Advocacy has been identified by the National Commission for Health Education Credentialing (NCHEC) as an essential skill for entry level health educators. This paper describes a project whereby service learning students partnered with a local nonprofit organization, Healthcare for All Massachusetts, to hone advocacy skills. Students photographed and interviewed people directly affected by the healthcare crisis in Massachusetts. Subsequently, students developed and disseminated a Photovoice exhibit to be used at various local and state events to advocate for affordable, quality healthcare.
The following is a description of a project that combined the development of advocacy skills with a service learning experience. Through the service learning project, students were in a position to apply what they learned about advocacy in the literature with the work of a nonprofit organization actively engaged in advocacy work.
In 1999, a survey of currently employed public health educators indicated their need for further development in the area of advocacy in order to function effectively in their jobs and ensure quality practice in the context of rapid social change (Eyler, 1999; Gebbie, 1998). Recently, the National Commission for Health Education Credentialing Inc. (NCHEC) has revised competencies that are required for entry-level Health Educators to include advocacy (1996). In 2005, the Competencies Update Project added the following as an area of responsibility: ‘communicate and advocate for health and health education.’ Within this newly updated framework, advocacy is highlighted as an essential skill. It is clear that academic programs preparing health educators have a duty to put increased priority on providing students with the opportunities to adequately develop these skills.
Engaging with the Community through Service Learning
A study published in April 2002 found that graduates working in public health valued generic skills such as communication and collaboration more highly than more specific public health skills and cognitive based information (Gebbie, 1999). These graduates also believed that their entry into the workforce could have been facilitated by stronger links between their academic program and the working environment of public health professionals. Service learning builds this linkage directly into the curriculum and allows for students to become engaged with the professional community prior to their entering that workforce. As defined by Eyler and Giles (1999, p. 7):
Service learning is a form of experiential education where learning occurs through a cycle of action and reflection as students work with others through a process of applying what they are learning to community problems and, at the same time, reflecting upon their experience as they seek to achieve real objectives for the community and deeper understanding and skills for themselves.
Partners in Advocacy Training
In the fall of 2004, the University of Massachusetts Lowell’s Community Health Education program partnered with Healthcare for All Massachusetts (HCFAM) and the International Institute of Lowell on a service learning Project. HCFAM is a nonprofit organization dedicated to making high quality, affordable healthcare accessible to everyone, regardless of income, social, or economic status. The mission of this organization is to empower Massachusetts’s consumers to be able to learn about how our healthcare system operates and to become involved in changing it. The organization is most concerned about the most vulnerable members of our society – the uninsured, low income elders, children, people with disabilities, and immigrants. The work of HCFAM combines policy analysis, information referral, personal and legal advocacy, community organizing, and public education.
The second partner in the project, The International Institute of Lowell, is a nonprofit organization founded in 1918 that assists immigrants, refugees, and other foreign born individuals to deal with government regulations, adjust to American society, and become self-sufficient. The Institute works for the acceptance of all, regardless of race, religion, country of birth or ethnic origin, as equal participants in life in the United States. The work of both of these organizations is critical and provides a rich environment for Health Education students to develop advocacy skills through service learning.
Nature of the Project
Students involved in this service learning project conducted a Photovoice Project in the City of Lowell. ‘Photovoice is participatory-action research methodology based on the understanding that people are experts in their own lives’ (Wang, et al, 1996). In this case, the Photovoice Project used the voices, photographs, and experiences of people to tell a story that is of great concern here in Greater Lowell, namely lack of access to affordable healthcare.
Student Preparation for the Project
The two students involved in the project were seniors in the Community Health Education program and enrolled in the required course, Service Learning in Health Education. Other required courses in the curriculum prepared students for this project, areas such as politics of health and health communications were addressed.
First, students were acquainted with the work of our two partners by meeting with organization staff, touring facilities, and participating in community meetings.
Next, the International Institute of Lowell introduced students to critical agencies within the City of Lowell whereby potential participants could be recruited for participation in the Photovoice Project. Upon receiving the list of agencies and organizations, students began to develop a protocol for communicating with the agencies’ leadership. During initial contact with agencies, students would describe the nature and purpose of the project and ask for their support in recruiting participants. Initially, students made telephone calls to agency staff to describe their work. However, students discovered that often these calls went unanswered and they were left at a standstill.
In light of this difficulty, students began visiting the agencies and establishing support for the Photovoice Project on site. This proved to be a much more effective method of recruitment. Students quickly realized that agency staff was often too busy to promptly return phone calls, but the personal visit was highly effective in generating support and enthusiasm for the project. Students learned that the first important step in the process was for them to actively advocate for the project itself, informing agency staff as to the benefits of such a project and why they should support it. In the end, six agencies assisted in the recruitment of participants; the local community health center, a senior center, a facility for recovering addicts, a social service agency, a nonprofit agency dedicated to the Portuguese community, and the International Institute of Lowell. Students also attended multiple ‘community conversations’ which led to the recruitment of participants.
After marketing the project to local agencies and securing agreement to participate, students began to recruit Photovoice participants. Local agencies were critical in identifying specific clients who were interested in participating. Students also were successful in recruiting clients by sitting in the agencies’ lobbies making connections with clients. Students first explained the project and determined each individual’s level of interest in participating. For those willing to participate, students then explained the informed consent to them and had them sign the document.
