Abstract
The application of models used for health promotion is a cornerstone of health education curriculum, but finding innovative teaching approaches can be a challenge. Using community service learning, students assisted in the development of a community health initiative that involved a soccer tournament for a diverse, low-income community struggling with obesity. While active learning pedagogy is commonplace across most healthcare disciplines, it has not been well documented in the area of health psychology. Activities, reflections, and assignments allowed students to learn about the process of community health promotion, collaboration, and the application of the socioecological approach. At the end of the semester, students reported a deeper and richer understanding of the course material and community health initiatives because of their real world experience.
Introduction
Psychology is known as the scientific investigation of behavior and has historically been focused at the individual level. Along those lines, health psychology is a discipline within psychology that focuses on how biological, psychological, and societal factors impact one’s health and wellness. Health psychologists develop models that are used to explain what motivates individuals to change their behavior and lead a healthier life. In turn, they use these models to design interventions that are meant to assist people with their behavioral change. These programs include but are not limited to dietary changes that reduce the amount of saturated fats consumed, smoking cessation, and moving from a sedentary lifestyle to being physically active. Students in health psychology courses learn that modifying old habits and establishing more healthy behavior is difficult. The key to success is to define environmental, personal and social factors that influence the likelihood that someone will make the change needed. However, lifestyle modification only explains a small percentage of health outcomes and these models often neglect the environmental causes that may underlie health and illness. Other factors such as educational status, chronic exposure to violence, and proximity to support systems can directly impact one’s motivation and ability to develop a healthier lifestyle as well as one’s health status overall. Furthermore, studies have shown that environmental factors can serve as chronic stressors, sources of danger, and, conversely, as health resources (Kaplan, 1996; Syme & Ritterman, 2009).
Evidence is mounting that interventions must include not only person- focused but environment-focused programs to enhance the well-being of individuals (Stokols, 1995). Therefore, contrary to traditional psychological approaches, public health practitioners often utilize social ecological approaches which integrate person-focused with environmental-focused modifications to enhance physical and social surroundings. This shift has resulted in an increased interest in working at a community level to define and research what environmental factors may impact the health of residents and how we can work to change outcomes. It is also clear that not all communities will have the same issues that need to be addressed. Thus, community health providers must do a good job of defining and researching the needs of each environment. Such community health efforts have been successful in dealing with health problems such as Type II diabetes, inactivity, and heart disease (Campbell, et al., 2007; Fitzgibbon, et al., 2002; Satterfield, et al., 2003). The community-level approach helps to reach a larger number of people in areas with particular targeted health concerns and expand the focus of health. Community health psychology has therefore evolved to take this more holistic perspective on health management.
Social ecological theory, employed by many community health educators, is seen as a more inclusive approach that targets the relationship between diverse personal and environmental factors in health and illness (Stokols, 1996). For
example, the biopsychosocial model examines biological, psychological, and sociological factors from a variety of sources that impact one’s health and illness and encompasses the socioecological perspective. This model is routinely included in health psychology textbooks and is a key model discussed in my courses. Traditionally, students study this model and its applications through lectures and readings. However, over the years, I have developed a more active learning approach implementing community service learning projects to add to the educational experience.
Research supports community service learning as an important tool that provides students with an opportunity to experience real-world examples of the material presented in class (Bingle, R.G. & Hatcher, J.A., 2009). Reflections from students have documented how this approach assists them in building a better understanding of the process of community health and the development of interventions to change health behavior (Sgoutas-Emch, 2010). Additionally, the link between community service learning and community health has been documented in other professions such as nursing (Brosnan, C.A., Upchurch, S.L., Meininger, J.C., Hester, L.E., Johnson, G., & Eissa, M.A., 2005). These studies have shown that service learning experiences allow students to reflect critically about the needs of a community in somewhat structured environments.
Unfortunately, the use of such pedagogy has not been well documented in the field of health psychology.
The community service learning component is meant to provide an application element to the material presented in class. Furthermore, the reflections and assignments required are tools that allow me to assess how well the pedagogy is working to increase student learning. Another important outcome is that these experiences will allow students an opportunity to participate in collaborative efforts to help build healthier neighborhoods and communities, which adds a level of civic engagement to the course. As a faculty fellow of the California Campus Compact-Carnegie project on political engagement, developing methods to infuse civic engagement into the course was the centerpiece of the community project. Research on undergraduates supports the link between service and civic engagement, such as their commitment to others and serving the community in the future (Einsfield & Collins, 2008).
Learning about Community Health
Community health efforts involve many essential steps including 1) identifying health concerns within a community; 2) developing appropriate interventions and programs to address these concerns; 3) identifying important community partners to help participate in the efforts; and 4) working within the community to make things happen. My course entitled Health Psychology of Women and Ethnic Minorities was designed partly to educate students as to the importance of community and a more collective approach the health care.
