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ervice-Learning n Integral Part of Undergraduate Public Health

uzanne B. Cashman, ScD, Sarena D. Seifer, MD

bstract: In 2003, the Institute of Medicine (IOM) described public health as “an essential part of the training of citizens,” a body of knowledge needed to achieve a public health literate citizenry. To achieve that end, the IOM recommended that “all undergraduates should have access to education in public health.” Service-learning, a type of experiential learning, is an effective and appropriate vehicle for teaching public health and developing public health literacy. While relatively new to public health, service-learning has its historical roots in undergraduate education and has been shown to enhance students’ understanding of course relevance, change student and faculty attitudes, encourage support for community initiatives, and increase student and faculty volunteerism. Grounded in collaborative relationships, service-learning grows from authentic partnerships between communities and educational institutions. Through emphasizing reciprocal learning and reflective practice, service-learning helps students develop skills needed to be effective in working with communities and ultimately achieve social change. With public health’s enduring focus on social justice, introducing undergraduate students to public health through the vehicle of service-learning as part of introductory public health core courses or public health electives will help ensure that our young people are able to contribute to developing healthy communities, thus achieving the IOM’s vision. (Am J Prev Med 2008;35(3):273–278) © 2008 American Journal of Preventive Medicine

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n its seminal 2003 report entitled Who Will Keep the Public Healthy?,1 the IOM described public health as “an essential part of the training of citizens” and

oted the importance of what it termed public health iteracy. According to the IOM, public health literacy ncompasses a recognition and understanding of how he social and physical environment shape health. In sserting that public health literacy is an “appropriate nd worthy” social goal, the IOM recommended that all undergraduates should have access to education in ublic health.” While it noted the importance of basing his education on an ecologic model, the IOM was ilent regarding the specific vehicles and approaches hat would best result in a citizenry that is public health iterate. It is our assertion that the vehicle of service- earning, a type of experiential learning, is an appro- riate and effective approach for teaching undergrad- ate public health.

rom the University of Massachusetts Medical School, Department of amily Medicine and Community Health (Cashman), Worcester, assachusetts; and Community–Campus Partnerships for Health, niversity of Washington (Seifer), Seattle, Washington Address correspondence and reprint requests to: Suzanne B.

ashman, ScD, University of Massachusetts Medical School, Depart- ent of Family Medicine and Community Health, 55 Lake Avenue

l orth, Worcester MA 01655. E-mail: Suzanne.cashman@umassmed. du.

m J Prev Med 2008;35(3) 2008 American Journal of Preventive Medicine • Published by

In contrast to experiential learning generically, ervice-learning is grounded in collaborative relationships nd emphasizes the development of engaged civil sectors nd student civic participation. The long-term aim of ervice-learning is social change and social justice— hrough the service provided by students as well as hrough their lifelong commitment to community en- agement. In this article we set service-learning within he context of experiential learning, identify its com- onents, summarize highlights of the impact of service-

earning, and offer resources along with a case exam- le. We also note the importance of local and state ublic health agencies as appropriate and relevant ervice-learning partners for undergraduate students.

xperiential Learning

xperiential learning, an approach to learning that ncompasses service-learning, is a term used to de- cribe learning undertaken by students who are given chance to acquire and apply knowledge and skills in

n immediate and relevant setting. It links theory and ractice, and involves a “direct encounter with the henomena being studied rather than merely thinking bout the encounter, or only considering the possibility f doing something about it.”2 It is, in short, education hat “occurs as a direct participation in the events of

ife.”3

2730749-3797/08/$–see front matter Elsevier Inc. doi:10.1016/j.amepre.2008.06.012

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Experiential education as a philosophy can be linked irectly to three historical figures—John Dewey, Kurt ahn, and Paulo Freire—all of whom viewed student

xperiences as playing a central role in the educational rocess.5 For each of these educators, the ultimate aim f education was active citizenship, that is, the develop- ent and enhancement of one’s capacity to participate

n democracy. Experiential education differs from more traditional

ducation through its process of actively engaging tudents in experiences that have benefits and conse- uences. Immersed in action, students make discover-

es and experiment with knowledge themselves instead f hearing or reading about others’ experiences. They lso reflect on these experiences, thus developing new kills, new attitudes, and new theories or ways of hinking.4 Students are encouraged to relate their xperiences to existing knowledge and theory, thus eepening their understanding of theory as it exists or ontributing to theory modifications.