Students developed an open-ended interview to guide the conversation regarding how participants were affected by the healthcare system. Questions included; What have your experiences been accessing healthcare for yourself or your family, what’s gotten in the way of your getting care, and what do you think could be done to improve the situation? All interviews were audio taped, digital photographs of participants were taken, and individuals had the choice of using their names in the Photovoice Project display. Interviews averaged approximately 20 to 25 minutes and a total of 22 interviews were conducted over six weeks. Students were enlightened, shocked, and empowered to take action by the people they met and the stories that were told.
Upon completing the interviews, students transcribed each of the interviews and, in consultation with faculty, developed criteria for determining which materials would be used for the public display of the Photovoice Project. Criteria included the unique nature of a story, the emotional appeal of a story, and how closely a story identified with the current crises related to lack of access to affordable healthcare. Finally, photographs and excerpts from interviews were woven together into a compelling story of people’s lives.
The following quotations are examples from Photovoice stories collected as a part of the service learning project.
I have three children. I used to have insurance through my work place but I couldn’t afford it because I am a single mother so I decided to turn to government assistance for help. One time I tried to apply for MassHealth but because my income was $6 too much per month they sent me a notice saying that I am not approved for it. I only asked for MassHealth for my son, not myself because I was concerned about him.
~Julie S. Hak, International Institute of Lowel
I am a single parent, work two jobs, go to school, and I live with my mom who is ill. I can’t afford to pay for the insurance with my first job. They make it available but I just can’t afford it.
~Trisha White, Social Service Agency
I pay $117 a month for Secure Horizons. Now, this month I have to pay over $200. I can’t afford it. I am on fixed income. I only make between $700 and $800 dollars a month, that’s my rent and my bills, I can’t afford that. I am just lucky I am surviving..
~ Shirley Gilbert, Senior Center
I took care of my mother, who was an elderly person and needed medication that was very expensive and not covered under MassHealth guidelines. Originally, her cardiologist got the medication for free from the company, but after a while the company stopped sending the medication and we had to pay for it. It was an expensive medication and one time I had to pay $400 for her meds for just one month. There were times where she was so bad off we had to go to the emergency room and have her admitted into the hospital just so she could get her medication. She got really sick one time, went to the hospital, and was discharged prematurely. She went to a rehab center and they denied her admission because she was too sick. They sent her to the emergency room and then back to the original hospital. A week later they said she was okay to go home and she died two days later..
~ Jay Tankanow, Facility for Recovering Addicts
I have no problem what so ever with my insurance. What I do have a problem with is the medication plan. I’m on a lot of pills and it’s over $100 a month just for pills. What I have been doing is shuffling them around. Instead of taking my diabetes medication every day I’ll take them every other day. I try to cut back to make them last..
~ Ruth Grout, Senior Center
Dissemination of Results
With generous funding from the University’s Council on Diversity and Pluralism, the Photovoice Project (photographs and interview excerpts) was prominently displayed on a mobile 36 square foot display board.
Healthcare for All continues to actively use the display at conferences, community organizing events, and legislative lobbying days. Students were able to present the board themselves at the statewide Healthcare for All conference and received accolades for their work. They were encouraged by the HCFAM staff that their work would have a positive impact on the state’s pursuit of affordable, high quality healthcare for all residents of the Commonwealth. HCFAM displayed the Photovoice Project on their website to further utilize the compelling stories to advance the mission of the organization.
Students also submitted a proposal to participate in the University’s annual undergraduate research symposium, which was accepted. Members of the University community were impressed by the work and were educated in a very humanistic way about the Massachusetts healthcare crisis, which pleased the students greatly.
Effect on Students
One of the students reported:
The impact on participants was significant. Through this advocacy project, the interviewees felt validated. We showed them concern with cause. They grasped that this was about them. They put their trust in us that we would do something important with their story, thus allowing them to feel a sense of empowerment.
This sentiment was echoed throughout students’ written and verbal reflection about the experience.
Through this service learning project, students were able to learn and practice advocacy skills by engaging with important organizations that use the media, the legislative process, and community organizing to help advocate for improving access to affordable, high quality healthcare for all Massachusetts citizens. They witnessed the impact that a lack of healthcare coverage has on hard working citizens, and were then able to translate those stories into a compelling educational display. The display was designed to bring those stories to people who may not comprehend the problem fully or who were distanced in some way from the people living in the midst of the healthcare crisis in Massachusetts. In a way, the students’ project gave a voice to a group of people whose stories would ordinarily not have been heard, and this is the essence of advocacy work.
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About the Author:
Nicole Champagne is assistant professor on the faculty at the University of Massachusetts Lowell in the Department of Community Health and Sustainability. She teaches courses for students enrolled in the Community Health Education program including Program Planning, Communication Techniques in Health Promotion, and Mind, Body, and Health. Nicole completed her doctoral work at Teachers College Columbia University. Her dissertation focused on the outcomes of service learning experiences on undergraduate Health Education students using the framework provided by the National Commission for Health Education Credentialing. Two articles pertaining to this dissertation study will be published in The American Journal of Health Education in 2006. Contact Dr. Champagne at: UMass Lowell, 3 Solomont Way; Suite 4, Lowell, MA 01854; email Nicole_champagne@uml.edu; phone 978-934-4132