Impact of an Arts-based Public Health Literacy Program Delivered Online to High School Students during the COVID-19 Pandemic

Figures & data

Table 1. School- and student-level demographic characteristics (school year 2020–21)

	The Bigger Picture (TBP; Intervention)	Traditional Youth Speaks (Comparison)	P-Value^B
School-level^A	n = 3 schools	n = 3 schools
Student enrollment, mean (SD)	643.7 (482.1)	570.3 (454.2)	0.857
Student race/ethnicity, mean % (SD) Black/African American Asian Hispanic/Latinx White Other	11.3 (3.9) 13.4 (16.2) 56.3 (16.4) 3.6 (2.1) 15.5 (4.9)	16.4 (5.3) 7.9 (7.5) 50.0 (12.5) 11.1 (8.5) 14.6 (4.7)	0.256 0.626 0.629 0.213 0.836
Student sex, mean % (SD) Female Male	44.0 (0.3) 56.0 (0.6)	42.5 (5.9) 57.5 (5.9)	0.675 0.675
Student eligibility for free or reduced-price lunch,^C mean % (SD)	64.1 (0.6)	61.6 (13.5)	0.765
Student-level^D	n = 77 students	n = 63 students
Grade, n (%) 9^th 10^th 11^th 12^th	22.1 ± 41.7 9.1 ± 28.9 51.9 ± 50.3 16.9 ± 37.7	52.4 ± 50.3 30.2 ± 46.2 7.9 ± 27.2 9.5 ± 29.6	<0.001 0.001 <0.001 0.209
Student race/ethnicity, n (%) White Hispanic or Latino Asian African American Other/Multiple/Prefer not to state	5.2 ± 22.3 54.5 ± 50.1 27.3 ± 44.8 5.1 ± 22.3 7.8 ± 27.0	14.3 ± 35.3 39.7 ± 49.3 22.2 ± 41.9 7.9 ± 27.2 15.9 ± 36.8	0.066 0.081 0.496 0.514 0.137
Student gender, n (%) Female Male Other^E	37.7 ± 48.8 59.7 ± 49.4 2.6 ± 16.01	46.0 ± 50.2 46.0 ± 50.2 6.3 ± 24.6	0.321 0.107 0.279

^ASchool-level data were obtained from the California Department of Education

^BP-value for difference between intervention and comparison calculated from unpaired t-tests

^CUsed as a proxy for socio-economic status. Students qualified if their household’s income is less than or equal to the federal income guidelines

^DStudent-level data were obtained from the student survey

^EIncludes students who identify as non-binary, transgender, and compound gender, and those who preferred not to state

Table 2. Adjusted^A differences in changes in the proportion of students who answered yes to question, which of the following you think makes it more likely that someone could get Type 2 diabetes^B

