ASCD respects intellectual property rights and adheres to the laws governing them. Learn more about our permissions policy and submit your request online. Ideas from the Field. Subscribe Now. Are You a Member? This is not a member book. For instance, substance abuse prevention practitioners working in cross-cultural settings are advised to be inclusive of those who have a stake in the program if resistance is to be minimized Orlandi, ; Scott, ; to use multiple methods that may emphasize oral traditions versus written and experimental protocols Airhihenbuwa, ; to take into account factors that are not only behavioral, but also contextual Braithwaite and Taylor, ; and to learn how to gain access and trust in forging cross-cultural relationships by being aware of and sensitive to cultural nuances in interacting with others Airhihenbuwa, Lack of cultural competence in domestic practice is one of the factors that guides the objectives in Healthy People U.
Educators, researchers, and practitioners must intensify their efforts to ensure that public health students are properly prepared to address the needs of these populations. The Council on Linkages Between Academia and Public Health Practice has developed eight competency domains for public health professionals, one of which is cultural competency. The committee believes that this core competency as explicated by the council is important and forms a focus for education of culturally competent public health professionals.
Ultimately, all areas of public health instruction are encompassed by cultural competence to a greater or lesser degree. The exploration of cultural competence improves core skills including attention to cultural-linguistic nuance in health screening, improving the ability of public health professionals to pose and answer research questions, redesigning interventions to fit ethnic community environments, and evaluating health policy issues.
Improving screening for cancer, diabetes, and heart disease, increasing exercise regularity, reducing toxic exposures, stopping tobacco use, reducing HIV risk, and helping individuals make informed decisions about health care providers are examples of typical public health projects improved by cultural competence. Cultural competence includes supply-.
There are now many research articles, books, and Web sites available that offer information and additional resources to provide a concrete foundation for commencing cultural competence instruction in programs and schools of public health. The next step is to integrate this information where it is needed across the curricula and to continue refining the knowledge base and pedagogy of cultural competence.
Cultural and ethnic awareness must also be increased in public health research. There has been relatively slow progress in including ethnic minorities in public health research and intervention trials. In recent years federal requirements at the National Institutes of Health NIH have made the inclusion of ethnic minorities nearly compulsory in research. However, these requirements pertain primarily to participation of human subjects in research.
There are no guidelines about researcher responsibility or ethical practices when research is conducted in minority communities. In addition criteria have not been established for adequacy of research designs that increase the likelihood of high quality research results with external validity for minority populations. Minority communities often are suspicious of, or even hostile to, public health researchers because they have seen little benefit or improved conditions within their own communities from previous research.
Padilla and Medina assert that cultural sensitivity should span the entire research study process, including the adaptation, translation, and administration of measures, along with the analysis, scoring, and interpretation of results. To reduce culturally induced bias, Suzuki et al. The approach is similar to that identified in the section on community-based participatory practices; therefore, the skills required are also similar. In particular, cross-cultural competence requires the public health professional to combine the perspective of a group that is the focus of study or practice with the science that informs public health research and practice.
To do so means that professional training should. Additionally, training in methodology should be multioperational, thus exposing the learner to a broad array of methods that take into account cultures in which oral and other non-Western traditions predominate. Training should focus on ways in which methods can be adapted in partnership with cross-cultural groups and still retain scientific validity.
Cultural competence skills and knowledge are applicable to dual priorities in public health education, global health, and U. There is substantial overlap in the cross-cultural and linguistic challenges each area presents for improving public health education. Thus, it is logical and parsimonious for programs and schools of public health to disseminate cultural competence skills that are applicable in a transnational context, bearing in mind the inescapable truth that local public health practice requires local knowledge—including awareness of the cultural world, its heterogeneity, resources, and conflicts.
Several schools of public health have strong international health programs that already emphasize the importance of cross-cultural understanding and the adaptation of practices for working outside of the United States. They may serve as models that may be more widely adopted and applied to both international and domestic public health.
A fundamental challenge in achieving cultural competency in public health education and research is the need to increase the number of students and faculty from under-represented minority groups. In some instances these groups represent a cultural continuum extending from nations of origin in Latin America, Asia, Africa, the Caribbean, and Europe, to new communities of resettlement in the United States. The volume of students from many of these ethnic groups in public health education is inadequate, especially blacks and Latinos, who comprise nearly 90 percent of the total U.
Aguirre-Molina, Columbia University, June 15, A total of 34 courses were offered among the remaining 17 schools, and of these, 29 were general survey overview courses. Only 10 schools offered 2 or more courses on health issues of minorities. This brief profile suggests that with few exceptions, U. The absence of undergraduate degree programs in public health at many schools delays the potential exposure of minority candidates, thus decreasing the number of recruits available for graduate training directly. Mentoring programs in the sciences have been developed at the NIH for high school students from minority backgrounds to better equip them to compete academically at the university level, thus increasing their survival rates for advanced career preparation in the sciences.
However, most of these programs are limited to the biological sciences. The minority pipelines at the secondary school and community college levels are poorly developed for public health. Even high school magnet programs in the health sciences tend to focus on classic career tracks, such as nursing and medicine. Public health has not established sufficient visibility in this arena and has received little federal support or leadership to do so. This must change. Programs and schools of public health must demonstrate leadership and creativity in developing outreach programs in their local areas.
They could sponsor courses in public health and help high schools implement their own courses by providing technical assistance. This program offers an introductory public health course at a local community college for both high school and community college students. The objective is to expose students to the opportunities available for positively improving their communities through a career in public health. Special programs on minority health accompanied by outreach to minority communities, secondary schools, and community colleges could also be created.
A related issue is the wholly inadequate supply of minority faculty. This is compounded by a dearth of tenured faculty that have direct experience with public health practice in minority communities. Some faculty may even be attitudinally resistant or substantively unprepared to address the renovation of curricula to achieve greater cultural competence among their students.