ervice-Learning

s a type of experiential learning, service-learning has a ong and substantial history. The origins of service- earning are directly traceable to the early 20th centu- y’s University of Cincinnati’s Cooperative Education ovement as well as to William James and John Dewey’s

edagogic writings.6 Service-learning is:

a structured learning experience that combines community service with preparation and reflec- tion. Students engaged in service-learning pro- vide community service in response to community- identified concerns and learn about the context in which service is provided, the connection be- tween their service and their academic course- work, and their roles as citizens.7

In distinguishing service-learning from volunteerism n the one hand and internships on the other, Furco8

tresses that service-learning is distinguished from ther forms of experiential education by its “intention o benefit equally the provider and the recipient of the ervice as well as to ensure equal focus on both the ervice being provided and the learning that is occur- ing.” While service-learning is sometimes considered o be synonymous with internships, they are actually ery different approaches to learning. In internships, tudents are the primary beneficiaries, with the experi- nce structured to facilitate student learning and acqui- ition of practical skills. Frequently, internships are djunctive to classroom courses. In service-learning, ervice is integrated into the coursework and co-occurs ith it, with the goal of placing equal emphasis on

tudent learning and the provision of meaningful com-

unity service.

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As a pedagogic methodology, service-learning pro- otes learning through a cycle of action and reflection.

tudents apply what they are learning in the classroom o community issues, and at the same time reflect on heir experiences as they strive to achieve specific bjectives with and for the community as well as deeper nderstanding and skills for themselves. Furco points ut that service-learning programs must have an aca- emic context and be designed so that the service nhances the learning and the learning enhances the ervice. In short, the service component is integrated nto the course curriculum. In public health education, ervice-learning can fit well into core public health ourses as well as be featured as part of public health lectives and practicum experiences. Service-learning comprises several components that

an be thought of as spokes of a wheel.9 This suggests hat the process is nonlinear and one in which entry

ay occur along any of the supporting spokes. Never- heless, establishing the community campus partner- hip is generally considered to be an essential first step. he spokes consist of the following components:

. Establish the community– campus partnership. Au- thentic partnerships are founded on a shared mis- sion, values, goals and outcomes; a relationship characterized by mutual trust, respect, and commit- ment; a balance of power and sharing of resources; bi-directional communication; agreed-upon roles, norms, and processes; and shared credit. Partner- ships take time to develop and evolve with time.

. Articulate learner outcomes and competencies. Spe- cific learning objectives and outcomes to which both the academic and the community faculty agree help make the transition from a classroom-based curric- ulum to a community-based collaborative model of learning and teaching.

. Select texts and other learning resources. Expand- ing the potential sources of teaching and learning materials to include items that community partners suggest helps ensure that resources include commu- nity voices.

. Plan course instruction and activities. Service-learning methodology calls for community needs and inter- ests to contribute to determining a course’s scope and activities. As a hallmark of service-learning, reflection is always included; it helps students make the connec- tion between their service experiences and class- room instruction.

. Design course evaluation and improvement plans. Developing and implementing a multi-tiered evalua- tion approach helps ensure that assessments include approaches related to student learning outcomes as well as community-, faculty-, institutional-, and partnership-related outcomes.

. Build course or program infrastructure. Service-

learning courses must follow required institutional

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policies and procedures as well as capture relevant community organizations’ interest and support.

. Sustain and maintain course and activities. Incorpo- rating structural elements that mesh with the insti- tution’s and community agency’s philosophy and mission as well as reflect state and local health objectives can help ensure that service-learning courses are sustained.

. Practice cultural humility. Service-learning courses provide opportunities for meaningful culture-related assessments and interventions to occur at multiple levels, including: the personal, partnership, institu- tional, faculty, student, and community.

. Develop community-engaged scholarship. The com- munity academic partnerships required for service- learning courses provide opportunities for scholar- ship that benefits the institution/faculty and the community. Often transdisciplinary, community- engaged scholarship integrates the scholarship of teaching, discovery, and application.

