Demystifying Public Health Policy Through Service-Learning Pedagogy

Education and Training in Public Health Policy

Contemporary standards for educating public health and health education practitioners in the United States emphasize learning and applying policy principles. For example, four of the Master of Public Health (MPH) Foundational Competencies espoused by the Council on Education for Public Health (2016) directly reference public health policy; they call for MPH graduates to be able to discuss the policy-making process, identify stakeholders and build coalitions, advocate for health-promoting policies and programs, and evaluate impacts of policies. Similarly, the National Commission for Health Education Credentialing, Inc. (2015) established a competency to ensure credentialed health education specialists (i.e., Certified Health Education Specialist and Master Certified Health Education Specialist) can “[i]nfluence policy and/or systems change to promote health and health education” (p. 11). This competency involves assessing the effects of policies and systems on health, projecting impacts of policy changes, using evidence-based policy analysis, and advocating for health-promoting policies (National Commission for Health Education Credentialing, Inc., 2015).

Teaching policy in public health programs is on the rise (Hearne, 2008), perhaps in response to these standards. However, literature examining the current state of teaching and training of health policy across health-related disciplines (including public health, medicine, nursing, and health care administration) reveals notable patterns. First, as Heiman et al. (2016) state in their systematic review, “Literature published in the past 30 years on health policy training remains limited” across health-related disciplines but especially in public health (p. 7). Second, in the context of teaching and training, educators and professionals in health-related disciplines tend to define health policy narrowly, focusing primarily on health care delivery systems rather the more expansive policy definitions embraced by public health (Heiman et al., 2016). Third, teaching and training in health policy faces several barriers, including inadequate resources, perceptions that it is of limited relevance, incongruity with faculty interests and expertise, time constraints, and insufficient research on best practices (Heiman et al., 2016).

Many public health practitioners, educators, and trainers indicate that learning health policy requires fusing classroom learning and practical application. Public health practitioners report the value of stand-alone public health policy courses, efforts to integrate policy concepts across the public health curriculum, and “practical policy experiences that involve students directly in the policy process” (Moreland-Russell et al., 2016, p. 653). Meanwhile, health policy educators and trainers recognize the importance of combining lecture-based learning with case studies, group projects, and discussions and emphasize skill-building and application, interactions with policy participants, real-world practice, and experiential and service learning (Hearne, 2008; Heiman et al., 2016).

Public Health Policy Through Experiential and Service Learning

Public health programs rely on learning by doing to teach various topics and skills (Gregorio, DeChello, & Segal, 2008). Experiential learning involves gaining classroom knowledge and skills and applying what is learned inside the classroom in a real-world setting with immediate consequences outside the classroom (Bentley & Swan, 2018; Cashman & Seifer, 2008). It connects theoretical information and practical skills to encourage discovery of knowledge through application, new ways of thinking, self-reflection, and civic engagement (Bentley & Swan, 2018; Cashman & Seifer, 2008). Service learning, a type of experiential learning (Bentley & Swan, 2018; Cashman & Seifer, 2008), is also frequently used in public health education. Service learning integrates community service with academic course-work “through a cycle of action and reflection” in which “the service enhances the learning and the learning enhances the service” as students, faculty, and community partners respond to community-identified needs (Cashman & Seifer, 2008, p. 274). Public health service learning emphasizes “learning how to intervene on the multiple factors that affect health and quality of life” (Cashman & Seifer, 2008, p. 274) and aligns with social justice values (Sabo et al., 2015). Public health service learning is also a useful teaching mechanism. Sabo et al. (2015) found that after a weeklong service-learning course focused on specific populations, graduate public health students in several U.S.-based programs reported enhanced communication skills, abilities to identify personal strengths, awareness of the health professionals’ roles, responsibility for their own learning, and leadership.

Service learning can help teach health policy (Heiman et al., 2016; O’Brien-Larivée, 2011). However, the literature contains few discussions of service learning in health policy courses, particularly in public health (Heiman et al., 2016). Examples of how to teach public health policy through service learning are needed because (1) policy plays a major role in public health practice, (2) public health practitioners report limited comfort with policy, (3) the literature contains limited information on teaching and training in public health policy, and (4) service learning shows promise to reinforce health policy concepts and develop professional identities. This article offers a way to structure a graduate-level, service-learning public health policy course.