Learning about the steps to community health promotion is a key objective. To actively engage students in the process, I have them get involved in community health efforts within diverse communities. For this particular semester, the focus became middle school children’s health. Because of previous community service projects, I have developed a long-term relationship with one of the local middle schools in our region. The school is an extremely valuable resource for my classes because of the student population and the community partners in the Linda Vista area. Through this relationship, I (with the help of our community partners) assisted in guiding my students (N = 15) through the various stages of building a community health promotion program.
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Identifying Health Concerns, Community Partnerships, and Possible Interventions
To begin, students researched some of the more pressing health issues concerning middle school-aged children in the Linda Vista community. This was accomplished by having them do some traditional research, attend community forums on health issues, and participate in conversations with students in the middle school. One of the most prominent issues mentioned was the number of students in the community that were overweight. Students found that obesity rates across the country have sky-rocketed to epidemic proportions, especially in minority and low-income children (Lobstein, Baur, & Uauy, 2004). The rates are a concern because of the link between childhood obesity and potentially lethal outcomes, including higher risk for adulthood obesity, hypertension, increased risk of Type II diabetes, and chronic inflammation. All of these factors increase one’s risk for cardiovascular disease and minority children are hardest hit (Ebbeling, Pawlak, & Ludwig, 2002). Furthermore, many studies focusing on children’s eating and physical habits have identified the link between personal, behavioral, and environmental factors pointing to the importance of multifaceted interventions when dealing with obesity (Stevens, 2009).
Traditional obesity intervention programs use a variety of tactics to help educate the public and raise awareness in neighborhoods with high rates of obesity. Programs on nutrition, diet, and the importance of physical activity are commonplace. Studies show the effectiveness of school programs that focus on changing school lunches and increasing the physical activity of students during school (Veugelers & Fitzgerald, 2005). Many afterschool programs have been developed to keep students active. However, these programs are not always readily available to all children and all neighborhoods. The Linda Vista a neighborhood has recreational areas that are underutilized by children and their families for a number of reasons including safety concerns. In fact, multiple studies have concluded that concern for safety and accessibility are important environmental barriers to physical activity for children and ethnic minorities (Franzini, et al., 2009). Therefore, if parents do not feel their children will be safe going outside or that there is a lack of access to indoor or outdoor facilities, these children will be less likely to exercise.
In order to address childhood obesity in the area, funding has been provided by the County of San Diego Health & Human Services Agency and other offices to form the San Diego County Childhood Obesity Initiative. The initiative was designed to reduce and prevent childhood obesity. Our university works closely with many of the partners that are part of this program including the Linda Vista Collaborative. During the beginning of the semester, many of these community members came to speak to my class to educate students on the history of the initiative and the role of the Collaborative so that they could get an understanding of the project assigned to them.
The Linda Vista Collaborative functions to identify the needs within the community in which the middle school is located and provides solutions and resources to help improve the quality of life for the people who live there. These partnerships allow each entity to share their resources so that a greater effort can be made to deal with very complex issues. Without the gathering of personnel and resources, many community health efforts would not be accomplished. It is important that our students become aware that health care professionals may have expertise when it comes to health matters, but may come from outside of the community and are not in tune with the concerns and needs of a particular community. Therefore, health providers and educators must work along with community partners and leaders to address the needs of the people.
During the fall of 2008, the Collaborative worked together to organize a soccer tournament to kick off what they hoped would be a continuing effort to have a permanent soccer league for students in the community to participate in. This diverse and low-income community was one of the few areas in San Diego that did not have a soccer league. Community organizers recognized this problem and decided to formulate a plan to have the American Youth Soccer Organization (AYSO) begin a league in the Linda Vista community. The idea behind establishing the soccer league was to help combat childhood obesity by getting children involved in a physical activity and providing them with a safe environment to be active. Focusing on such environmental factors may seem like a low priority, but as mentioned before in this paper, lack of access and safety concerns can be linked with sedentary lifestyles. Syme and Ritterman (2009) state that developing health models that focus on environment may help to better design programs based on things like crowding, traffic, and safe spaces.
The Collaborative developed what they called the Linda Vista Cup which was a kickoff soccer tournament for the league. This collaboration was a natural partnership for students in our health psychology courses to learn about and assist with the development of this community health initiative. This was an opportunity for my students to learn and apply a number of skills that are addressed in the course material and to actively engage in the health promotion process. Learning how community partnerships are formed and function are key elements to understanding how community health efforts work. Another factor we discussed in class is the importance of learning about the community you are asked to work with and to develop relationships within the community to establish a presence and a level of trust among community members. Students in the course were asked to assist in organizing, advertising, and running the initial soccer tournament. Students learned of the frustrations, inspirations, and collaborations that go along with community health efforts.
