1. 1 Maricel Santos, Ed.D. San Francisco State University mgsantos@sfsu.edu Logic models in service of community- based research: Lessons learned from ESL Diabetes Prevention Project

2. 2 Today’s Agenda 1.Introductions 2.Lecture: Overview of Logic Models 3.Lessons learned from ESL Diabetes Prevention Project a.Backdrop: Why focus on adult ESL in health disparities b.Theories of change c.Interactive exercises 4. Q & A

3. 3 About me Applied Linguistics Training: adult ESL teacher, adult literacy researcher, SF State: O Coordinator, MA TESOL Program, Certificate in Immigrant Literacies Program O Faculty Research Fellow, National Center on Minority Health And Health Disparities (RIMI Program)

4. Mentors Dean Schillinger, MD UCSF- CVP Margaret Handley, PhD UCSF-CVP Rima Rudd, PhD Harvard School of Public Health

5. Harnessing the U.S. Adult ESL System 44.3% of 2.5 million adults in federally-funded adult education programs 72% of 590,000 adult learners in California 35,000 learners in ESL/vocational classes at City College of San Francisco each year U.S. Dept of Education, http://www.ed.gov/about/offices/list/ovae/pi/AdultEd/aedatatables.html Workforce Investment Board of San Francisco, http://www.picsf.org/research/misc2003/brief_06-03_ccsf.pdf

6. A process of finding focus 19912011 ¡Ánimo, que tú puedes! がんば ります ! Stay on track - you can do it!

7. Coming full circle

8. Familiar goals, new frames REACH Reaching people where they are ESL students often  small sub-populations of transnational communities who have migrated together ENGAGEMENT Students motivated to learn and figure out the US system (community resources, health care, etc) Social support between classmates to provide ongoing motivation TOOLS Participatory, critical thinking to confront inequities Beyond the brochure Utilization of educators already in place

9. Expanded definition of health literacy (Nutbeam, 2001)  functional health literacy (eg., reading safety signs)  interactive health literacy (eg., communicating with health practitioners)  critical health literacy (eg., advocating for one’s health)

10. Health care communication is never just about language Proficiency ≠ success “Right to speak” is unequally distributed Communicative competence defined by the learner’s “power to impose reception” and to “shape the very context in which the language is learned and used” (Bourdieu, 1991; Gee, 1996; Kramsch & Whiteside, 2008; Norton, 2000)

11. ESL participation as a possible health- protective factor ESL participation as a possible health- protective factor (Santos, McClelland, & Handley, 2011; Santos, 2011) Classrooms viewed as “safe places” to admit confusion, ask questions, analyze information … and display shared expertise Access to communities who often are hard to reach Links to existing social networks within marginalized communities Learners explore social positions that are less accessible to them in their extant social networks Photo © Jon Crispin

12. Engaged classroom learning (Moriarty, 2011) What does this student need from this lesson today?

13. Moriarty (2011)

16. Exercise 1. Analyzing the situation Premise: Identifying the situation clearly and concisely is key to the development of a good logic model… in the face of many complex contextual factors Applications to the ESL Diabetes Prevention Project: What is the problem/issue? Why is this a problem? (What causes the problem?) Who is affected by this problem? Who has a stake in the problem? (Who cares whether it is resolved or not?) What do we already know about the diabetes prevention issue within immigrant communities, ESL learners, ESL teachers, public health practitioners? What research, experience do we have?

17. Whose discourse do we use to articulate the problem? Individuals with lower English literacy levels are: Less likely to engage in screening & preventive action Less likely to have chronic disease under control More likely to be hospitalized More likely to report poor health More likely to die earlier (Rudd 2010)

18. Articulating the problem Beyond the brochure Beyond a skills focus Health literacy as a social outcome (Rudd, Nutbeam) Emphasis on positive change, not deficit

19. Our Project

20. Inputs “Resources dedicated to or consumed by the project” Examples - Funding from CDC and SF State - ESL Task Force members, ESL teachers - ESL learners, community leaders - Facilities, technology - Curricula - Existing research 20

21. Activities “What is done with the inputs to fulfill project objectives” Examples Task Force activities: meetings, trainings Research activities: survey, focus groups, literature review, curricular review/development Implementation of curriculum Classroom learning 21

22. Exercise 2. Distinguishing outputs from outcomes Premise: Need to clarify outputs (what is produced as a direct result of project activities) from outcomes (how community is benefiting or changing as a result of those activities) Applications to the ESL Diabetes Prevention Project: “…The objective of this project is for 1000 ESL learners to….” OR “…The objective of this project is for ESL teachers to….” “…The ultimate goal of this project is…”

23. “There is a shift in the ways that CBO funders and communities measure success. ‘Simply measuring the number of organizational outputs (houses, counseling sessions, events, and so on) is no longer adequate. Now we need to answer the 'so what' question. What outcomes have occurred because of your work?’” - Martin Johnson (Executive Director of the Isles Community Development Corporation, Trenton, NJ)

24. 24 Outputs “What is produced as a direct result of project activities” Examples - TF creates logic model, evaluation/dissemination plan - TF develops, implement lessons - Teacher training materials - Learner completion of lessons 24

25. 25 Outcomes “Benefits or changes for participants during or after project activities” Examples - Classroom level: improved health literacy, English proficiency, retention/engagement, Reduced risk for diabetes in immigrant communities - Programmatic level: stronger infrastructure within ESL programs to support diabetes prevention - Broader community: reduced diabetes risk, capacity for change 25

26. Exercise 3. Negotiating the ‘so what’ Premise: Need to clarify outputs (what is produced as a direct result of project activities) from outcomes (how community is benefiting or changing as a result of those activities) Applications to the ESL Diabetes Prevention Project: Focus on engagement processes – Is social engagement an outcome, or an activity that leads to an outcome?

29. 29 The ‘fundable’ logic model What is the minimum amount for which you could accomplish at least part of your project? What constraints exist in your work context for making this happen? What is the time window for building and running your program? Who are likely funders??? 29

30. Which public guides public health messages? “Hierarchies of biomedical knowledge do not lend themselves to identifying who is most capable of deciphering the complex pragmatics of public discourse about health…..why not include people who are ‘experts’ in reading how information is interpellated within their own communities? In doing so, we might learn a lot more about the full range of publics that emerge as discourse about health circulates.” Briggs C Med Anthro Quartlerly p 313- 2003

31. Participation in ESL as a possible health-protective factor “Our ESL classroom [provides] students with an opportunity to share their personal difficulties, evaluate them against the experiences of others, and begin to recognize them as socially constructed and potentially transformed through social action. We might see this process, and its active facilitation in our classes, as a primary means by which new solidarities and ‘traditions’ are developed within immigrant communities.” Morgan, B. (1998). The ESL classroom: Teaching, critical practice, and community. Toronto, Canada: University of Toronto Press.

32. 32 Into the classroom Who does an ESL-learner initiated dissemination model reach? Does an ESL-learner initiated dissemination model provide a broader ‘reach’ to vulnerable populations? What unique opportunities does an ESL-based model create for improving health promotion, and how specific is it to local community identity?