The flyer was also e-mailed to the participants from the first phase of the YAACOV study and posted to the project team's social media page.

Training of the Young Ambassadors
Following their selection, each participant completed the participation survey and consent form. Next, they participated in a 45-minute virtual training to learn more about COVID-19, the YAACOV study, and their roles and responsibilities [9].

Training topics included:
• An introduction to COVID-19 and pathological and clinical characteristics of the virus, • The disparities observed in COVID-19 morbidity and mortality, • An introduction to the YAACOV study outlining the purpose and methodologies, • A description of the Young Ambassadors program, including the roles and tasks of the YAs and discussions about the performance metrics that would be monitored, • And best practices and strategies on how to engage their peers, select useful information, and verify the information before sharing, and • An overview of the COVID Talk topics for the monthly public webinars.
The training was delivered by one principal investigator and two graduate students. The graduate students being members of the priority age group (18-29 years), assisted with the development and review of the training materials. Additionally, a manual consisting of the training contents and additional resources was developed and presented to each Young Ambassador.

Young Ambassadors' Performance and Evaluation
The Young Ambassadors' performance was based on several factors that included the number of posts and social media interactions and the number of individuals who registered for and attended the COVID Talk webinars. After the training, the YAs were expected to: • Share accurate and current information about COVID- 19 prevention strategies (i.e., Infographics, Memes, links, videos, and images) provided by the MS CEAL, NIH, and the Centers for Disease Control and Prevention (CDC) on all the popular social media platforms such as Twitter, Instagram, and Facebook.
• Complete bi-weekly performance evaluation forms detailing their activity on social media. This included the number of posts and the number and types of engagement received on the posts. phase one focus groups. Public Health figures and topic experts engaged with the young adults, educating them and responding to any questions or concerns they had. The goal was for each Young Ambassador to recruit at least 25 people for each webinar. Table 1 includes the list of the COVID Talk webinar topics.
• Participate as moderators/hosts for 1 -2 webinars on COVIDhealth-related topics and attend the scheduled webinars during the term.
A monetary stipend was attached to the position, payable in the form of gift cards to the Young Ambassadors after each webinar, provided they had satisfactorily completed their performance evaluation forms and invited webinar attendees (Table 1).

Data Collection and Analysis
The data collection instruments were created as web-based forms using Qualtrics. A participant survey was used to capture demographic details such as age, race, and Mississippi residency, and another electronic form was used to collect social media metrics such as the number of posts and online interactions. A third questionnaire was administered to collect feedback on satisfaction with Covid Talk webinars, YA engagement, and emerging health concerns/topics. Descriptive statistics such as frequencies, percentages, and counts were used to explain the demographic characteristics of the Young Ambassadors and social media metrics, and brief summaries of the responses to openended questions are discussed.

Participants
The YAP cohort consisted of ten individuals. There were seven women and three men who completed the training. Ten individuals self-identified as African American and one also self-identified as having Hispanic ethnicity. The average age was 24.38 years. The trained young adults were geographically dispersed, representing North Mississippi/Delta Region (n = -1); Central Mississippi (n = 3); Southern Mississippi (n = 3), and three from West Mississippi. There was no representation from the Eastern counties of Mississippi. Eight of the individuals were college/university students, one was in high school, and one was not attending school.

Young Ambassador Performance Outcomes and Engagement
Eight Young Ambassadors submitted their performance evaluations and attended the Covid Talk webinars. Comments from the Young Ambassadors shared during bi-weekly meetings included, "The information [shared during the training] was adequate", "I feel that I can engage my peers", "I think we need something official letting people know that we are Young Ambassadors for this project", and "I have been able to find the information [about Covid] that I need on the MS CEAL sites". "The training topics can be fit other health problems, like mental health or obesity." Table 2 outlines the number of posts by all the YAs across 3 major social media platforms (Instagram, Twitter, and Facebook). Table 3 shows the number of engagements on these platforms. These engagements included likes, reposts, retweets, and interactions.

COVID Talk Webinars
Approximately 140 young adults registered for the COVID Talk Webinars. Thirty-nine individuals attended COVID Talk  than 30 years. Other attendee characteristics were: Seventy-five (75%) were female, 75% were African American/Black, 12.5% were Caucasian, 2.5% were Asian, 2.5% were Hispanic and 2.5% were American Indian/Alaskan and 65% were currently in college. Of those, participating in the COVID webinars, 40% stated a Young Ambassador informed them of the webinars and 82% of the attendees felt that they had learned enough about COVID through their webinar participation.