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Learning about Community
Students were asked to research the community in two important ways. Firstly, they were asked to complete a brief research project of the demographics and history of Linda Vista. This research included a tour of the community, web searches, and a visit to the local library. Content analysis of the student reports found themes of ethnic diversity, low income, and lack of resources. In particular, the majority of students commented on the lack of access to fresh and
healthy food and the prevalence of fast food restaurants. These observations related to the course material on environmental factors that correlate with obesity. For example, one student commented:
‘In visiting around the Linda Vista Community, I have realized the difficulty the residents face in staying healthy. The food options that these families have are very limited. In this small community there are more than five fast food restaurants, while on the other hand, there is only one grocery store.’
Another theme mentioned by half of the students was the lack of safety.
The lack of safe spaces for children to play has been seen as a barrier in the community for children to remain active.
‘There were no pedestrians, as if no one was in the immediate vicinity and no people visible from their porches, yards, or driveways. It felt strangely vacant, as if no one was currently living in the houses and apartments.
Since it was around the time that children are already home from school, I imagined that all the kids in this neighborhood were hiding away behind the walls on either side of the street. The neighborhood was empty and lonely, and because of that, it didn’t feel safe or inviting for anyone.’
Secondly, students were asked to attend some of the community meetings to learn more about how community collaborations work. Students attended a number of different meetings ranging from the gang commission, Linda Vista Collaborative, Youth Action Team, and Healthy Initiatives. Students learned about how community partners are working together to provide resources and services to reduce violence in the community and increase wellness. Themes discussed in their reflections included the importance of partnerships for the community, the sharing of resources, the role of politics, and how difficult it would be to accomplish the goals presented without these collaborations. For example, this student stated:
‘These types of meetings are very important for the community because they create a group of individuals with a common goal, to better the health program opportunities for the families and children in the Linda Vista community. Without these groups, the success of these community programs, such as the mobile immunizations connected to the libraries and the growing health programs in accordance with the different elementary schools, would not be possible.’
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Working with community and importance of collaboration
In addition to attending community meetings, students were asked to assist with a number of activities prior to and during the day of the soccer tournament. The organizers of the tournament needed assistance with registration, advertisement, and many activities throughout the day of the tournament. Students learned about the process of gathering volunteers and sponsors to help support the event. Organizers of the event had a number of tasks that needed to be completed for the event; some ran smoothly and others did not. For example, my students were asked to run a registration desk at the local community center for the event throughout the month prior to the tournament. Unfortunately, because the registration was not well organized or advertised, my students showed up and no one at the center knew of the registration and very few kids came to register. Luckily, the organizers were able to rally together and get children registered in time for the tournament.
USD students also assisted in gathering donations for the event. Here they were able to witness the importance of corporate and individual donations. Local establishments donated breakfast items, while national chains such as Target and Chick-Fil-A provided free soccer equipment and lunch, respectively. Even local politicians donated their time during the tournament and the USD soccer team helped provide referees. Finally, USD students in the course participated during the day of the tournament helping to set up, getting children ready, refereeing, giving out food and equipment, and cleaning up after the event. Themes that students reflected upon around the organization of the tournament included the need for collaboration, the complexity of the effort, the passion of the volunteers, barriers to success, and the need for donations and support.
Student 1: ‘Many groups, organizations and individuals poured their valuable time and energy into this project because of the shared belief that children are the future and deserve the opportunities needed to grow and flourish into health human beings. The kind of obvious passion demonstrated by the leaders and project directors of this event fuels the success of volunteer endeavors. Their determination, persistence, and optimistic outlooks are contagiously spread through the contacts they make, inspiring and motivating other people to take ambitious position as well.’
Student 2: ‘By functioning as a part of the team that put on the Linda Vista Cup, I saw first-hand how difficult it is to organize a community program. Within the healthcare system, program leaders struggle every day to move through all the legal obstacles and necessary procedures in order to make successful difference in the way the broader systems currently operate.’
Students reflected on the importance of community partnerships and becoming part of that community to progress health initiatives in a community:
Student 1: ‘This soccer tournament was such a great opportunity not only for the children of the Linda Vista Community, but also their families.
This event could not have been successful without the community support and effort to organize and it put on. The children need safe events to take part in, but without community organizers creating their events they would not have any opportunity to participate. When community members work on an event such as this soccer tournament it becomes part of the community, which is very important. If this event was put on by an organization outside of Linda Vista it may not have been as successful because then it would not have been ‘Linda Vista’s’ soccer tournament.’ Student 2: ‘The soccer tournament was successful because there were community members that helped recruit children to play in the tournament. Community members and health professionals came together to create a program that effectively incorporated the resources of the community and the promotion of health.’