Programs and schools must be willing to engage in reform and leadership development and to examine mechanisms for attracting, training, and retaining faculty from minority backgrounds. A comprehensive approach is needed to identify, encourage, and support a greater diversity of students in schools and programs of public health, and to help those students complete their graduate degrees at the masters and doctoral levels. Greater attention should be given to undergraduate courses in public health that specifically address minority health issues and to developing outreach efforts to minority organizations to garner their assistance in reaching minority students.
Programs could be established to partially or wholly support education to earn a master of public health M. These messages must be based on high quality information, obtained in a timely fashion, and shared in a manner that respects the values, opinions, beliefs, and practices of the communities with which public health interacts. In an era of expanded awareness of health disparities and an emphasis on prevention, do we have the requisite knowledge to reach ethnic minority communities and create awareness of specific health threats and reduce population risk?
Will the enriched public health infrastructure adequately incorporate the needs of ethnic and cultural minorities? These are long-range challenges. Some progress has been made, but an active use of technological capability is needed to identify and rapidly disseminate cultural competency information and to integrate it into the core competency curricula. The importance of supervised practical experience to the mastering of cultural competency cannot be overstated.
This may require some public health faculty to augment their own personal experience in minority communities in order to provide improved student field supervision and classroom instruction. Cultural competency should be supported as an essential element in teaching, research, and practice. Public health research has contributed greatly to improvements in population- and individual-level health. Basic research, conducted for the purpose of advancing our knowledge, has helped us learn about such things as the basic biology of infectious agents e.
Applied or translational research, designed to use the results of other research to solve real world problems, helps us understand, for example, how antibiotic resistance develops in certain types of organisms, so that the most effective treatments can be used. Evaluative research can be used to help us analyze the impact of welfare reform on the health of immigrant children or the effectiveness of high blood pressure prevention programs. Descriptive research that attempts to discover facts or describe reality provides us with hypothesis-generating studies, epidemiological studies, observational studies, and surveys.
A prime example of this type of study is the original Framingham study that led to identification of risk factors for cardiovascular disease in middle-aged adults. All of these types of research are crucial to the field of public health and continue to be necessary components of the public health research portfolio. Additionally, given the demographic transformations in the United States, there is increasing need to incorporate lessons learned about community engagement, and the complex nature of interventions into community-based research.
Community-based research is an overarching concept of collaborative research that encompasses many different types of studies, for example, applied, descriptive, and evaluative. Minimum participation requires involvement in question formulation, interpretation, and application of findings. To Green and Mercer, the focus on participation separates community research from basic and applied research, with basic research involving only the researcher, and applied involving the research and practitioners. Thus, CBPR and the training that it requires is most linked to practice in geographically-determined community settings.
The NIH National Institute of Environmental Health Sciences defines community-based participatory research as a methodology that promotes active community involvement in the processes that shape research and intervention strategies, as well as in the conduct of research studies NIH, Green and Mercer observe that communities often find that they participate in research that has limited applicability and is insensitive to the community in the process.
Lack of access to and cooperation from community groups are common ramifications of poor relationships with communities. The breach in relationships also is discussed in the IOM reports on the future of public health and linkages between research and practice It is further recognized by investigators who have wrestled with the complexities of community research and who have helped reshape public health programming in community settings over the past 25 years.
For instance, in considering the mixed record in protecting the integrity of research subjects, Strauss et al. The authors define the functions required of investigators in the research process, including the following:. In addition to the ethical considerations that incorporate active oversight by community groups, the complex nature of the interventions underscores the importance of CBPR approaches. Of particular note are the 10 year community trials in the late s and early s, funded by the National Heart, Lung and Blood Institute NHLBI , and directed at cardiovascular risk reduction Farquhar et al.
Each implemented numerous community activities that included risk factor screening, general and specific media messages, work site physical activity, menu labeling at restaurants, grocery labeling, school programs, work with health practitioners, community-wide contests, community task forces, and speakers bureaus, as well as others Jacobs et al. The lessons learned about community engagement from these complex community trials were reinforced during the last decade by the emergence of social ecology principles for informing public health interventions Shinn, ; Green and Kreuter, Social ecology is the application of multiple and linked intervention strategies across multiple social levels—the individual, family, social network, service organizations, community groups, and policy bodies Goodman, a; McLeroy et al.
Stokols and colleagues suggest that research and practice based on comprehensive ecological formulations are needed in community health because limited intervention programs produce high relapse and attrition rates. Empirical evidence is accumulating that suggests that CBPR approaches are consequential in producing important outcomes.
As discussed earlier, in CBPR the community is a full partner in identifying the research questions to be addressed. These research questions are not developed or structured in the same manner as those posed by the quantitative researcher nor are they necessarily hypothesis driven, and they are not determined a priori and out of context from the communities in which the solutions arise. Participants included migrant farm workers, community representatives, analytical chemists, epidemiologists, exposure assessment scientists, investigators skilled in qualitative research methods, and neurobehavioral scientists.
The community benefits from the increased knowledge of the nature and extent of pesticide exposures in their work and home environments while the basic and applied scientist gains an increased sensitivity of community priorities and the need for culturally appropriate research methods and communication www. The CBPR approach has developed in response to the lack of success of other approaches that excluded the community from the research process Green and Mercer, As with other evolving approaches e.
Currently, CBPR approaches are receiving a great deal of attention from the public health community. Furthermore, practical considerations dictate that community cooperation is predicated on processes that are participatory. Lastly, complex, interventions require communities to work in partnership with researchers and providers. Without comprehensive community approaches, pockets of prevalence may not be addressed effectively. Israel et al. Three levels of practice that are analogous to the research levels include:. Proponents of CBPR and practice view them as distinct paradigmatically from levels 1 and 2, whereas the IOM report views the three types as a continuum along which research may evolve.
Research into social determinants of health SDOH is another area that has implications for community engagement and that can be distinguished from CBPR. SDOH has its foundations in social epidemiology, particularly that aspect which focuses on social inequalities in contributing to disease and disability Berkman and Kawachi, The SDOH perspective shares many characteristics with social ecology principles in that both take a population perspective, highlight social context in understanding individual behavior, and operate on multiple social levels.