The Course—Public Health Policy: Integrating Theory and Practice

This course is designed to introduce students to disciplines and theories pertinent to the policy-making process and tools relevant to understanding, making, and advocating for health-promoting policies. It is structured as an interdisciplinary, service-learning course available to graduate-level students of public health (i.e., MPH and PhD level), law (i.e., second and third years), and other health-related disciplines. The goal of the course is to enable students to engage directly with the public health policy process. It aims to achieve this goal by simultaneously examining public health policy from a theoretical vantage and applying policy concepts and skills through a community-oriented, semester-long project. By the end of the semester, students should be able to do the following:

This course is offered at a large, public, research university. Student enrollment is capped at eight students to facilitate collaborative service learning. The class meets weekly during the semester for 2 hours and 45 minutes. Meetings are divided into two complementary segments: (1) examining public health policy theory through readings and facilitated class discussions and (2) applying public health policy knowledge through a service-learning project.

Conceptual and Theoretical Content

To understand how policy shapes public health, students explore a series of topics, theories, and disciplines during the first segment of most class meetings. The course defines “policy” as decisions of governmental and private organizations regarding rules, practices, and processes as well as their implementation (Golden & Moreland-Russell, 2016). Topics and related learning objectives are summarized in Table 1. Assigned readings include segments from two books (Bhattacharya, 2013; Eyler, Chriqui, Moreland-Russell, & Brownson, 2016) as well as peer-reviewed journal articles and policy reports. They serve as the basis for class discussions.

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Table 1.

The Theoretical Component: Course Topics and Corresponding Learning Objectives.

Weekly topics	Learning objectives
The role of policy in public health	• Define health and distinguish public health from health care. • Define and distinguish “policy” and “public health policy.” • Give examples of policies that affect health determinants or outcomes. • Describe mechanisms through which policy can affect health. • Compare policy as a public health intervention to clinical and education-based interventions.
Policy analysis	• Define policy analysis and discuss its purpose and function. • List and describe the steps in policy analysis and the considerations examined at each step. • Determine what makes a “good” policy analysis. • Evaluate sample policy analyses and consider their strengths and weaknesses.
Fundamental policy concepts	• Discuss when government intervention is suitable to address a health problem and how it is justified. • Describe the structures of U.S. governmental systems. • List and describe the (theoretical) steps in policymaking. • Analyze the advantages and limitations of thinking of policymaking as a sequential process. • Explain and illustrate what types of groups influence public policy and how.
Legal foundations of public health policy	• Compare and contrast definitions of “law” and “policy.” • Discuss the sources of law in the U.S. legal system. • Define public health law. • Describe the legal principles most relevant to public health policy work. • Describe how law influences public health policy outcomes.
Scientific foundations of public health policy	• Discuss the scientific underpinnings of epidemiology. • Define key epidemiological concepts. • Discuss how disease burden is measured and which measures interest policymakers. • Contrast the concepts of evidence in science, policy, and law and discuss how to connect them.
Public policy theories	• Contrast “theory,” “model,” and “framework.” • Discuss the role of theories, models, and frameworks in understanding policy. • Define and discuss specific public policy theories, models, and frameworks and evaluate their value to understanding public health policy. • Apply the defined and discussed theories, models, and frameworks to a public health problem.
Political considerations	• Distinguish policy from politics. • Identify and discuss why health can be politicized through specific examples. • Outline the process through which a health problem becomes political. • Contrast incrementalism and innovation in health policy. • Discuss the role of politics in implementation and enforcement.
Ethical considerations	• Define ethics and describe its role in public health policy. • Identify and define ethical principles that are integrated into public health ethics frameworks. • Define and discuss ethical frameworks commonly used to approach public health problems. • Apply ethical principles and frameworks to contemporary public health policy problems.
Health equity considerations	• Define the social determinants of health, identify specific social determinants of health, and discuss their roles in shaping health outcomes and health disparities. • Discuss the implications of the social determinants of health and health equity for public health policy. • Illustrate, through examples, how to discuss the social determinants of health and health equity with policymakers and stakeholders.
Measurement and causality	• Define causality for purposes of evaluating public health policies. • Discuss how to measure causality in policy evaluation. • Identify examples of how impacts of specific policies can be measured and the limitations of such measurements.
Keeping up with and disseminating research	• Discuss the purpose of keeping up with policies and how they change. • Distinguish policy surveillance from policy tracking through examples. • Identify existing resources for policy tracking and policy surveillance. • Identify commonly used best practices to communicate with policymakers and stakeholders about public health policy. • Generate a communication plan around a contemporary public health policy problem.
Policy advocacy	• Define advocacy and identify its steps. • Discuss barriers to advocating for science-based policies and ways to overcome these barriers. • Create an advocacy plan around a contemporary public health policy problem.

