Seeing “The Bigger Picture:” Impact of an Arts-Focused Type 2 Diabetes Education Program in High Schools

Figures & data

Table 1. Description of the bigger picture and traditional [author organization] curricula delivered in San Francisco unified school district high schools from spring 2019 – Spring 2020

	Traditional Curriculum (Comparison Schools; n = 3)			The Bigger Picture Curriculum (Intervention Schools; n = 3)^1
	Residency^2	SLAM Club^3	All-School Assembly	Residency^2	SLAM Club^3	School Assembly
Learning Objectives	To learn how to find, develop, present, and apply their voice through written and spoken word at the introductory level.	To learn how to find, develop, present, and apply their voice through written and spoken word at the intermediate level via preparation of a poem for an audience.	To demonstrate to students how to find, develop, present, and apply their voice through written and spoken word.	To learn how to find, develop, present, and apply their voice about Type II Diabetes through written and spoken word at the introductory level.	To learn how to find, develop, present, and apply their voice about Type II Diabetes through written and spoken word at the intermediate level via preparation of a poem for an audience.	To educate students about the environmental determinants of Type II Diabetes. To demonstrate to students how to find, develop, present, and apply their voice on Type II Diabetes through written and spoken word.
Example Topics Covered	Voice, Identity, Power, and Imagination as applied to: Non-health related topics identified by students			Voice, Identity, Power, and Imagination as applied to: Type II Diabetes as an environmental issue, structural violence, and sugar- sweetened beverage marketing
Example Activities	Free writes, word palettes,^4 check ins, and poem sharing	Free writes, word palettes,^4 check ins, and poem sharing, performance drills, poem revision, group poems	Poetry performance from Poet Mentors	Free writes, word palettes,^4 check ins, and poem sharing	Free writes, word palettes,^4 check ins, and poem sharing, performance drills, poem revision, group poems, audience consideration for Type II Diabetes poetry, incorporating statistics into Type II Diabetes poetry	Raising hands if student neighborhoods have grocery stores, parks, or liquor stores, Type II Diabetes writing prompt
Example Products	Individual poem notebook, in-class open mic	Polished poems to be shared with a poetry slam festival or written/ video anthology	Open mic	Individual poem notebook, in-class open mic	Polished Type II Diabetes-related poems to be shared with a poetry slam festival or written/video anthology	Open mic

A description of the Traditional and Bigger Picture curricula that students received. Both curricula allow for flexibility in responding to student needs and interests. Activities and products varied by classroom and semester.

¹Intervention schools received both traditional (non-health related) and Bigger Picture content in residencies and Slam Clubs.

²In-class residencies took place during school hours and were integrated into preexisting courses in partnership with a classroom teacher.

³SLAM (Student Led Arts Movement) Clubs were voluntary spoken word clubs and took place during lunch or after school.

⁴A collective brainstorm where participants expand on an initial idea, defining it or offering their perspective in their own words.

Table 2. School-level demographic characteristics, baseline (School year 2018–19)

	Intervention Schools (N = 3)	Comparison Schools (N = 3)	P-Value^a
Student enrollment, mean (SD)	602 (442)	583 (473)	0.96
Student eligibility for free or reduced-price lunch, mean % (SD)	69 (3)	58 (15)	0.28
Student race/ethnicity, mean % (SD) White Hispanic or Latino Asian African American	4 (2) 49 (17) 15 (17) 15 (6)	12 (9) 46 (9) 9 (7) 18 (8)	0.23 0.81 0.60 0.59
Female students, mean % (SD)	47 (3)	43 (5)	0.44

^aCalculated from t-tests.