For instance, Krieger enumerates research studies on the effects of discrimination on a range of health outcomes, including blood pressure, hypertension, cigarette smoking, depression, and other forms of psychological distress. Thus, discrimination as a social determinant is linked empirically to health outcomes.
The question remains, what can public health offer in the face of pernicious social determinants like discrimination, poverty, and job dislocation? Community capacity is one example of a cluster of SPF that do not necessarily reduce the presence of negative determinants like discrimination, but may bolster proactive community responses in the face of such determinants. Currently, CDC funds several special interest projects to understand how community capacity may improve community health outcomes.
Measures for capacity, social capital, and SPF are in development. Preliminary findings indicate that communities that are most successful in producing desired community health and social outcomes tend to have important capacities in leadership, a strong set of values and principles, organizing abilities, and strategic community actions. Although these findings remain preliminary, they reinforce the prominent role that community-based participatory research and practice should be accorded in public health.
Israel and colleagues characterize CBPR as incorporating several operating principles including the following:. Israel and colleagues also suggest that challenges in implementing CBPR include the following:. The principles and challenges suggest the skills necessary to conduct CBPR and practice. For many researchers and practitioners, the development of new skills or the modification of existing skills will be required, including the ability to collaborate and share control in decision making and action regarding program design, implementation, and evaluation; the non-trivial use of community resources, skills, and relationships; and the cultivation of new capacities and partnerships among organizations and individuals Paxman et al.
Several programs at schools of public health teach skills in CBPR e. The curricula from these programs may provide guidance for establishing additional training requirements. Researchers engaged in CBPR are program stakeholders, collaborators, and builders of capacity for the community interventions. They must have competencies in team building, group process, negotiation, developing consensus, teaching, interpersonal communication, and the acquisition of political acumen.
Programs and schools of public health have at least three important roles that they can take in training researchers and practitioners to use community-based participatory approaches. First, course work on community engagement concepts should be integrated into the M. Topics to include involve community theory, development strategies, promising interventions, group development techniques, community diagnosis, and capacity assessments. Secondly, the practicum or capstone experience should incorporate community-based experience.
In many instances, students receive no academic credit for this requirement, and little faculty time is devoted to group discussions or debriefing sessions with students regarding community practice. The practicum or capstone experience may be used more fully to train in community-based approaches.
Third, faculty should be encouraged to include students on funded community-based research enterprises.
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Many facets of community-based research and evaluation are unique. For instance, in CBPR the researcher provides continuous feedback to the community. In classical research approaches, such incursions by the researcher are considered to be threats to internal validity because the researcher influences the intervention. In research that is participatory, the investigator learns to develop methods for assuring internal validity that may deviate from classical approaches Goodman, b.
Moreover, the movement towards multiple, complex, and community-based interventions has implications for redefining the types of skills required to research and practice community public health approaches. Flay focused on the impediments in implementing complex community programs, including reaching the planned targets at the correct time with adequate intensity and desired effects.
Altman sought methods for disaggregating program components to understand the multiple causal mechanisms within complex community interventions. Research, development, and assessment of community programs are difficult because they are necessarily different in different communities, need to be flexible and responsive to changing local needs and conditions, have broad and multiple goals, take many years to produce major outcomes, and require multiple data collection and analysis methods extended over long periods of time Goodman, b.
Programs and schools of public health should have a central role in training researchers and practitioners to research, implement, and evaluate complex community interventions. The implications for programs and schools of public health concerning training for CBPR and practice are that multiple methods are important given the complexities of community health factors.
The researcher, evaluator, and practitioner should be trained to tailor strategies to the specific questions and concerns of a community project. In developing the widest array of possible strategies, the public health profession requires training in both quantitative and qualitative approaches. Quantitative approaches typically use statistical techniques to judge whether program recipients benefit from the program in contrast to controls or comparisons. Qualitative approaches seldom use randomization and often do not have comparison groups; rather they focus on the program itself and use detailed observations of activities and events, interviews with program stakeholders, and reviews of program documents to judge program results.
Moreover, new approaches should be incorporated as they develop. For instance, recent advances in geographic information systems GIS technology allows for increased availability and interpretation of geographic or location-based information Richards et al. First, an array of research methods courses, both qualitative and quantitative should be part of training, particularly at the doctoral level.
Second, the courses should focus not only on the acquisition of technical skills in design, data collection, and analysis but also on developing creative problem solving skills in contouring designs to fit with community input and social ecology principles that is, multiple interventions at multiple social levels.
CBPR takes time. Researchers and practitioners must be responsive both to the slow and deliberate pace that often accompanies community engagement and to the pressures and timelines programs and schools of public health maintain for promotion and tenure. If expectations regarding scholarly productivity are not met, those early in their careers may soon be out of a job.
The irony is that those who become well-mentored in CBPR may not have the opportunity to build upon years of productive partnering because they do not pass muster at the university. If CBPR and practice are to be established as core methods in public health, then reward and incentive systems for faculty promotion and tenure may require adjustments to accommodate the complex nature of the work.
Community-based research involves active partnerships between the community and researchers. These partnerships are important to developing prevention research and health promotion programs because no single agency or institution has the resources, access, and trust relationships to address the wide range of community determinants of public health problems Green and Mercer, Public health professionals in. America has a vital and direct stake in the health of people around the globe, and.
It is clear that health concerns and interventions cannot be limited by national borders. Increased travel, migration, and refugees from conflict have had an impact on the demographics of the United States. It is not unusual for a local U. The extent to which these immigrants adjust well to life in the United States and experience healthy development depends on several things, including 1 the assets and resources they bring from their country of origin, 2 how they are officially categorized and treated by federal, state, and local governments, 3 the social and economic circumstances and cultural environment in which they reside in the U.
