The purpose of this article is to discuss the results of implementing political engagement activities in my Health Psychology of Women and Ethnic Minorities course during the fall of 2008 at the University of San Diego (USD). USD is a Roman Catholic institution whose core values are linked with Catholic social teachings which include dignity of the human person, common good and community, options for the poor, rights and responsibilities and participation. To address these ideals, I originally developed my course to offer majors in psychology an opportunity to learn about how gender, race and economic status relate to physical and mental well-being and illness. Furthermore, the role of community organizations in providing resources and programming on health care issues was emphasized during the semester through a variety of community service learning projects. There is a large body of evidence that points to the importance of community health programs and organizations on health particularly in the groups we were discussing in class. Community service projects are commonplace in my courses and opportunities to engage with diverse populations through these projects had always been an essential part of this course.
Unfortunately, mainstream psychology does not often take on issues such as defining the causes and solutions to health inequalities. To highlight this point, a special edition of the Journal of Health Psychology was published in 2004 where authors Campbell and Murray discussed the limited role psychology and specifically health psychology has played in helping us to understand the root causes of the ever-growing health disparities we see all over the world. They state that community health psychology was a way to increase awareness of the need for health psychologists to dig deeper into these issues and become more socially active. Community health psychologists unlike mainstream psychologists often work within community organizations to help not only define inequalities but provide potential solutions for change. Having the opportunity to help my students delve deeper into the importance of political and civic engagement particularly in health care was intriguing to me. My main objective for participating in the California Campus Compact-Carnegie Foundation Faculty Fellows: Service Learning for Political Engagement Program was to help increase the awareness of my students as to the role that politics play in health and wellness for women and other underrepresented people. Secondly, I hoped that the students would become more engaged in the political process and want to participate more in local and national politics. Government programs and policies play an integral role in health outcomes and have been a topic of discussion in my course in the past but to a limited extent. Also, I needed to make modifications to the existing course in order to help students increase their understanding of how politics impacts community organizations that provide health care services.
Because we rarely discuss politics in most psychology courses, many students were not prepared for such deliberations. I made significant changes to my course in order to make a stronger connection between the course material and political engagement. These changes and additions included modifying previous community service projects and adding a variety of readings on political and civic engagement and on the roles of government policy and agencies in health care decisions. Previously used assignments and reflections were altered to aid students in making connections between class content and the political process.
Reflections on health care policies
One of the major platform issues of the last presidential election was health care reform. Each candidate from the major parties had their own ideas of how the system should function to provide health care for over 300 million Americans. The election provided a perfect opportunity for my students to research the health care policy of the candidates and the health care propositions that were on the ballot in California. In order to assess how presidential candidates were addressing the health care issues of women and ethnic groups, students were randomly assigned to groups and asked to research the health care policies of one of the major candidates during the last election. In addition to the Democratic and Republican candidates, I wanted students to investigate some lesser known parties so I included Ralph Nader (the green party candidate) and Bob Barr (the libertarian candidate). Students were asked to pay particular attention to any information specific to the groups we were discussing in class. Each student was to write a paper summarizing what they found and the criticisms of the policies by opposing candidates/ political parties/other organizations. Group presentations were added in order to expose all the students in the course to what each candidate was saying.
An informal discussion after the presentations revealed that after reading and hearing the different approaches the candidates held, students believed that Nader’s proposal for universal health care was the best system and most equitable. I was truly surprised to hear this group of mainly conservative students (based on self disclosure and their scores on a questionnaire about liberalism/conservatism) draw such conclusions.
Another assignment had students researching and writing about their reflections on the various propositions that were on the California ballot that 1) dealt with health care issues and/or 2) civil rights issues. Issues about funding a hospital for children, parental notification for abortions, and gay marriage were examples of some of the topics students chose to write about. The idea was to expose students to how the voting public had the power to influence the health care of all and the civil liberties of individuals.
Additionally, several students chose to examine the parental notification proposition. This particular subject matter was a struggle for many of the students who had strong Catholic beliefs. However, after examining and researching the proposal, students developed some interesting discussions.
Student 1: Good parental support is a positive and beneficial element in the decision-making process of pregnant teenagers, but the idea that simply notifying will elicit such support is impractical and idealistic. Opponents of Proposition 4 point out that a law can’t mandate good family communication and trust, which is at the heart of Proposition 4. Pregnant teens ought to have guidance from a responsible individual or group of individuals, but it is not the law’s place or right to dictate who makes up the support system.Student 2: Being a woman, not far from my teenage years, I have a hard time understanding the logic behind Proposition 4. I understand that the intent is to keep minors safe and hold predators responsible. Yet I do not see how forcing notification will be able to change this. It is unreasonable to believe all teens come from a family that is supportive of such communication and short sighted in thinking that a teen may have another role model in their life they can turn to for advice and support.