Discussion
The Young Ambassador Program aimed to prepare select young adults to identify and disseminate accurate and reliable information via social and digital media to inform Mississippi young adults about COVID health. Based on the Young Ambassadors' feedback, the YAP training equipped them to identify and disseminate accurate information and communicate with their followers about COVID-19. The YAs were sharing Covid health information and resources, addressing questions, establishing trust and credibility for discussion and engagement in a safe forum, and leveraging various channels and platforms [9][10][11]. Like the research of Hudson and colleagues ( [9], our Young Ambassadors entered the training feeling confident in their current knowledge of the issue and their ability to engage their peers. By regularly reviewing the content made available to them and having bi-weekly check-in meetings and discussions with the project team, they were eventually able to start selecting accurate information on their own, and they got better at discerning accurate information. During the bi-weekly meetings, some of the Young Ambassadors provided positive feedback about their preparation, acknowledging that information was accessible and that they were glad they could share information with their peers.
The YAs in the study were active on all the major social media platforms and were able to select posts that were most accurate for those platforms and those that would drive engagement. Enke & Borches [16] supported using social media to reach individuals and that a variety of ways would be needed to engage. In all, the YAs made a total of 134 posts across Twitter, Instagram, and Facebook during March, April, and May. The posts were of varying formats. These included infographics, short messages, and links to online resources. According to Chico-Jarillo and colleagues [13] and Logie and colleagues [20], young people can identify content that most appeals to other young people. The total number of engagements and interactions with their posts on all these sites was 9354. This highlights the vital role that change agents have in spreading information over the internet and engaging their target audience. This work aligns with the position of Harrington and colleagues [14] that young people avail themselves of online engagement with their peers and have an increased level of trust and belief in the information shared. In addition to the engagement on their social media platforms, the Young Ambassadors promoted participation during synchronous learning events such as the Covid Talk virtual webinars. Approximately 32.5% of webinar attendees were invited by one of the YAs, and 7.5% had seen the advertisements on social media and decided to attend. Participant feedback suggests it was a good idea to deliver the health messages via the Young Ambassadors' social media pages. One of the YAs shared that she felt it was effective to share health information on social media. Enke & Borches [16] agreed that social media influencers' activities legitimize the "purpose" or "objectives" in the minds of the audience.
The Young Ambassadors recruited webinar attendees who believed they knew enough about the virus itself, but they wanted further engagement on certain aspects of life that were affected by the pandemic. For example, one recurring theme among the suggestions for areas where they would like more engagement was the effects of COVID-19 on mental health and teachings on ways to deal with these effects. They also wanted to know more about the resources available to them, and ways to interact with people who had differing opinions about the virus and pandemic. The webinars provided a forum for group discussions where questions were presented and addressed by subject matter experts and the Young Ambassadors.
Relying on their social media platforms enabled the Young Ambassadors to disseminate the Covid health information more broadly, achieving nearly 10,000 interactions. Contrastingly, the webinars had lower engagement numbers but allowed for realtime conversations with various stakeholders. The social media metrics for the posts, shares, and likes met the bi-weekly goals. The webinar attendance was lower than the set goal. This means that the number of priority individuals reached is lower than the expectations and therefore, project modification may be required.

Limitations
There were some limitations in the implementation of the Young Ambassador Program that included relying on a small group that lost two participants. According to the research, a pilot project such as this one should have a minimum of ten participants; the data is based on eight individuals. Thus, the information may not be appropriate for others. Unexpected issues prevented the implementation of the final three Covid Talk webinars. Also, based on webinar registration, at least 180 people saw and interacted with the posts from the YAs, yet the percentage of people who attended the webinars was minimal. In these instances, there were commitments from the young people without the action being completed.

Implications for Practice
Future research will continue to evaluate the Young Ambassador Program as a resource for preparing young adults to identify Volume  and disseminate health information in addition to COVID-19 materials. There are opportunities to examine how such training can be implemented in different settings such as the local churches and youth groups as well as with younger populations who also have higher rates of social media activity. This work offers insights for engaging young adults in developing culturally and ageappropriate health content which they can share with their peers and community.

Conclusions
Our work addressed the value of equipping young adults to identify and disseminate reliable and trusted Covid health information to other young adults. Implementing a brief training, young people were prepared to leverage social and digital media to spur information sharing, debunk misinformation, and establish a virtual forum for candid discussion and inquiry. They utilized the bi-weekly team meetings to discuss their interactions with other young people. The online format and brevity of the training were favored by the participants. The Young Ambassadors may benefit from additional training to ensure they can sustain their skills for identifying, disseminating, and discussing information. The training modules should be amended based on the feedback and recommendations of the prior Young Ambassador Program participants. The training can be adapted to prepare young people to address other health crises and pandemics. Further efforts will examine new cohorts who will complete training.