These rapidly growing immigrant communities are creating a need for new services or for providing old services in a way that takes into account the traditions and beliefs of the different cultures. There is a growing need to address issues that impact global health, such as the increasing income differentials between and among countries that foster poverty-associated conditions for poor health; the variance in environmental and occupational health and safety standards that contributes to hazardous production facilities and dangerous working conditions; global environmental changes leading to such things as depletion of freshwater supplies and the loss of arable lands; and the re-emergence of infectious diseases IOM, ; McMichael and Beaglehole, Poverty and ill health have long been associated, and the number of poor and marginalized people is increasing Macfarlane et al.
For every , births in developing regions, women die as a result of pregnancy and childbirth while the rich countries have a rate of 7 maternal deaths per , births IOM, Poverty contributes to population growth, which, in turn, leads to overcrowded and unsanitary living conditions in poor communities which, in turn, leads to the spread of infectious diseases. Other diseases. Table , outlines factors contributing to disease reemergence. Overpopulation also affects the environment. With increasing population comes a need for increased food production.
Some multinational companies, taking advantage of cross-national variations in environmental and worker safety standards, place hazardous production facilities in developing countries that either do not have strict regulations governing such facilities or that have lax enforcement. Issues related to food safety and diet are also of global concern. Lyme disease, malaria, plague, rabies, yellow fever, Rift Valley fever, schistosomiasis. Rabies, tuberculosis, trench fever, diphtheria, whooping cough pertussis , cholera. The transfer of unhealthy diets e. For example, the decline in smoking in western countries has been accompanied by massive marketing and increased smoking rates in low- and middle-income countries.
It is estimated that one-third of Chinese males under age 30 will be killed by tobacco and about 22 percent of all deaths in Eastern Europe will be related to smoking by the year Kickbusch and Buse, Another area of concern is preparedness against bioterrorism. Since the anthrax attacks of September , there has been heightened awareness of the possiblity of bioterrorism. International surveillance and safeguards against man-made infectious outbreaks are in the process of being strengthened. Public health professionals of the 21st century must be better prepared to respond in the face of such attacks, including understanding the actions available to them to respond and the authorities under which those actions can be taken.
Global health challenges are increasingly important. Many of these challenges are beyond the scope of this report. However, the committee believes that public health professionals must understand global health issues and their determinants; they must understand how local actions can have health impacts across the globe. Public health must be prepared to work with individuals from other countries to solve the problems facing our global community.
To effectively engage with others on an international basis will require not only knowledge and skills described under the other seven content areas discussed in this chapter, but also an ecological perspective of the determinants of health. We are all on this planet together. It behooves us to care for the natural and human resources so vital to the existence of us all. Although the importance of policy in public health has long been recognized IOM, , education in policy and law at many programs and schools of public health is currently minimal.
Education in policy analysis and, in particular, in policy methods, needs to be strengthened and systematically provided to all students, consistent with the inclusion of policy development as a core competency for public health professionals Council on Linkages, Policy-makers are accustomed to making decisions based on incomplete information; public health professionals can be a more effective part of that process if they are familiar and equipped with reliable data produced on a shorter time frame. It is also important to recognize the underlying difficulty that choices based upon incomplete information are inevitable and that our programs and schools of public health are not doing a particularly good job of educating students to manage the associated uncertainties.
Educating students in traditional epidemiologic and biostatistical methods is important, but in addition to those methods, students also need training in quantitative methods e. Engagement in policy also requires a set of practical political skills IOM, ; Gebbie and Hwang, Successful community public health work at the policy level typically requires political collaboration with stakeholders Freudenberg and Golub, Public health professionals in the community can be more effective if they can understand the dynamics of community politics, identify and work with stakeholders, identify legal and policy structures currently influencing community health and efficacy, and motivate and educate stakeholders and officials.
People in practice report the need for more skills in policy development and law Liang et al. Law is an essential component of training in policy. Most public health policies are embodied in or effectuated through law, and law provides the institutional framework and procedures through which policies are debated, codified, implemented, and interpreted Burris, ; Gostin, Law is more than just the rules written down in statutes and court decisions; it encompasses the institutional arrangements and day-to-day practices through which law influences behavior and attitudes Ewick and Silbey, ; Sarat, ; Burris, The effectiveness of public health leaders at the local, state or national level will be significantly enhanced by knowledge about law including its structure, its typical modes of operation, the powers and the limitations on power provided for public health actions, and its role in population health and behavior.
These do-. A critical area in public health policy research is engagement with law. Public health research seeking to understand the relationship of multiple determinants of health will be enhanced by integrating law and legal practices into research on individuals, partners, communities, and whole populations. Because laws are used as structural interventions to regulate individual behavior and to change social and material conditions that endanger health Blankenship, ; Hemenway, ; Schmid et al. Research in public health can help to document how health policy is made and the process influenced Backstrom and Robins, ; Mittelmark, , as well as the difference between law on the books and law in practice Boden, ; Cotton-Oldenburg, The operation of law cannot often be studied in experimental designs.
More attention to and respect for observational studies, rapid assessments, qualitative methods, and modeling is essential to expanding the public health research base in law. Major barriers to increasing law-related research in public health are lack of funding and faculty incentives for efforts to make research more useful in the policy process Nutbeam, Historically, funding for law-related research in public health has been minimal.
In recent years, the CDC has made an important commitment to funding public health law research, but awareness of and support for this field of work remains rare in the National Institutes of Health. Ethics, too, play an important role in politics and policy development as elsewhere in practice. Ethics are a tool through which public health professionals can interrogate their own values, formulate policy goals, and articulate a rationale for change in policy. Gostin suggests that. While the content of public health ethics will continue to develop, the committee believes that ethics are an important and heretofore neglected element of a thorough education in policy.
Finally, policy training in programs and schools of public health also can be enhanced by considering human rights and their relation to health. As used in public health circles, human rights cut across law, ethics, and advocacy. When evoked in terms of the various international human rights conventions and national constitutions, they are a species of law Burris, As deployed in efforts to secure just and effective public health policies, they are a tool of advocacy Gostin and Lazzarini, Jonathan Mann argued that human rights could also take the place of an ethics for public health Mann, While much work remains to be done to develop the public health potential of human rights analysis Gostin, , a human rights perspective has already become an important part of international health practice.