Table 3. Themes from youth interviews

Theme	Example Quotes
Mind-Sets & Expectations	“[Youth Speaks] definitely like enlightened me on … type II diabetes and how … some people in different communities are more likely to get type II diabetes … [My school makes] it so much fun to learn about these topics and make you excited to help out and figure out how you can help them … ” (Intervention school student) “I think my biggest takeaway [from The Bigger Picture program] is that … like black and brown community have higher numbers of diabetes, like that’s not a mistake … That’s something that has been implemented into our neighborhoods on purpose. And it’s honestly something that it’s stuck with me because … these are things we learn about in school … The government kind of puts us at the bottom of the list.” (Intervention school student) “A phrase that stuck out to me a lot was how companies make propaganda lying to people, hiding the fact that the things they create are not very healthy. For example Skittles, they’re saying to ‘taste the rainbow.’ And [in Youth Speaks] we change it to ‘taste the poison.’ So it made it kind of fun to be in the program … I also wrote how … I’d be going to the stores after school and buy chips and sugary drinks with my friends and having a good time, but not being aware of how that affects our health.” (Intervention school student) “In the Youth Speaks club, we learned how Hispanic people always grew up drinking Coca Cola and how Coke is never missing on the table because it’s a drink that we have learned to like a lot. And it’s part of a tradition now to have soda and yeah just grab a drink.” (Intervention school student)
Sense of Belonging	“I wasn’t judged, it felt like a safe space … If I did need to be corrected about something like, I wouldn’t be corrected about it like in a bad way … It would be sort of protected in a positive way. I mean, [the Poet Mentor] was very encouraging and supportive of anything … If we ever needed help, we would just like ask him and he’d be down to help … I feel like I got the sense where like everyone can say what they want to say And we won’t be judged.” (Intervention school student) “I feel like we all were connected … We do assignments, where we’ll write on a piece of paper and then pass the paper to the person next to us, and then we’ll all just write on each other’s paper and then we have a full poem … Wall share out and then I feel like our bond was tight because like everybody could agree with each other … And everybody was just like engaged. So then that just made us all closer.” (Comparison school student) “At the end of the day … the [Slam] club made me more excited to go to school as well … The club it made me very excited to learn about like- I was already so excited to learn about different cultures and everything cause … I didn’t really get to learn much about that. And then the club it … made me even more excited to learn about it because there’s so much stuff that I hadn’t learned yet.” (Intervention school student) “I think [my motivation to go to school] did change because, at first I didn’t really wanna go to school … but [the Poet Mentor’s] club was like fun and he taught a lot, but not in a like a teacher to student way, more like friends.” (Intervention school student)
Using Your Voice (Civic Engagement)	“[Youth Speaks has] definitely given me more of a sense of confidence and everything to talk about the topics that everyone is talking about … (Intervention school student) “[Another club member,] … everything I would have said there … he would have disagreed with it … So we would like debate and talk about that. So I feel like that Youth Speaks definitely like it helped me express like my opinions, but it also helped me like debate other people’s opinions on those type of things … ” (Comparison school student) “I just feel like I wouldn’t be as involved because I wouldn’t like, speak up more about the Black Lives Matter movement. [The Poet Mentor] taught me to speak up more.” (Comparison school student) “No, [my confidence for creating change in my community did not change] because I don’t know how to do that unless like I go on social media or something like that.” (Intervention school student) “I think [poetry is] very convenient because us youth are very attracted to art and images … At the same time … art can be very informative in little words and with images … I think it is very important to bring out to the youth … that … we are living in a world where … some people are privileged more than others. And I feel like we need to acknowledge that, because once we acknowledge that, we’re gonna want to make a change. I mean, unless you don’t care. But you should … ” (Intervention school student) “ … My poem kind of teaches the way that these industr[ies] are targeting us and I think … these things that we’re so familiar with are actually a part of a bigger picture, you know … I think in that way, my poem can make social change by teaching people to be more aware of, like, things that happen in a community. Like why is it that I’m more likely to see you know advertisements for alcohol or like sugary drinks … I think my poem could create some change just by teaching people to be more aware.” (Intervention school student) “ … I wrote a poem during one of our … freestyle sessions … and actually ended up reading it to my family. And it was a very beautiful morning because I was … talking about them … Youth Speaks gave me the opportunity to like bring my family together in that way … That kind of like left an imprint on me.” (Intervention school student)