Which of the following do you think makes it MORE LIKELY that someone could get Type 2 Diabetes? (proportion responding ‘yes”)	The Bigger Picture (TBP; Intervention) (n = 77)			Traditional Youth Speaks (Comparison) (n = 63)			Difference-in-change between groups mean± SE (95% CI)
	Pre mean± SE	Post mean± SE	Difference mean± SE (95% CI)	Pre mean± SE	Post mean± SE	Difference mean± SE (95% CI)
Being born without enough insulin.^B	37.6 ± 5.7	36.6 ± 5.7	−1.9 ± 4.9 (−11.461, 7.607)	48.4 ± 6.4	48.4 ± 6.5	1.1 ± 6.6 (−11.7, 14.0)	−1.0 ± 8.1 (−16.926, 7.283)
Having that disease run in your family.	74.2 ± 5.1	71.5 ± 5.1	−2.1 ± 5.1 (−0.120, 0.079)	80.6 ± 5.7	78.8 ± 5.8	−1.3 ± 4.4 (−9.986, 7.305)	−0.8 ± 6.9 (−14.377, 12.819)
Eating fast food or drinking soda/sugary drinks.	84.1 ± 4.0	93.5 ± 4.0	8.5 ±4.2 (0.347, 16.781)	86.5 ± 4.4	83.2 ± 4.5	−2.6 ± 5.0 (−0.123, 0.072)	12.7 ± 6.5 (−0.147, 25.462)
Living in a neighborhood that has lots of fast food.	49.9 ± 5.8	63.0 ± 5.8	12.4 ± 5.3 (19.697, 22.827)	60.1 ± 6.5	59.6 ± 6.5	0.6 ± 6.0 (−11.215, 12.446)	13.7 ± 8.1 (−2.067, 29.506)
Not exercising regularly.	79.8 ± 5.0	73.3 ± 5.0	−7.6 ± 6.0 (−19.331, 4.033)	74.8 ± 5.6	75.6 ± 5.6	1.9 ± 6.7 (−11.262, 15.051)	−7.3 ± 8.9 (−24.920, 10.301)
Living in a neighborhood with few safe parks and playgrounds.	19.3 ± 4.9	25.9 ± 4.9	7.0 ± 4.7 (−2.183, 16.159)	18.7 ± 5.5	25.7 ± 5.5	6.9 ± 6.2 (−5.352, 19.082)	−0.5 ± 7.5 (−15.360, 14.364)
Seeing lots of ads for unhealthy foods and drinks.	40.6 ± 5.8	55.5 ± 5.9	15.0 ± 6.4 (24.309, 27.561)	32.5 ± 6.5	39.0 ± 6.6	6.3 ± 7.2 (−7.861, 20.494)	8.4 ± 9.6 (−10.321, 27.203)
Not having enough money to buy the kinds of food you want.	21.4 ± 5.0	23.6 ± 5.1	2.8 ± 5.7 (−8.388, 13.968)	17.7 ± 5.6	27.6 ± 5.7	9.9 ± 6.4 (−2.591, 22.384)	−7.6 ± 8.5 (−24.329, 9.125)
Living in a neighborhood with few or no grocery stores.	41.0 ± 6.0	58.2 ± 6.0	17.5 ± 5.1 (7.470, 27.511)	52.1 ± 6.8	51.0 ± 6.8	−0.8 ± 5.4 (−11.572, 9.783)	18.4 ± 7.5 (3.671, 33.074)

^AData derived from mixed effects regression models, adjusted for student race/ethnicity, gender, and grade, and with random effects for school and student.

^BAll response options are correct, with the exception of “Being born without enough insulin,” which is linked to type 1 diabetes.

Table 3. Adjusted differences in changes in pre- and post-online residency program survey responses between intervention and comparison students for questions related to health-related mind-sets and expectations, sense of community, and civic engagement^A,B