Public health raises a number of moral problems that extend beyond the earlier boundaries of bioethics and require their own form of ethical analysis Callahan and Jennings, They also served as mentors to the high school students. During the first year of the class, the project staff included three interns—two graduate students and one undergraduate. The second year, staff increased to seven graduate student interns. Access to the college was a boon for the high school. Many of the students have learning challenges, and the school is considered one of the most troubled in New York City.
For students who have never been on a college campus before, taking a class at a college can be an exciting experience that opens the door to future possibilities. Although teenagers generally are not keen on attending school on Saturday, holding the class at Hunter College provided the draw. Students had the opportunity to use the college library and laboratory while also learning about campus life.
The course provided them with a stimulating and challenging academic experience. Roberts made a presentation to promote the class at a special assembly for Academy of Health students. A number of students enthusiastic about learning something new signed up; however, several others registered for different reasons. Participants received a small stipend to cover lunch and transportation to the college. The first year, 15 students registered and 10 completed the course. The following year, 20 students registered and 15 saw it through to the end.
The small class size proved to be beneficial in a number of ways. Project staff found it easier to monitor students and follow through with accountability. The smaller class allowed the teachers and mentors to give students individual attention. The students thrived under the attention, the responsibility, and the high expectations the college had for them. However, the second year the director decided that the students should participate in an opportunity to collaborate with the National Cancer Institute NCI on a tobacco-use prevention campaign targeting Latino youth.
Multiple champions An unusual partnership developed the second year that gave students the chance to be involved in a health education campaign for NCI. A college student in the public health program who also worked with the Cancer Information Service at NCI received a fellowship to develop a tobacco-use prevention campaign with input from Latino adolescents from New York City.
She approached the college professor who codirected the high school College Exploratory Program in Public Health class. The class decided to make tobacco their focus, and student teams developed strategies to implement a public health education campaign. Without prompting from their mentors, they approached their former middle school principal about presenting their play at his school. The principal arranged a presentation of their play to the entire 5th grade. The college interns were also important champions. Although they were primarily drawn to the College Exploratory Program to fulfill internship requirements, their participation added immensely to its success.
Only two of the interns had experience working with high school students, yet their support and commitment to these adolescents went well beyond what was expected of them. It was not unusual for them to meet outside of class to assist the high school students with research projects and other public health assignments. By establishing support for the project from the new Academy of Health coordinator, turnover had minimal impact. During the transition, communication between the school staff and the other partners decreased, resulting in missed opportunities for collaboration.
For example, the Hunter College team did not learn that the high school health clinic was offering a series of smoking cessation workshops until the students in the public health class began conducting a Knowledge, Attitude, and Behavior survey on tobacco use among the student body.
Despite the breakdown in communication with the school during the second year, the class remained intact and continued along a productive course. The school restructuring did not threaten the survival of the class because there was solid infrastructure support for it. Outcome At the end of the year, the high school students presented their public health projects at a culminating event on the college campus with a keynote speaker.
The member audience included college faculty and interns, schoolteachers, administrators, and family members.
This event put more pressure on the students than if they had only presented their projects to their classmates. It is located in a distressed innercity neighborhood of Philadelphia. Living in an environmentally and economically impoverished community, these children are at high risk for physical, mental, and emotional health issues. This population stands to benefit greatly from collaborative efforts between health and education.
The public health curriculum initially fit into the pre-existing health instruction time slot. Input from the school nurse and a review of adolescent health data and local environmental issues determined the health topics. Student representatives worked with school staff, university student nurses, and the public health nurse to analyze the data and provide a report to the principal for future planning. Students also conducted an environmental and economic health assessment of the neighborhood.
During the summer the project continued with a camp. Students participating in the summer program were excited to visit the university and learn about environmental health issues. The curriculum focused exclusively on the topic of carbon monoxide poisoning, a pertinent community health issue as a neighborhood family had died the previous winter when they left their car running in a closed garage. During the second year, the project provided the only health education to 8th graders at the elementary school. Because of low test scores, the district eliminated health education from the curriculum.
Challenges Most of the students attending Thurgood Marshall live in poverty and, as a result, have considerable mental, emotional, and physical barriers to learning. A number of the students performed well below grade level and could not read or write. Others had behavior problems. Lacking direct classroom experience, the nurses and nursing students from LaSalle struggled with class instruction and classroom ASCD44A. Even though the principal at Thurgood Marshall originally backed the project, the district changes demanded much more of his time and attention.
Many of the teachers initially involved in the project left the school, and eventually the principal also resigned. Health education was eliminated from the curriculum; therefore, the project had to find a new home. By shifting the focus to environmental health issues, the project could fit into the science curriculum. Many of the same topics could be covered—asthma, lead poisoning, air pollution—by concentrating on how the environment affects health.
Although the curriculum found a new home in science, other districtwide and staffing changes disrupted the overall success of the project in the second year. When the school district reorganized and terminated the position of the school liaison, who had been the project champion in the district, the level of support at the school was difficult to maintain. Is your school project-friendly and open to new ideas? Is it a school that supports teamwork? Is the district supportive of the project? Use existing infrastructures to brainstorm and develop ideas and curriculum.
Tap into school-community committees, summer workshops, and school inservice professional development sessions. Incorporate existing data such as community health assessment, Youth Risk Behavior Survey, and state health data. Piggyback on current projects and work with existing curricula. Find out who can offer what and use what you have in order to do what you can. Be sure to include backup teachers in training sessions. If you can bring more than one advocate into the project from each organization, that is even better.
Acknowledge the potential for staff turnover and determine in advance who would step in at each partner organization should this occur. Be sure to involve these backup people in orientations, training sessions, and communication about the project. Concentrating on one topic allows for much greater depth in learning and instruction.