Note. Course topics and learning objectives map onto the assigned texts (Bhattacharya, 2013; Eyler, Chriqui, Moreland-Russell, & Brownson, 2016) and other reading assignments.

Students and the instructor define concepts, examine their contribution to understanding public health policy, and apply them to contemporary public health problems through discussions and exercises. Service-learning projects illustrate how theories and concepts apply. For instance, after students read about various public policy theories, the instructor facilitates a discussion to define each theory, analyze how it informs public health policy, and apply it to the service-learning project topic (e.g., youth obesity or levels of public health funding). Similarly, after students read about ethical frameworks, the instructor facilitates discussion to outline each and to apply it to the policy alternatives examined in the project.

Diverse academic and professional backgrounds enable students to alternate as “experts” and “novices.” For example, public health students take the lead to describe concepts of morbidity and mortality while law students lead analysis of legal constraints on governmental authority. Diverse student perspectives simultaneously ensure students are exposed to new concepts and are also challenged to explain, apply, and teach familiar ones.

Application Through Service Learning

Students simultaneously apply public health policy concepts through a semester-long, service-learning group project that concerns a public health problem with policy components. This project involves a thorough policy analysis modeled on an established process described by Chriqui and Young (2016). The project is completed in conjunction with a community partner organization.

Selecting a Community Partner Organization and a Policy Problem

The instructor selects a potential community partner to work with students before the start of the semester. The partner is identified after considering: preexisting relationships between the instructor and the partner, the partner’s active participation in the public health system, and the partner’s knowledge about public health issues affecting the community. The instructor approaches the potential partner to assess levels of interest, reciprocal value of collaboration, and commitment to working with students all semester.

If the instructor and partner decide to collaborate, they generate a list of possible project topics. The needs of the community partner drive topic selection. However, the instructor also considers the availability of research, how other communities use policy to handle this problem, governmental authority, policy history, and feasibility of completing the policy analysis in a semester. The topic is selected both to generate useful deliverables for the partner or community and to provide a valuable pedagogical opportunity. The community partner appoints a staff member as the primary point of contact for the class.

Conducting the Policy Analysis

Students first read about and discuss the policy analysis process, as outlined in Chriqui and Young (2016), and sample policy analyses. Then, they complete a series of assignments designed to research, analyze, and produce the components of an objective policy analysis. Students (1) craft a problem statement, (2) conduct background research and analysis regarding the problem, (3) analyze the policy landscape and stakeholder perspectives, (4) generate policy alternatives to address the problem, (5) establish and define evaluation criteria, (6) analyze the policy alternatives based on the selected criteria, and (7) ultimately generate policy recommendations (Chriqui & Young, 2016). Students apply public health policy knowledge and skills to the real-world community problem in each exercise. All assignments must be informed by outside research, including scientific peer-reviewed literature, gray literature, public health data, legal documents (e.g., relevant statutes, regulations, cases), and publicly available information.

Table 2 outlines the policy analysis assignments and activities. Assignments, as well as pre- and postassignment activities and feedback, occur in a week-by-week pattern of (1) preparation; (2) completion; (3) discussion, reflection, and feedback; and (4) revision. The problem statement assignment illustrates this pattern. First, students encounter the project problem by reading community partner documents and interacting with a partner representative. Then, they draft and turn in a problem statement. Students receive written feedback from the instructor on how to improve the draft. They also critique each other’s problem statements as the instructor circulates in the classroom to provide additional feedback and to answer questions. Finally, the instructor facilitates a group exercise to integrate draft problem statements into a working problem statement that the group uses and revises for the remainder of the project. The purpose of feedback is to improve assignment quality and to encourage critical thinking and reflection about what makes a “good” policy analysis.

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Table 2.

The Policy Practice and Service-Learning Component: Policy Analysis Assignments.