Impact on Community
An important aspect of community service learning projects is the impact on the community partners as well as the students themselves. During the tournament, students reported their observations on the community impact and on their own experience.
Student 1: ‘At the Linda Vista Cup, I was also surprised about the experience I had. I expected to hand out waters, help kids register, and clean up at the end of the day – nothing more. I actually left the tournament feeling a connection to the children and their families. The day got off to a rocky start; attendance was low and many people were pessimistic about the day’s possibilities. During one of the activities, we were giving out soccer gear. It was during that time that I realized the
impact we were having on these kids’ lives. One mom approached me and told me how much we were appreciated; some kids had never had anything new until then. It was amazing to see the joy on their faces as they won these prizes and actively participated in their community.’ Student 2: ‘The Hispanic and Vietnamese communities of Linda Vista struggle with many things like poverty, language barriers, and discrimination. The Linda Vista Cup was a day for these kids to interact with others in their community as well as older students who were interested in their well being without concern for these problems. Soccer is a great sport that enabled us to interact with them, regardless of language barriers.’
Finally, two years after the initial soccer tournament, the partners were able to maintain the tournament and introduce the community to organized soccer. Children who participated in the tournament received free equipment to help them continue with their soccer teams. Fields have been reserved to provide access for the soccer teams and families of the schools in the area have been provided with resources and information to get their children involved and active.
Conclusion
Using student writings and oral reflections, it was clear that the main goals and learning outcomes of the project and course were met. Students progressed through most of the essential stages of building a community health promotion program by identifying a health concern within the community (childhood obesity), targeting appropriate partnerships (Linda Vista community partners), learning about the community, and working together to organize and execute the program (the soccer tournament). All students in the course overwhelmingly reflected that their experience was extremely positive and helped them better understand the amount of effort and collaboration that is needed to help communities stay healthy. Additionally, students were able to identify environmental factors that impact the health of the Linda Vista community as discussed in the socioecological approach. Access, safety, and awareness are key variables that impact health according to the biopsychosocial model. This project raised their awareness of the barriers that these factors may place on wellness but also offered solutions to attempt to overcome these barriers. This may have been the most important part of the project. So often, we
only learn of the barriers and only read about potential solutions. This project gave my students the opportunity to experience how environmental change can work and implemented in the real world. As one of the students reflected at the end of the course:
‘My experience with the community service project this semester has offered me a unique shot at rising above the constraining effect of everyday excuses that are regularly used to justify passivity. I have always been and will continue to be involved in volunteer activities, but the Linda Vista community has served me personally as a profound opportunity to expand my knowledge of health and society, and allowed me to explore the multitude of barriers, pressures, and concerns involved with encouraging others to make safe and healthy choices.’
Additionally, community health efforts are essential for the health and wellbeing of communities as a whole but can be difficult and require many resources to be successful. Students were able through community service learning to experience the birth of a health promotion campaign that was rather unique. For example, students recognized the importance of selecting soccer:
‘Soccer was a great way to expose these kids to a sport that can keep them healthy and fit. Soccer can also give kids the opportunity to be a part of a team, which can result in self-confidence and keep them away from things like joining gangs. The soccer tournament allowed parents to get to know one another and participate in a positive and uplifting community event. This will hopefully reinforce behavior to participate in future community programs.’
By utilizing an active learning pedagogy such as community service learning, my students were able to get a better and deeper understanding of the process that is involved in community health psychology and community health promotion. The socioecological approach was made more concrete over the course of the project because of their experiences. Although traditional teaching techniques are certainly important in providing context, history, and knowledge, these approaches do not provide the experiential opportunities that active learning approaches can. Traditional teaching also neglects the important element of having the students become more civically involved in their community. Using these pedagogies together exposed my students to a more holistic learning experience. In fact, one student summed up her reflection by quoting Margaret Mead, who said, ‘Never doubt that a small group of thoughtful, committed citizens can change the world. In fact, nothing else ever has.’
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About the author:
Sandra A. Sgoutas-Emch
Dr. Sandra Sgoutas-Emch is a professor in the department of psychological sciences and the director of the Center for Educational Excellence at the University of San Diego. She is the recipient of a California Campus Compact- Carnegie fellowship for political engagement. Dr. Sgoutas-Emch teaches courses in health and biological psychology.
Professor, Department of Psychological Sciences, University of San Diego, 5998 Alcala Park , San Diego, CA, 92110. [email protected]
© 2013 Journal for Civic Commitment