The impact is more lasting. Students learn skills they can use to access services and resources pertaining to any health issue to make better decisions about their own health and well-being. If the class is focused on one topic, everyone can share resources and materials. It is also easier to coordinate service learning activities, thereby providing students with opportunities to practice intervention and advocacy skills in a real context. Through authentic learning experiences, students gain a deeper understanding of public health. The argument in favor of including a number of fundamental health issues in the curriculum is understandable, because many communities experience multiple public health concerns—nutrition, physical activity, tobacco use, drugs, alcohol, and sexually transmitted diseases, for example.
Although these topics are all equally important, ASCD found that the most successful projects focused on a single issue. Moreover, they concentrated on an issue relevant to the school or local community. The volume of information required for each issue spread the class focus too thin. Teachers and project coordinators also found the workload far more time-consuming and cumbersome when they needed to learn about and teach multiple public health issues. While some projects created an entirely new public health education class, others incorporated public health into the existing curriculum.
Integration of public health education can make learning a deeper and richer experience for students as they explore different aspects of a health issue through various subjects. A math class, for example, may analyze and chart the health data for the school. An English class might write articles for the local newspaper to raise awareness about community health issues and changes that could support healthy behaviors.
Health education is commonly taught in isolation without either integration into the curriculum or opportunities for students to practice their new skills in the school environment. Although this method is much easier than reworking the curriculum and creating a school environment where students can try out skills acquired in class, it is less effective. Students need to learn about healthy choices, but they also need to be supported in their ability to make those choices.
Incorporating public health into the existing curriculum requires staff to rethink the subjects they are teaching and create new lesson plans. This demands extra effort up front, but it is far more effective than tacking public health on to another subject. Once an integrated curriculum has been developed, it also requires less time and fewer resources than creating and maintaining an entirely separate public health class.
Choosing an issue With a single focus, staff can predetermine the issue or allow the class to choose. For greater success, the public health issue should be immediately relevant to the school or community. When selecting a topic, be sure to consult several epidemiological sources. Find out what health data already exist for your school or community at the local health department, mental health department, or public health office.
If class time is tight, predetermining the issue might make more sense. However, if there is time, experience shows that students will have greater enthusiasm and a more authentic experience if they are given the opportunity to analyze the data and choose the public health issue themselves. Cons: Less buy-in from students; less student responsibility. Cons: Time-consuming. Children learn better when the subject matter is real and of interest to them Curtis, Choosing a topic relevant to the school or community provides a genuine context for learning.
This empowering experience teaches that they can have an impact on their community in a positive way. It helps to cultivate their identity as responsible, contributing citizens. The rate of lead poisoning in Rhode Island is among the highest in the country, affecting 8. Compared to the national rate, twice as many children in Rhode Island have lead levels in their blood that exceed the standard of concern set by the CDC.
Further, the rate of poisoning mirrors racial disparities. One in five black children in Rhode Island is identified with lead poisoning, owing primarily to the large proportion of ethnic groups living in urban areas where lead poisoning rates are highest. Lead paint is the most common source of poisoning, although lead is also found in contaminated soil, dust, and water. The sale of lead paint was prohibited in Rhode Island Kids Count, Little was done, however, to remove the lead paint that already covered the walls of homes.
Even low levels of poisoning can be debilitating for children, causing nervous system and kidney damage, stunted growth, and hearing problems. This is a public health issue where knowledge is the key to prevention. Therefore, it is critically important to get the word out to the community. Schools can play a key role. Many Latino and Cape Verdean arrivals are unaware of the health threat on the walls of their old homes. In , an estimated 16 percent of the children entering kindergarten in the Pawtucket School District had a history of lead poisoning Rhode Island Kids Count, This rate is even higher than their peers statewide.
When the Pawtucket School District joined forces with Rhode Island Youth Guidance Center, there was no question that lead poisoning would be the sole focus. Its relevance to the community made it a natural choice, and educating students about the dangers of lead was a surefire way to alert and inform those most vulnerable to this threat. By focusing on lead poisoning to teach students about public health, this project put into practice an essential public health intervention strategy: health promotion and education of the target population.
The movement to deal with lead poisoning was well under way at the Department of Health and Rhode Island Housing. These agencies were natural allies and became long-lasting partners. The Childhood Lead Action Project, concentrating on this issue at the public policy level, became another important and active partner.
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With outreach into the neighborhoods, the partners were eager to get involved in the classroom and welcomed students as interns. Targeting middle and high school students, the curriculum covered lead poisoning facts, demographics, information on how it occurs, prevention and interventions, community resources, laws and regulations, and jobs in the field of public health relating to lead poisoning prevention and remediation.
Opportunities for students to participate in school-to-career and project-based learning activities were also organized. The initial goal of the project—dubbed Lead Smarts—was to establish a knowledge base by educating as many students as possible in a wide variety of classrooms. At the two Pawtucket high schools, the curriculum was integrated across subjects in a variety of classes: family and consumer sciences, child development, ESL, parenting classes for pregnant teens, school-to-career, and special education classes.
In some of the subjects it initially took a slight shift in thinking to work lead poisoning into the curriculum; in others it was a natural fit. For instance, ESL teachers are always looking for good, new material to teach English language skills, so focusing on a community issue turned out to be tailor-made for this class. At the middle school level, the Lead Smarts curriculum was taught in five classes.
The final assignment required each student to create a brochure focusing on some aspect of the lead issue. Many of these ethnically diverse students designed brochures in their native language. Once the groundwork was laid and community relationships solidified, the project assessment clarified what needed to be revised. In year two, the emphasis shifted to project-based and community service learning opportunities for the students in the high schools. With a core of teachers on board, the project directors could move to the next level of implementation and work directly with public health professionals to get students involved in raising awareness of lead poisoning in the community.
In the second year, the project staff actively recruited more teachers to participate in the Lead Smarts project and integrated lead poisoning into their curricula. Science classes such as chemistry, physiology, and environmental science easily incorporated lead education into their courses. Teachers determined the depth of education they would provide on lead awareness in conjunction with required student-initiated community service learning projects.