While relatively new to public health, service-learning as its historical roots in undergraduate education, here it has been shown to positively influence stu- ents’ personal development, leadership, and commu- ication skills; racial and cultural understanding; sense f social and civic responsibility; course content learn-

ng and ability to apply classroom learning in real-world ituations.10

Over 25 years ago, in describing higher education’s ocial responsibilities, Derek Bok, president of Harvard niversity, noted the importance of the community as locus for education and research.11 In a seminal piece n scholarship, Ernest Boyer, another well-known edu- ator, urged universities to engage with communities as

way of developing knowledge and contributing to tudent education as well as of applying knowledge.12

hile universities have long related to communities for he purpose of educating students and carrying out esearch, through service-learning the emphasis ex- ands to assure that community needs are also met. It

s noteworthy that the recent Consensus Report on ublic Health and Undergraduate Education13 recom- ends that experiential education such as service-

earning be a component of undergraduate public ealth and an integral part of a public health minor. In the health professions, service-learning has been

onceived “not only as a strategy for preparing community- esponsive and competent health professionals, but lso as a strategy for changing the relationship be- ween communities and . . . schools, fostering citizen- hip, and achieving social change.”7 The Health Profes- ions Schools in Service to the Nation (HPSISN) rogram, the only national demonstration program of ervice-learning in the health professions, documented hese benefits across a wide range of institutional and

ommunity contexts.14,15 Students participating in the

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PSISN program, for example, benefited from trans- ormational learning experiences that clarified values, ncreased awareness of the social determinants of ealth, deepened their sensitivity to diversity, broad- ned their knowledge of health policy issues, and rovided leadership development opportunities. Short- erm benefits for participating community partners ncluded expanded services, access to grant funding, nd increased awareness of university assets and limita- ions, while long-term benefits included volunteer and taff recruitment and retention.

chieving a Balance Between Service and Learning

ervice-learning strives to achieve a balance between ervice and learning objectives; in service-learning, artners negotiate the differences between their needs nd their expectations. Service-learning places an em- hasis on addressing community concerns and grows rom authentic partnerships between communities and ducational institutions. Importantly, service-learning mphasizes reciprocal learning. In service-learning, tra- itional definitions of faculty, teacher, and learner are

ntentionally blurred. Everyone becomes a learner. In mphasizing reflective practice, service-learning helps tudents make the connection between practice and heory while fostering critical thinking. Critical think- ng enables learners to analyze, synthesize, evaluate, nd explain their thinking, thus decreasing the likeli- ood of acting on false premises.16 Finally, service-

earning places an emphasis on developing citizenship kills and achieving social change. Through this educa- ional modality, students place their roles as future itizens and professionals in a larger societal context.7

hus, service-learning is a teaching and learning strat- gy that integrates meaningful community service ith instruction and reflection to enrich the learning xperience, teach civic responsibility, and strengthen ommunities.

In achieving a balance between service and learning, uthentic service-learning experiences have several ommon characteristics.17 They:

. are positive, meaningful and real to the participants;

. involve cooperative rather than competitive experi- ences and thus promote skills associated with team- work and community involvement and citizenship;

. address complex problems in complex settings rather than simplified problems in isolation;

. include a reflection component that helps students synthesize their theoretical and practical learnings;

. offer opportunities to engage in problem-solving by requiring participants to gain knowledge of the specific context of their service-learning activity and community challenges, rather than only to draw upon generalized or abstract knowledge such as

might come from a textbook; as a result, service-

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learning offers powerful opportunities to acquire the habits of critical thinking, particularly, the ability to identify the most important questions or issues within a real-world situation;

. promote deeper learning because the results are immediate and uncontrived; there are no “right answers” in the back of the book; and

. are reciprocal in nature, benefiting both the com- munity and the service providers by combining a service experience with a learning experience.

mpact of Service-Learning

s a consequence of this immediacy of experience, ervice-learning is more likely to be personally mean- ngful to participants and to generate emotional re- ponses. In addition, it challenges values as well as deas, thereby supporting social, emotional, and cogni- ive learning and development. Service-learning in un- ergraduate curricula has been shown to enhance tudents’ understanding of the relevance of course ontent, change student and faculty attitudes, encour- ge support for community initiatives, and increase tudent and faculty volunteerism.10,18,19