Preassignment activities	Assignments and primary learning objectives	Postassignment feedback
Discuss the policy analysis process Critique sample policy analyses Discuss the public health problem the project aims to address with community partner Discuss how to write a problem statement	Assignment 1  Problem statement Policy Practice Objective  Articulate a community public health problem the project aims to address through policy Service-Learning Objective  Recognize a critical need in the community	- Compare and discuss draft problem statements - Written instructor feedback - Select a working problem statement for the group to use for the project
Facilitate brainstorm about issues requiring background research to understand the problem Assign one background issue per student	Assignment 2  Background analysis Policy Practice Objective  Analyze a background issue pertinent to the public health problem Service-Learning Objective  Gather real-world information	- Discuss major findings of background research - Peer feedback workshop - Written instructor feedback
Facilitate brainstorm about organizations and groups potentially interested in the problem Select stakeholders for analysis Assign one stakeholder per student	Assignment 3  Stakeholder analysis Policy Practice Objective  Determine how one community stakeholder group or organization perceives a policy problem and policy proposals Service-Learning Objective  Describe the community and recognize its assets and perspectives	- Discuss major findings of stakeholder analyses - Peer feedback workshop - Written instructor feedback
Facilitate brainstorm regarding policymaking bodies that may be concerned about the problem Select policymaking bodies for policy history analysis Assign one policymaking body per student	Assignment 4  Policy history analysis Policy Practice Objective  Describe how one policy-making body has previously attempted to address this problem Service-Learning Objective  Identify and assess organizations involved in community decision making	- Discuss major findings for each policymaking body - Peer feedback workshop - Written instructor feedback
Discuss potential policy alternatives with community partner Facilitate discussion to select policy alternatives Assign one policy alternative per student	Assignment 5  Proposed policy alternative Policy Practice Objective  Formulate a proposed policy alternative to address the problem Service-Learning Objective  Assume responsibility for a community problem	- Peer feedback workshop - Written instructor feedback
Discuss potential policy evaluation criteria with community partner Facilitate discussion to select several evaluation criteria for policy analysis Assign one evaluation criterion per student	Assignment 6  Evaluation criteria Policy Practice Objective  Select and develop evaluation criteria to compare competing policy alternatives Service-Learning Objective  Seek and use community input	- Peer feedback workshop - Written instructor feedback - Select wording for each evaluation criterion
Discuss policy alternative analysis	Assignment 7  Policy alternative analysis Policy Practice Objective  Evaluate one policy alternative based on selected evaluation criteria Service-Learning Objective  Develop problem-solving through application of theory	- Discuss major findings and conclusions - Peer feedback workshop - Written instructor feedback
Discuss and select policy analysis recommendation	Assignment 8  Complete policy analysis draft a Policy Practice Objective  Create a policy analysis draft that integrates the steps of a policy analysis and previous feedback Service-Learning Objective  Demonstrate responsibility for own work product and collaborate with colleagues	- Written instructor feedback
Examine sample executive summaries and fact sheets	Assignment 9  Draft executive summary a  Draft fact sheet a Policy Practice Objective  Design written documents that present policy information in audience-friendly formats Service-Learning Objective  Articulate and communicate information in various written formats	- Peer feedback workshop - Written instructor feedback
Discuss what makes a “good” presentation	Assignment 10  Draft and moot presentation a Policy Practice Objective  Orally convey policy-related information Service Learning Objective  Articulate and communicate information orally	- Moot presentation peer feedback - Moot presentation instructor feedback
	Final Deliverables Final presentation delivered to community partner a  Final policy analysis a  Final executive summary a  Final fact sheet a Policy Practice Objective Develop and present meaningful policy analysis in response to an articulated needService Learning Objective Recognize the value of community involvement	- Facilitated discussion to reflect on the project

Note. Preassignment activities occur in class the week before an assignment is due. Assignments are due at the beginning of class. Postassignment feedback occurs during the class meeting after each assignment is submitted and/or is provided by the instructor after the class meets.

a

Group assignment.

The project culminates in group deliverables: a final policy analysis, an executive summary, a fact sheet, and an oral presentation to the partner organization. Importantly, the final policy analysis contains policy recommendations to address the identified problem that are generated by analyzing policy alternatives along evaluation criteria selected through brainstorming, research, and discussion with the community partner. For example, for a project focused on obesity rates among minority youth, students generated and examined policy alternatives: maintaining the status quo, enacting a sugar-sweetened beverage tax, amending physical education requirements, enhancing implementation of an existing school wellness policy, incentivizing healthy weight through college savings accounts, expanding vending machine labeling requirements, and increasing funding for a child nutrition and food security program. Students analyzed the legal authority, scientific evidence base, equity implications, administrative feasibility, and political feasibility of each alternative. They ultimately recommended enhancing implementation of a school wellness policy because this policy alternative received the highest marks across the five evaluation criteria.