Actively involving the teachers and students increased their engagement. Challenges In spite of regular communication between the agencies and staff, school politics was an ongoing challenge. Some teachers found it difficult to fit the lead curriculum into their subject or class because of the bureaucratic constraints imposed on them. Staff had varying skills of figuring out their own roadmap within the imposed limitations. Outcome Diligent planning, flexibility, hard work, and dedication contributed to the success of this project.
Along with a dozen teachers, approximately students participated the second year. A single focus on lead poisoning fostered strong service learning activities. Nearly 75 percent of the youth reported that they helped educate others about lead poisoning through creative and varied service learning projects. Students wrote a play about lead and a nutritional guide to help minimize the effects of lead in the body. It took a lot of effort and energy to build relationships and develop a curriculum to fit each class, but focusing on one issue that already had momentum in the community proved extremely beneficial.
Allies came naturally and easily, eager to build and sustain partnerships to further their own objectives. Student-initiated community service learning activities gained recognition and drew media attention. With such strong community support, the project will continue in the years to come. This rural community, with a population of 43,, is spread out across the land. The dying steel and coal industry have taken a toll on the economy—the per capita income had fallen to ASCD44A. Grand Rapids High School students experienced higher-than-average rates of teen pregnancy, substance abuse, and domestic violence.
The school wanted to engage students in project learning activities that strengthened their connection to the community to build resiliency and improve their health.
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The health department needed youth involvement on a number of committees and projects. The two partners developed a curriculum for a Public Health and Community Issues class offered at the high school. Five public health issues affecting children were central to the course: fetal alcohol syndrome, child and adolescent growth and development, environmental health, violence prevention, and tobacco-use prevention.
Through a variety of guest speakers, class discussions, research, and surveys, students learned about the public health issues.
Education and Public Health: Natural Partners in Learning for Life
For class assignments and intervention projects, students could choose to investigate topics of personal interest to them or relevant to the community, provided it related to one of the five issues. The students found that making a choice was not easy. With 55 to 60 students in the class—many with learning challenges—the teachers found it difficult to keep students focused on intervention projects. The students had to look for ways to get involved in building the health of the community. They were required to spend a total of 50 hours during the school year at an agency that addressed one of the five public health issues.
This experience exposed the students to organizations and to socially conscious adults concerned about the welfare of others. The students were surprisingly enthusiastic about volunteering in the community. Challenges Alterations in available resources threatened this project early on.
Budget cuts at the school reduced the number of teachers involved in the Public Health and Community Issues class from four to two after the first year. Simultaneously, tight finances and staffing changes at the Public Health Department severely limited its involvement, creating a schism in the partnership. As originally designed, the course covered numerous public health issues, which affected the depth of the course.
Two dozen guest speakers urging students to develop projects related to their particular area of expertise further scattered the energy of the class. In doing so, they became engaged in an authentic public health experience. The class concentrated exclusively on this one topic, learning as much as they could about the impact of a coal-burning power plant on the well-being of the community. They invited guest speakers from all sides of the issue—power plant representatives and their main opponents—two doctors from the medical community, and the local public health agency.
Each day, students read and discussed articles from the local paper about the topic. Once they felt they understood the issue in depth, the students decided to educate their peers about what was happening in the community. Outcome By focusing all their attention on one topic, the students experienced public health at the grassroots level.
They learned how to assess all sides of an issue to make good decisions to improve health. They took responsibility for educating others. From this experience they also developed skills they can use to explore other health issues. Because the topic the students chose was an environmental health issue immediately relevant to their town, they were able to ASCD44A. This kind of genuine affirmation not only built the self-esteem of these youth but also fostered their connection to the community in a way that no class, guest presentation, or field trip could accomplish.
The rewards these students experienced by getting involved in this authentic public health issue and working alongside public health professionals will have a lasting impact as they grow into adults. Participating in real issues, taking responsibility for others, having their voices heard and respected—this is what turns youth into productive, contributing members of society. What We Learned: Single Focus 1. Instruction provides more opportunities for students to gain a true understanding of public health. Service learning is an important component to public health, and it offers students a more authentic learning experience.
They will be able to apply their skills to access resources and services to make better decisions about their health. Consider the pros and cons of who makes the choice. Analyze several sources of health data pertaining to the school or community to be certain it is a topic of relevance. Is it potentially resolvable? Is a large segment of the community affected? Does it fit well with different courses or can it strengthen the curriculum?
The Samples and Tools section of this book includes a tool to help you select and prioritize your focus. The best outcomes occurred when students initiated their own interventions in their school or community.
When learning is connected to real life, as it is in effective service learning projects, students are more committed and motivated Curtis, The capacity for learning is far greater. Service learning provides opportunities for authentic student engagement in the community. Effective service learning fulfills a genuine community need while also maintaining a connection to academic content.
In service learning projects for public health, students get involved in creating interventions to deal with real public health issues affecting the school or community. Service learning is an excellent way for students to have a true experience of public health and learn about careers in this field. However, volunteering does not engage students in the same way that service learning does Allen, ; Glickman, Volunteers typically perform a task e. In service learning they examine data, think critically, use communication skills, interact with others, confront diversity, and develop an acceptable solution.
As volunteers, students may feel good about contributing, but they generally do not experience a wide range of educational opportunities. They do not learn and grow in the same way they can through service learning. This includes an understanding of their role, the skills and information required to perform the tasks, safety precautions, and knowledge about and sensitivity to the people with whom they will be working.
Reflection is done before, during, and after service work. National Service-Learning Cooperative, The degree of implementation and effectiveness of service learning varied among the projects featured in this book. They all required students to develop public health projects. However, at some schools students did not apply interventions in the school or community; they simply presented their projects to their classmates. Although these students gained public health research skills, their projects did not constitute service learning. Students who made presentations did not have the experience of connecting their efforts to school or community improvements.
Collaborative partnerships with community agencies and institutions are critical if students are to perform interventions in the community in any meaningful way. Failure to build or maintain these partnerships made it more difficult for several of the Health in Education Initiative projects to provide students with service learning experiences. Students participating in those projects did not get the chance to truly engage in the community.