RWJF Culture of Health Framework Construct(s)^A	Survey Question, with response options on a Likert scale from Strongly Disagree (1) to Strongly Agree (5))	The Bigger Picture (TBP; Intervention) (n = 77)			Traditional Youth Speaks (Comparison) (n = 63)				Difference-in-change between groups mean± SE (95% CI)
		Pre mean± SE	Post mean± SE	Difference mean± SE (95% CI)	Pre mean± SE	Post mean± SE	Difference mean± SE (95% CI)
HME	I am comfortable sharing my story and speaking my mind.	3.1 ± 0.1	3.4 ± 0.1	0.3 ± 0.1 (0.071, 0.499)	3.6 ± 0.1	3.4 ± 0.1	−0.3 ± 0.1 (−0.498, −0.015)	0.5 ± 0.2 (0.205, 0.865)
HME	I believe that my voice matters and is powerful.	3.7 ± 0.1	3.9 ± 0.1	0.2 ± 0.1 (−0.043, 0.376)	3.8 ± 0.1	3.8 ± 0.1	−0.08 ± 0.1 (−0.269, −0.101)	0.2 ± 0.2 (−0.070, 0.618)
HME	Policies and laws can have a greater impact on my health than the choices I make.	3.2 ± 0.1	3.3 ± 0.1	0.1 ± 0.1 (−0.124, 0.317)	3.3 ± 0.1	3.4 ± 0.1	0.1 ± 0.1 (−0.140, 0.336)	0.0 ± 0.2 (−0.320, 0.330)
HME	My country should do whatever is necessary to make sure everyone has an equal opportunity to be healthy.	4.3 ± 0.1	4.4 ± 0.1	0.1 ± 0.1 (−0.071, 0.354)	4.4 ± 0.1	4.1 ± 0.1	−0.3 ± 0.1 (−0.524, −0.024)	0.4 ± 0.2 (0.069, 0.719)
HME, SC	I understand what leads to health or disease in my community.	3.6 ± 0.1	3.9 ± 0.1	0.4 ± 0.1(0.099, 0.516)	3.5 ± 0.1	3.6 ± 0.1	0.0 ± 0.1 (−0.140, 0.203)	0.3 ± 0.1 (−0.003, 0.558)
SC	I am comfortable being myself around others.	3.5 ± 0.1	3.7 ± 0.1	0.2 ± 0.1 (−0.012, 0.383)	3.8 ± 0.1	3.7 ± 0.1	0.0 ± 0.1 (−0.239, 0.196)	0.2 ± 0.2 (−0.085, 0.068)
SC	I understand perspectives different from my own.	3.9 ± 0.1	4.0 ± 0.1	0.1 ± 0.1 (−0.038, 0.269)	4.1 ± 0.1	4.1 ± 0.1	−0.1 ± 0.1 (−0.221, 0.111)	0.1 ± 0.1 (−0.092, 0.386)
CE	I know who I am and the things I care about.	4.2 ± 0.1	4.1 ± 0.1	0.0 ± 0.1 (−0.180, 0.209)	4.0 ± 0.1	3.9 ± 0.1	−0.1 ± 0.1 (−0.289, 0.104)	0.1 ± 0.1 (−0.223, 0.362)
CE	I could see myself becoming a writer, performer, or leader in my community.	2.6 ± 0.1	2.7 ± 0.1	0.1 ± 0.1(0.227, 0.330)	3.1 ± 0.1	3.1 ± 0.1	0.0 ± 0.1 (−0.263, 0.257)	0.1 ± 0.2 (−0.302, 0.497)
CE	I care about issues in the world and am inspired to take action.	3.5 ± 0.1	3.7 ± 0.1	0.1 ± 0.1 (−0.076, 0.339)	3.8 ± 0.1	3.7 ± 0.1	−0.1 ± 0.1 (−0.250, 0.058)	0.2 ± 0.1 (−0.223, 0.505)
HME, CE	I am comfortable standing up for what I think is right.	3.7 ± 0.1	3.9 ± 0.1	0.2 ± 0.1(0.027, 0.424)	4.0 ± 0.1	3.8 ± 0.1	−0.2 ± 0.1 (−0.313, −0.010)	0.4 ± 0.1 (0.107, 0.644)
HME, CE	I am aware of the social and racial issues going on that affect my community right now.	4.1 ± 0.1	4.1 ± 0.1	0.1 ± 0.1 (−0.102, 0.260)	4.1 ± 0.1	4.1 ± 0.1	0.0 ± 0.1 (−0.170, 0.203)	0.1 ± 0.1 (−0.188, 0.353)
HME, SC, CE	I have ideas for what I can do to improve my school or community.	3.1 ± 0.1	3.3 ± 0.1	0.2 ± 0.1 (−0.043, 0.467)	3.4 ± 0.1	3.1 ± 0.1	−0.2 ± 0.1 (−0.390, −0.045)	0.4 ± 0.2 (0.091, 0.749)

^BData derived from linear mixed effects regression models, adjusted for student race/ethnicity, gender, and grade, and with random effects for school and student.