Student–Community Partner Interactions

Students interact with community partner representatives at multiple stages in the policy analysis process. A partner representative attends class to discuss the public health problem and its salience to the community. A representative also attends class to participate in the discussion that generates and selects policy alternatives and evaluation criteria. In these classes, students drive the dialogue and the representatives provide real-world input to guide how students approach the problem and potential solutions. Such discussions allow students to practice formulating questions, gathering information, interviewing, and synthesizing and integrating feedback.

The end-of-semester presentation to the partner organization’s staff serves as the final interaction. The point of contact assists with coordinating this event. During the presentation, students spend 35 minutes presenting their policy analysis and their ultimate recommendations. The remaining 25 minutes consist of exchanges between students and partner organization staff in which students answer staff questions and receive feedback on their analysis. The partner organization posts project deliverables on its community resources website, and the presentation informs community partner discussions.

Assessment of Student Work and Student Reactions

The instructor evaluates all assignments. Individual assignments cumulatively comprise 30% of a student’s course grade. The instructor considers timeliness, the extent of research, the depth of analysis, the quality of writing (e.g., grammar, syntax, cohesiveness, readability, and citations), and the students’ ability to demonstrate how the assignment fits into the larger policy analysis process when evaluating assignments. Another 40% of the grade, which is assigned to the group, is based on the final project deliverables: the policy analysis, presentation, executive summary, and fact sheet. The instructor considers the same criteria used in evaluating individual assignments as well as fidelity to the policy analysis process, organization, integration of feedback received over the semester, and cohesiveness and polish of deliverables. Class attendance and the quantity and quality of in-class participation comprise the remainder of the grade.

Students have articulated overall positive reactions to the course. Table 3 contains selected excerpts from anonymous, end-of-semester course evaluations. These comments indicate that students appreciated applying public health policy concepts in a real-world setting and in an interdisciplinary manner. Some students emphasized the influence of the course in shaping their professional goals and identities.

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Table 3.

Selected Student Comments Regarding the Course.

“[There was] real-world applicability.”

“[There were] meaningful discussions. Discussing readings in class with the professor was incredibly helpful to understand the material, especially when applied to the class project. Great class!”

“Overall, a good course—would recommend to others. I liked that it was so dynamic and was influenced by law, public policy, sociology, psychology, history, and politics.”

“Amazing opportunity to get hands-on experience in the field! This class has confirmed the professional path I am working towards.”

“Fantastic class and very interesting final project. I have thoroughly enjoyed taking this class.”

“[The professor] does a great job of integrating the didactic material from our textbook to the overall project in the class. I particularly enjoyed the dynamic way in which [the professor] presented the material and had our class participate in a dialogue in regards to the topic. [The professor] was very thorough with the comments he gave us on our submitted work, which I thought was very constructive.”

“I really appreciated [the professor’s] openness to discussion, as well as [the professor’s] input on our assignments. . . . I am grateful for the opportunity to gain hands-on experience in the field I hope to continue on professionally.”

Conclusion

The power of policy is central to public health. However, many public health practitioners and students appear uncomfortable with policy concepts and the policy process. Research, theory, and case studies help illuminate policy. Alone they cannot prepare students for public health policy work. Hands-on learning is essential. A service-learning course that uses a real-world project creates an opportunity to apply policy principles through engagement with a community partner. Such a course requires preplanning and flexibility. The instructor must foster a relationship with a community partner, select a project that is useful to the partner and optimal for learning, and join students in a world of uncertainty where “right answers” may be difficult to discover.

However, a service-learning course with a real-world project helps demystify public health policy for students. It allows them to tackle the challenges of how to frame problems, grapple with scientific research, and formulate and analyze solutions in a complex and dynamic world. It enables learning through experience and service, demonstrates that data are not always accessible, and necessitates difficult choices. A public health policy course with a real-world project illustrates how and when to apply policy theories and also how and when they break down, how competing considerations fit together, and how to communicate with users in mind. Finally, it fosters connections among students, faculty, universities, and community partners while enhancing the capacity of the public health system.