Table 4. Themes from adult interviews

Theme	Example Quotes
Mind-Sets & Expectations
Stigma to Systems Shift	“ … If they still came away from the project feeling like, “yo this is an individual thing,” then I failed on my end, like (laughs) that’s, that’s not it … Even if we’re increasing the awareness of Type II Diabetes, but they’re not seeing it as a systemic thing, then I didn’t do the thing” (Participant 24, PM-I^1) “It’s nice to like have a way to talk about nutrition and … focus on things other than individual choice … I’d like move away from the shame and blame.” (Participant 17, WC-I^2) “[Students] had internalized some stigmatization without even like realizing it.” (Participant 16, PT-I^3) “We had conversations on … shaming people, but we had to center it back to it’s not about the fact that you’re getting McDonald’s. You have to question why McDonald’s is what you can afford and why this is the stuff that you feel like, offhand, is the stuff that you should be eating, and why isn’t is second nature to eat a salad instead because these are the factors that affect that. So yeah. It’s a weird cycle of shame, but then understanding, but it was really, really good for them … to learn. (Participant 15, PM-I)
Personal Connection to Content	“The themes, really hit home … We have students that actually had type II diabetes and … working in the black and brown community, that is a big issue in our … communities. So that was like something that kids gravitated towards.” (Participant 25, PT-I) “I could tell that … minds would be racing, pens would be moving and after we’re … having … a fruitful discussion, I feel like I have reason to think like okay, this is working, this is tight.” (Participant 30, PM-I) “[A student] said that … both her grandma and her mom had diabetes … but … they don’t really talk about it and she kind of thanked me for helping her with this because … it opened up … a conversation with her mother that … they … just hadn’t really happened before then … I thought was pretty powerful.” (Participant 30, PM-I) “We did the whole look to your left, look to your right, one in three, because one of y’all are going to get diabetes. And in black and brown communities it’s even smaller than that. And so it was a big thing of denial of, “It’s not going to be me. It’s not going to be me,” (Participant 15, PM-I) “ … Maybe … the Coca-Cola doesn’t need to be a daily thing or … maybe my Hot Fries don’t need to be a daily thing.” (Participant 30, PM-I)
Systems Understanding	My little freshman … didn’t even know there were two different types of diabetes.” (Participant 30, PM-I) “So, [the students] were definitely like connecting the dots … when I would ask them like what their neighborhoods looked like and … what in your neighborhood keeps you healthy and what in your neighborhood makes you sick … So a lot of folks like, were connecting the dots right away of like yeah, liquor stores, fast food restaurants … you know, these are things that like make us sick but … like we’re eating it anyway … I would see the aha moment if like a student would … make a connection from the content of the class to their own lives, or … in their own neighborhood … So when we’re saying things like … how would you make your neighborhood healthy … and like responses sound like affordable … produce, or … an actual … community center where we could go exercise … that had good equipment … There were several instances where somebody would refer back to like, “oh yeah … like that day you had the [Bigger Picture] assembly when you was talking about the parks being all dirty and what not, that’s what the park in my neighborhood looks like,” And they knew … we would get more exercise if there were actual nets in our basketball hoops or if … . our swings and slides weren’t rusty … ” (Participant 30, PM-I) “I hang out at a corner a store, and now I’m starting to see that the millions of dollars that corner stores are using to target me and have me become addicted to things.” (Participant 1, PM-I) “Just [the students’] initial reactions of being like, “That’s really messed up” … knowing that [corporations are] not doing this to other populations and to other groups of young people … [But] there were a lot of jokes that were like, “Well, I really like sugar.”” (Participant 8, PM-I)
Sense of Belonging
	“ … Even … the quietest students were voicing, sharing poems, or answering questions. So [the Poet Mentor] made sure … that everyone was involved one way or another.” (Participant 31, PT-I) “What I saw that was pretty consistent was real, strong, engaged pedagogy on the part of the youth mentors and Youth Speaks curriculum … Looking at students’ asset-based, using student language, using … appropriate cultural references, thinking about you know urban students of color and how students see the world. Like that was very prominent and evident in every class that I went to.” (Participant 19, DS^4) “This community that’s forming … I remember when a fight did break out … .I remember all the students went up to the windows … .just to see what’s happening. They’re like, “dang,” and then it was like … “Cool, are we gonna continue this workshop?” (Participant 24, PM-I) “I had kids that sometimes wouldn’t even come to class, but they would come in on Wednesdays because they knew [the Poet Mentor] was there.” (Participant 25, PT-I) “I had kids who are failing every class who were like sharing every time and staying for the club, so that was really cool.” (Participant 16, PT-I)
Civic Engagement
	“In their neighborhoods, in their communities … this is [another thing that’s wrong with my community]. So … I didn’t really get as much of a sense of, “Oh, we’re going to act and change something.” Or “We want to campaign around this, or figure out how to get more people to talk about this.”” (Participant 8 PM-I) “I think they wanted to change it in ways that were more personal to them. Some of them … I think felt more agency to speak up with their families.” (Participant 15, PM-I) “So a lot of my freshmen were in BSU, and I was starting the curriculum … around Black History Month … and they had this big banquet coming up … Historical soul food is just like hella salt, hella fat … and they had a conversation on that. And so they were bringing better options for their BSU banquet, which was a connotation they never had, but I think that was because of Bigger Picture … So they had made the move to ask for healthier options … ” (Participant 15, PM-I) “They would make comments like, you know what [TBP content] would be good for us to learn about in our regular classes, or like why don’t they teach us this in science. Like this is the type of sh*t that we should actually know about.” (Participant 30, PM-I)

¹Poet Mentor, Intervention School ²Wellness Coordinator, Intervention School ³Partner Teacher, Intervention School ⁴District-level Wellness Staff

Table 5. Themes from student poems written about T2D (n = 10)

Theme	Example quote(s)	# (%) of poems theme appeared in
Determinants of health
Systems	“Symptoms of systemic inequality Jasmine starts to experience them”	9 (90%)
Sociocultural factors	“My classmates at school reject the school provided lunch and pull out faygo and a loud bag of chips from their bag”	8 (80%)
Individual behavior/choices	“One day while we are in middle school our science teacher plays the movie Supersize. A movie where the man CHOOSES to eat fast food everyday for a month and we all flinch in disgust.”	7 (70%)
Access	“Grocery stores out of reach. Liquor stores on every other block”	5 (50%)
Envisioning change around health determinants
Challenging Mind-Sets & Expectations^1	“The food we ate was comforting … What is not comforting is sugar running through our veins and clogging our arteries. But what do we know?”	9 (90%)
Civic Engagement^2	“I’m still hungry hungry for healthiness but what is healthiness? i wouldn’t know you never gave us a chance to taste it give us those healthy options that we deserve how are you. no. how are WE going to make a change for OUR future generation and youth?”	9 (90%)
Sense of Belonging^3	“They target kids like you and me. They target minorities and they target low income families. They know that we are desperate”	5 (50%)

¹Challenging Mind-Sets & Expectations is defined as a strategy that poets used to inform readers and reveal what may not be commonly known about disproportionate health outcomes. With this strategy, they may also challenge assumptions that are made about individual or community health.

²Civic engagement is defined as a strategy that poets used to call for collective engagement in response to injustices that perpetuate health disparities.

³Sense of Belonging is defined as a strategy that poets used to highlight the interconnectedness between themselves, the readers and the marginalized groups they write about.