Table 4. Adjusted differences in change in pre and post survey responses between The Bigger Picture (intervention) and Traditional Youth Speaks (comparison) students for questions related to civic engagement

	Proportion of youth responding they DID this in the past 12 months at baseline (pre)^A			Proportion of youth responding they PLAN TO do this in the next 12 months^B
				Intervention (n = 77)			Comparison (n = 63)			Difference-in-change between groups(95% CI)
	Intervention(n = 77)	Comparison(n = 63)	p-value for difference between groups	Pre	Post	% Change(95% CI)	Pre	Post	% Change (95% CI)
Write/make a presentation about a community health and justice issue.	44.7	39.2	0.3550	31.5	40.0	9.2 (−1.971, 20.450)	44.2	34.5	−9.8 (−21.307, 1.783)	17.9 (1.919, 33.915)
Plan or participate in a meeting or event (like a march or rally) directed at community change or a local health and justice issue.	17.1	22.6	0.2556	26.2	38.2	11.3 (1.070, 21.582)	48.5	41.3	−5.9 (−19.463, 7.672)	19.1 (2.406,35.829)
Collect signatures on a petition or ask people about their opinions on community health and justice issues.	11.8	15.2	0.4155	20.6	26.3	5.0 (−3.902, 13.976)	23.7	25.6	2.2 (−7.815,0.123)	3.6 (−9.887, 17.032)
Talk to people about voting.	39.2	48.8	0.1096	29.8	51.5	21.6 (10.039, 33.234)	48.0	39.0	−8.3 (−20.578, 39.635)	30.8 (13.950, 47.647)
Send an e-mail, letter, or other communication to a public figure or organization.	13.2	32.0	0.0001	28.6	37.2	8.8 (−3.604, 21.111)	42.3	39.6	−4.4 (−14.878, 5.978)	11.4 (−5.272, 27.980)
Post my views on a blog, Facebook, Instagram, Twitter, other social media, or online platform.	36.8	44.0	0.2279	34.5	49.4	15.2 (3.668, 26.791)	50.0	46.4	−3.453 (−14.250, 7.342)	18.4 (1.863, 35.032)
Volunteer time for an organization active in community change.	12.5	18.5	0.1652	34.7	44.0	9.3 (−3.107, 21.816)	60.9	48.7	−12.9 (−26.489, 0.794)	21.5 (2.916, 40.007)
Change my online profile picture to demonstrate solidarity with a health and justice cause or movement.	18.7	29.6	0.0337	26.7	52.6	26.0 (14.573, 37.502)	32.5	35.6	2.9 (−7.924, 13.721)	22.8 (6.651, 38.999)
Attend a (virtual/in person) meeting of a government or public agency	13.8	12.0	0.6561	16.2	28.4	12.3 (2.249, 22.407)	41.1	31.6	−9.614 (−23.674, 4.447)	21.7 (3.828, 39.580)
Talk to family and friends about health and justice.	59.5	80.8	0.0001	65.2	79.5	14.6 (3.714, 25.505)	75.3	70.0	−6.0 (−16.328, 4.294)	19.7 (4.428, 34.897)

^AData derived from unpaired t-tests.

^BData derived from linear mixed effects regression models, adjusted for whether student did that activity in the past 12 months, student race/ethnicity, gender, and grade, and with random effects for school and student.