Among the features of service-learning that make it n appropriate and relevant vehicle for undergraduate ublic health education is its emphasis on developing itizenship skills and achieving social change. As a rofession committed to social justice, public health as generally placed a high value on vehicles through hich students can place their theoretical knowledge

nto practice and larger context. Service-learning tresses the importance of students’ understanding and earning how to intervene on the multiple factors that ffect health and quality of life. With its recent empha- is on eliminating disparities in health status, public ealth is well served in using service-learning as a edagogic modality to enrich and deepen student

earning and skill development.20 Further, the evalua- ion of the HPSISN program concluded that students enefited most from service-learning activities that ad- ressed the social determinants of health rather than edical care.14

The stakeholders in service-learning are multiple and ll stand to gain from the use of this modality. Stake- olders include students, faculty, academic institutions, ommunity-based organizations, community members, nd municipalities. Because it is predicated on an uthentic partnership between the academic institution nd the community, service-learning changes the way hese stakeholders relate to one another.21,22 Commu- ity organizations and community members become

eachers in a co-learning environment, as academic aculty deepen their understanding of a community’s tructure, assets, challenges and priorities.15 Students’ kill development is no longer the sole or even the

rime rationale for the experience. Rather, the student i

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s more likely to become integrated into ongoing ommunity program development and implementation nitiatives. With public health traditionally focused on ataloguing and acting on a community’s deficits, ervice-learning opportunities aim to help students nderstand that all communities have assets and that trengthening those assets can be an effective way to educe and counteract the community’s challenges.23

n summary, service-learning holds great promise for chieving the vision of the IOM report.

xample

lacing students in community organizations and set- ings for specific learning experiences needs to grow rom partnerships between the academy and the com-

unity. Given what for at least some schools has been troubled town– gown relationship, knowing the

istorical legacy of this relationship is fundamental to eveloping balanced, respectful partnerships for learn-

ng.21,22 While becoming acquainted with and acknowl- dging elements of this historical legacy, faculty can dentify organizations with which they might develop artnering arrangements for service-learning. Partners articularly well situated for helping students under- tand the principles and essential elements of public ealth as well as the role and function of epidemiology are

ocal, county, city, and/or state health departments.24 It is n these health departments that much of the core activity elated to public health is carried out. These departments re often understaffed, so having competent, energetic tudents can be a benefit, even with the added respon- ibility of precepting that student. Faculty should not iew this first step lightly, however, for developing and urturing partnerships with community organizations is a

ime-consuming endeavor; it often requires months of etting to know one another and of conversations that ay the groundwork for long-term relationships built on rust and respect.

Specifying learner outcomes and competencies is a ey element in service-learning. Taking time to articu- ate student learning goals helps ensure that the expe- iential elements provide opportunities that move from olunteerism to genuine service-learning. Working with heir community partners, faculty should specify learn- ng and service objectives as well as separate service- earning objectives. To help prepare students for expe- iences in a range of public health agencies and rganizations, the course materials should include ackground information at the micro level (specifics bout the history of the organization as well as the types f clients usually see) as well as the macro level (role nd function of public health broadly). Students placed n a health department to work on issues related to a igh incidence of babies born with low birth weights,

or example, might have as a learning objective to

dentify the conditions that contribute to babies being

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orn with low birth weights. The service objective might e to provide supportive services to mothers and their ewborns through the department’s Healthy Start Ini-

iative. The service-learning objective might be to work ith advocates to write a policy statement aimed at nsuring that an adequate and accessible supply of rimary prevention and health promotion services are vailable for women.

When placing students in public health agencies, aculty are often challenged by the need to allow ommunity needs and interests to contribute to deter- ining the scope of students’ activities. Accustomed to

ontrol in the classroom, faculty must find ways to ecome comfortable with sharing that control.24 Com- unity partners are key to helping students expand

heir frames of reference and understanding so that hey are more comfortable and competent working ith community members, especially if those members ome from communities different from their own. dditionally, it is often the community partners who nable students and faculty alike to see the resources nd assets that are present in any community, no matter ow distressed. For the course to be a service-learning course, a

ridge— usually consisting of reflection activities— ust be present to make the explicit link between

ervice and learning. Methods for reflection include ialogue, keeping a journal, photo-voice, and elec- ronic discussion groups. In the example of students laced with a health department and working on issues elated to reducing the incidence of babies born with ow birth weights, students could benefit from keeping

journal in which they record their thoughts and eelings about why women find themselves unable to btain recommended prenatal care services. They ight also ponder why a certain array of services is ore available in some communities that in others, why

ome women might be fearful and mistrustful of the edical and public health establishment, or why cer-

ain women enter child-bearing years healthy and fit hile others enter these years with their health status ompromised. In addition to keeping journals, students ight also engage in small-group discussions where

hey can share their perspectives and experiences, ncluding exploring their own values, beliefs, and tereotypes.