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This is particularly important when offering a public health class that is open to all students or if the curriculum is integrated into a variety of classrooms. For example, Lead Smarts included ESL students, students with special needs, and advanced placement native speakers. The service learning projects were designed to reflect the different strengths and abilities of the students.
Ideally, students should also have mentors whose backgrounds match their own. Because most teenagers live in the moment and may be accustomed to short-term class assignments and immediate feedback, ASCD44A. Be sure to clarify expectations up front. Some youth require close monitoring and follow-up. One teacher voiced concern that his students might not be capable of acting responsibly in the community; so instead, he had the students design their intervention projects for the school population. Engaging low-performing students in service learning can be extremely beneficial.
Lower-performing students are less likely to leave the community to attend college; they are inclined to stick around and become the future citizens of the town D. Elhard, personal communication, May 6, If they continue their community involvement into adulthood, the community also greatly benefits. Because we now know that everyone learns in a different way, authentic student engagement in the community offers an alternative learning experience.
It might excite hard-to-reach students as well as deepen the learning for others. Although it is important that service learning be rigorous, it is equally important that students succeed in their intervention efforts. Others choose to give credit rather than a grade. As you would for any educational component, consider what students should learn or be able to do through their service learning experience. Collaborate with public health professionals or professors to develop rubrics that include demonstrations of knowledge about how public health is carried out.
They cultivate creative and critical thinking skills. Reflections can take many forms: group discussions, journal entries, short stories, speeches, drawings, slide shows, videos, and even cartoons. Prior to beginning service learning projects, reflections prepare students for the experience. During service learning, reflections give them the chance to consider their experience and ask questions, share observations, and solve problems. Afterward, reflections examine the impact of the service learning project: students can assess their intervention and evaluate what they learned in order to gain meaning from the experience and guidance for the future.
The Samples and Tools section includes suggested service learning reflection activities. Rewards and incentives The most successful Health in Education Initiative projects also included concrete incentives. When student engagement is authentic, incentives are often authentic. Feeling valued by the adult world bolsters self-esteem. Since teenagers can be self-absorbed, service learning shifts their attention outward.
Service learning focuses students on the health issues of the community. Through positive community service experiences, students learn the personal satisfaction that goes beyond monetary reward. As they develop a sense of responsibility for other people, the bond they feel toward their school and community strengthens, affecting academic outcomes Billig, They become better students and better citizens as they learn the role they have in improving their community.
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A significant risk factor present in many communities like Pawtucket—with a large influx of immigrants and many lowperforming schools—is the alienation youth feel from where they live, according to Bob Wooler, executive director of the Rhode Island Youth Guidance Center, one of the partnering organizations in the Lead Smarts project. Many among the large population of recent immigrants feel unwelcome, and many ethnic groups and natives feel displaced.
Nearly a quarter of the students, ages 3 to 21, are enrolled in special education. High school graduation rates are among the lowest in the state. In only 63 percent of the seniors graduated, compared with 81 percent statewide Rhode Island Kids Count, Service learning activities foster a connection between students and their schools and communities—replacing alienation with resiliency and promise. Students who are engaged in their community in a positive way learn about its strengths, building a sense of hope about their home. Helping to address the immediate health concerns of the community through this kind of hands-on learning also boosts student achievement.
The model To address the serious problem of lead poisoning among the children in Pawtucket, this school district and its partners initiated a broad-based lead awareness education campaign. Five hundred middle and high school students were taught a curriculum in lead poisoning. Nutrition classes wrote a nutritional guide and cookbook with recipes full of important nutrients that help prevent lead poisoning.
The book was distributed to elementary classes, preschools, early start programs, and parent support groups. Students in a media class learned how to design PowerPoint presentations illustrating the critical points of lead poisoning. In an ESL class, students learned English by interviewing each other about lead poisoning on videotape and created pamphlets and posters in their native languages.
Challenges In spite of the engaging nature of these hands-on activities, the greatest challenge Lead Smarts staff and teachers faced was follow-through ASCD44A. Working on time-consuming projects and making a long-term commitment to a community organization were new experiences for students accustomed to tests and brief assignments. Immediate and ongoing incentives—from snacks to stipends—helped motivate them.
Real-world incentives One of the project partners, Rhode Island Housing, provided an exceptional real-world incentive. The education and training coordinator at the office offered to teach an eight-hour class to students on lead-safe home repair. A high school industrial arts teacher, a champion of the project, enrolled all 50 of his students and followed up to be sure they attended.
Twelve of them sat for the exam, receiving financial assistance from Lead Smarts to pay for the test fee. One student, who previously saw himself as a failure, got a perfect score on the exam and ran around the room with his arms up in triumph! Of these, 21 students passed and were licensed. To apply, students completed a lengthy application, submitted a teacher recommendation, and were interviewed by their prospective on-site mentor.
The student interns worked at these agencies after school. During the course of his internship he made presentations to approximately people, including children, in a variety of community venues. Some gained valuable work experience to add to their resumes and college applications. The project staff noted that it was an accomplishment for these students to speak in front of an audience and to have their voices heard by the community. Cambridge Rindge and Latin School, with nearly 2, high school students, sits near the heart of an urban center just across the river from Boston.
Like any inner city zone, Cambridge has poverty and crime. Yet this is juxtaposed with the wealth and intellect drawn to the university at the hub—Harvard. Grady, personal communication, May 15, It is also racially diverse: 40 percent of the students are Caucasian, 30 percent are black, and the remainder are a mix of ethnicities. The model When teachers from the school collaborated with Harvard University to develop a curriculum, they created a rigorous public health course targeting the more advanced juniors and seniors.
Student-initiated research projects also addressed ethical considerations and legal issues of public health. Because of this math component, students considered Future Shock a difficult class, and only those interested in the challenge enrolled Grady, The original design of the course called for a team of four teachers from different disciplines, which allowed for collaboration across subjects and a manageable distribution of the workload. The four teachers could give each student adequate support in pursing topics self-selected for their research projects.
Future Shock attracted a high caliber of students, motivated and capable of working independently.
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