Table 5. Themes and salient quotations from key-informant interviews

Theme and sub-themes	Sample Quotations
Health-related mind-sets and expectations (understanding of and experiences with health, health equity, and the social determinants of health, including, but not limited to, COVID-19, Climate Change, Racial Justice, Police Violence, and Mental Health)	[Students] definitely talked a whole lot about food habits and why food habits are the way they are. And the proliferation of fast food and how much easier it is to get fat as opposed to healthier options. So those are I think two or three, which also they are very clear how they’re interconnected that they bring up in terms of Type 2 Diabetes and how it’s connected too. It’s yet another way to ridicule someone who’s African American. That comes up a whole lot and evidently so. I really did notice the fact that they aren’t desensitized to it. They’re very aware that it happens, and they know why it happens too. And very often, they are ready to speak up about that. – Poet Mentor, TBP School … starting off conversations and asking them like …,”Who’s most heavily impacted by something like COVID-19?” … On the very first day, a lot of the first responses are probably rather literal, right. It was like what the science said: elderly folks, people with preexisting medical conditions. And a couple of them maybe really early on would be like, “Homeless people,” or something. I was like, “Okay, I see. That’s not an obvious one. That’s not the one that the news is telling you. How do you know that?” And already showing them how some of those connections were being made … . When it came to who’s least affected, their answers went from young people or able-bodied people to wealthy people or people who have the privilege to stay … in the house or people who have the privilege to order delivery. … when it came to type 2 diabetes, it was like, if we look at a map, it’s the same folks in the same neighborhoods that maybe are most impacted by type 2 diabetes because they are food deserts, and they don’t have any clean facilities, outdoor facilities for folks to get exercise and whatnot. These also happen to be the neighborhoods where most of the people work low-wage jobs as essential workers … it was just really eye-opening to see in real-time it start to make sense to them. – Poet Mentor, TBP School In our school, specifically, our student population and their families have been hit really hard by the experience of the pandemic. A lot of our students’ parents are immigrants or frontline workers. People with a lack of resources when it comes to financial resources and other things like that that I think have really impacted families in really serious and extreme kind of ways. When people don’t have a way to earn a living to provide for their family or don’t have stable housing, [there’s] a number of health issues. So I think that … poverty, immigration. There’s always issues related to the trauma connected to community violence, health. I think all of those things. And then, the mental health of students for sure. The depression and anxiety and lack of a healthy connection is a big challenge. – Wellness Coordinator, TBP School There’s a lot. There are issues related to the pandemic. There’s issues related to racial injustice. There are issues related to immigration status. There are issues related to just housing and affordability living in San Francisco. It’s pretty widespread, I would say.– Partner Teacher, Traditional School I’ll say it influenced me really good because now– so first, I just knew what I knew. But when I went to YS, it opened my mind up to me knowing more things and new things, and it’s not just that part where I see. It’s the whole picture, stuff like that. I can see the whole picture now instead of that one picture. – Student, TBP School I think a lot of mental health is being undermined by a lot of people, especially in the pandemic, people have felt very depressed or very– yeah, very depressed or very tired. And they don’t have those support systems where they could find mental health. And I think it’s very important to have those systems, which a lot of people may not have. - Student, Traditional School
Sense of community (belonging to, and affiliation with, a group, including the school environment)	Yeah. I mean, it’s painful. I’m the school social worker, so got my little finger on the pulse of the emotional well-being of the school, and it was pulsing, it was high blood pressure all year long for these kids, a lot of increased anxiety and depression, and then just the inability to really address it in a meaningful way. And then we have five therapists working for me, and they were busy all year long. I was proud of that. They did a great job, but there are so many barriers to success there, like kids not having a private space to talk, being around family. Just an increase in anxiety and depression. So it was a tough year, and there was some trauma the school went through, suicide, staff that was killed, and another boy who died, accidental health condition like a medical condition. So the traumas this school went through that– about as bad as anything I’ve seen in 15 years, or worse than anything I’ve seen in 15 years there. So it’s hard to do all that. Now, it’s all done online. It was crazy. Trying like that with all this trauma and stress, it’s just a little debilitating to see the students go through this. So it’s the whole thing if students to go through it, and it was just– so a lot of us felt really powerless trying to figure out how to best help them and support them. So we all did the best we can. The teachers were all amazing. I popped into lots of classes to see how kids were doing, but it was like– the children are not meant to be learning through computers, screens, so. That’s all. – Wellness Coordinator, Traditional School [The Bigger Picture] made me feel connected. Yeah. Because I got to understand where everybody was coming from and the struggles. I mean, everybody’s going through some stuff. They’re just not saying it out loud.