Every course benefits from having course evaluation nd improvement plans. In the case of service-learning ourses, this means that in addition to university-based aculty and students who traditionally assess and com-

ent on a course, community-based faculty and com- unity beneficiaries of the students’ endeavors are also

ncouraged to provide feedback. For example, in our ase example, health department personnel as well as ommunity members with whom the students worked

ould be invited to provide systematic feedback. i

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Developing a new course requires complying with nstitutional policies and procedures for offering new ourses. Faculty must to determine whether the course ill need curriculum committee approval or whether

he course could be considered a revision of an existing ne. Gaining support for the service-learning course rom deans, department leaders, faculty, students, and ommunity partners can be helpful in the early part of his approval process. Areas to consider in building upport include benefits/risks to the institution and he community, how the course can help students chieve specific competencies, and the identification of olleagues or partners who can be helpful.

Decisions will need to be made about number of redit hours to assign the course, distribution of time pent in the classroom and in the community, and hether to pilot the service-learning component with a

elected number of students or require it of all stu- ents. These decisions depend in part on the time and

nfrastructure support available to the faculty member. or example, a university with a campuswide center for ervice-learning may be able to offer release time for aculty to design new service-learning courses or may be ble to leverage existing community relationships so a aculty member does not have to start from scratch. ne should not underestimate the amount of time re-

uired to develop and teach a service-learning course: it is reater than a traditional in-class lecture course and equires a high degree of on-going face time between nstructor and community partner. Faculty on cam- uses with offices of service-learning or of community artnerships should use these resources. Additional esources can be found through Community–Campus artnerships for Health (www.ccph.info),25 State Cam- us Compacts (www.compact.org), The Corporation for ational and Community Service (www.cns.gov) and Area ealth Education Centers or AHECs (www.nationalahec.

rg). Service-learning opportunities in health departments

nd in any of many other community-based public ealth organizations will expose students to the issue of ealth disparities and the nation’s goals to eliminate

hem. Before being placed in a community agency, tudents might complete a self-assessment of their own ultural awareness, learn more about cultural groups ith which they will be working, and be encouraged to iscuss their feelings and human tendency to stereo- ype as part of their reflective journals.

Service and service-learning can become areas of xcellence and an asset in faculty promotion and enure when they become scholarship. The Report of he Commission on Community-Engaged Scholarship n the Health Professions defines community-engaged cholarship as “scholarship that involves the faculty ember in a mutually beneficial partnership with the

ommunity . . . . [it] can be transdisciplinary and often

ntegrates some combination of multiple forms of

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cholarship . . . . service-learning can integrate the cholarship of teaching, application, and engage- ent . . .”26 In developing service-learning in under-

raduate education, faculty should be aware of oppor- unities to use the experiences to inform their teaching, esearch, and service.

onclusion

ndergraduate public health can help us achieve the OM’s goal of a citizenry that is literate in public health. sing service-learning as a pedagogic method to teach ublic health will advance public health literacy while ncouraging the development of young people who ave a deep understanding of the influence that cul-

ure, class, economic status, neighborhood of resi- ence, and education have on an individual’s and a ommunity’s health. With its emphasis on reciprocal earning and reflective practice, service-learning can elp ensure that students who pursue public health tudies as undergraduates enter their adult lives pre- ared to make positive contributions to the nation’s ealth.

his publication was made possible through the CDC–Asso- iation for Prevention Teaching and Research (APTR) Coop- rative Agreement No. 3U50CD300860. The conclusions in his article are those of the author(s) and do not necessarily epresent the views of the CDC or APTR.

No financial disclosures were reported by the authors of his paper.

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