– Student, TBP School It did change my opinion about my community. That not everybody has the chance to– how can I say this? Everybody has a voice. And that they need to be heard no matter what. And that they’re humans and they have feelings and they also go through stuff in life too. And as any other human, they need help and– yeah. And they should receive it.– Student, TBP School I don’t think [Youth Speaks] really changed my opinion of my community, because I think I already had a pretty positive idea of it.– Student, Traditional School
Civic engagement (any activity where students speak about, initiate or contribute to change beyond the individual level)	Because I’m a woman. And a lot of people expect woman to stay quiet. And I don’t. I don’t like to stay quiet. I don’t like to be shut down or anything like that. So if I want to talk, I will say it, and I don’t care if you don’t want to hear me. It’s just how I feel. And no one’s going to block my feelings out just because they don’t want to hear my feelings. I’m as human as you are. And I have a right to be heard, no matter what. – Student, TBP School [The program] provides them with a sense of empowerment and a tool for really feeling like they can change the world with their words. And I really hope that the students in my particular program … continue to use those skills that they developed in the workshop to change the world around them because they have this– there’s just this innate natural skill that develops throughout the course of the workshop that was really special and that energy needs to be cultivated and shared with the rest of the world. – Partner Teacher, TBP School They make me excited for just this next generation that’s coming up. They know so much … And a lot of them, also, are down to create community farms and go learn … about gardening. A lot of the students, too, are newcomer students. So they’re used to being out on the horizon and instead of either being out with nature and greenery and then they come here to a concrete jungle, and the only thing that they see are buildings and concrete on the floor. But a lot of them have asked for trying to reconnect to the Earth. They’re trying to do something about it. – Partner Teacher, TBP School Yeah, once again, I think that YS is really good at targeting real-life situations and tapping into each person that it impacts and releasing this kind of mental clearance for that mental awareness that what you do has an impact, what you do matters. And whether it be study skills, help school skills, and mental skills, it really is something that– it’s something that took me a long time to understand. But one little thing can lead up to another thing and another thing, and eventually snowball to this big effect. So I think that, yeah, YS definitely helped bring awareness to that. And it really helped me look at it in a broader picture. – Student, Traditional School I think more than any program we have, the world around them is influencing their perspective on police violence and health than anything we’ve done. Our space is more like a place of expression and safety than a deep dive into causes or interest in change.– Partner Teacher, Traditional School
Online learning	Honestly, it was one of the greatest experiences I experienced because, honestly, I didn’t really know anything about YS. But then once, the person who was representing YS, she was introducing it to us. And I was like, “That sounds very interesting.” We’re basically just expressing ourselves by writing. And at first, I was like, “Writing, I’m not really good at writing.” But then later, it was just writing about yourself and how you felt about this whole pandemic. – Student, TBP School And honestly, every time when it was YS, I would be very excited to come to school because usually, since I has been virtual, I’m not very interested. Well, I am interested [but it’s] mandatory. But other than that– I was very excited to come to class because it was YS. I was like, “Okay, I’m ready for this class. I’m going to do it. And I like it anyways. I’m just going to go.” And then, it was really fun. The instructor that was representing YS, she was very nice, and she always had a positive energy, and that just inspired me to keep going no matter what. – Student, TBP School [The Bigger Picture] was extremely influential. Students were able to just go really deep into how they were feeling about a lot of different issues, about depression, about family trauma. YS gave them the platform that allowed them to really open up about those things that clearly had been bothering them for a long time and the poetry and the assignments in the way they were framed gave them a voice and an outlet to really speak about that. And I’d say that’s across the board. For the eight to nine students who pretty much engaged in the program for all six weeks, that they’re all able to make really big, deep emotional breakthroughs into what their experiences were and how they were feeling.—Partner Teacher, TBP School [Youth Speaks] just added a bit more. It felt just more interactive because we don’t really– it’s not a very– school right now isn’t that interactive because it’s just the teachers talking and then everyone else doing the work, but [Youth Speaks] felt very interactive. - Student, Traditional School