On the other side, students made comments such as:
Student 1: I can see both sides of the argument, but I believe the pros of passing proposition 4 would outweigh the cons. I think it is good to take responsibility and help protect minors from the array of problems that could result from a secret abortion. While it is naive to think that this proposition will genuinely protect minors from sexual predators, it can help identify its victims and perhaps catch the criminals.Student 2: In my opinion and from the research I have done, Prop 4 is a positive change that California can make. Although I agree that the government cannot force families to communicate, I think this law might encourage girls to communicate with their parents.
Several students commented on the role of the church in some of the battles for propositions. For example:
Student 1: The propositions in California were surprising to me as well, because of the huge influence that the church played in decisions on voting. I was led to believe that church and state were separated, if no other reason than for the churches to avoid large taxes, but it was very apparent to me in this election that the churches put a lot of money into getting their opinions widespread on propositions 4 and 8.Student 2: Religion and race played a large role in the 2008 election not only in the presidential election but the propositions on the ballot. The Catholic and Mormon churches greatly supported Proposition 8 and obviously put a lot of money, time and rallying for this cause. Most Catholics I talked to couldn’t even attend church without their priest suggesting they vote for Prop 8 or take signs supporting the prop to put on their lawns. The church felt as though this issue was compromising a moral belief and emphasized the importance of it passing.
Health care disparities, society and the government
The existence of health disparities in our society along economic and racial lines has been well documented (Gaskin, Price, Brandon, & LaVeist, 2009; Cook & Manning, 2009). The class discussed the fact, for example, that African Americans have the highest mortality rates for heart disease and more cancers than any other racial/ethnic group (Cooper, Cutler, & Desvigne-Nickens, et al., 2000). A statement made by the American Civil Liberties Union (ACLU) points to the civil rights issues that are inherent in the health care debate.
Although the United States Constitution does not guarantee a right to adequate health care, the denial of such care can threaten an individual’s constitutional rights to life, liberty and property. In addition, an improperly designed health care system may undermine equal protection, privacy and due process. The ACLU intends to remain an active participant in the national debate on health care reform in order to sensitize the public and Congress to the civil liberties issues involved in this massive and vitally important undertaking.
Students were asked to read a report published by the Institute of Medicine (2003) entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Carewhich argued that the health care system in the United States is a major contributor to the disparities in health.
Students later wrote reflection pieces on the health care system and existence of disparities. I provided students with additional readings as well as videos and lecture notes on the topic. Statements as these below display the evolution of awareness for students:
Student 1: There are many complexities within the American health care system that I really did not understand the extent of until this class has made me focus on the different levels that one could experience oppressions or privileges within the system. I am very privileged in this system for many different reasons, especially when comparing my situation with that of many other people my age.Student 2: I have been very lucky when it comes to health care. In reality I know it is due to the fact that my parents could afford to give me the health care that my siblings and I needed. Others are not so lucky. If our country cannot convert to universal health care completely, I feel that every child should at least have sufficient health care. If our country focuses on not only the health care of children, but also education, many of our societal problems will be significantly reduced in the future.
Student 3: This course increased my awareness about the relationship between politics and health care. The current problem facing our society is that health care is too expensive. Too often it is those who need it most who cannot afford the care that they need. Our government does have the power to regulate big business. Although American ideology is built on capitalism, we also as a society hold sacred our freedom of choice. The cost of healthcare has taken away that choice for many Americans. The greatest tragedy is preventing people from accessing knowledge and treatment that they need to live their lives.
Students also were able to discuss how the system might work to increase inequities:
When I was eighteen, I was diagnosed with an acute illness, and underwent treatment that used injectables. My insurance did not cover any kind of injectables, and so we had to switch companies to get coverage for the expensive medications. I then realized how many people this clause would inhibit from getting treatment, diabetics in need of insulin shots, or anyone else with injectables in a treatment program. It made me wonder how a company could simply pick and choose what to cover and what to exempt from their coverage, and how exactly they decide what is important enough to cover and what can be left out.
Community forums
As part of the community service learning component of the course, students participated in a number of activities which allowed them the opportunity to become engaged in the community. The projects accounted for around 25% of their course grade and included organizing a soccer tournament to help promote physical activity and developing a survey with community members to assess community needs.
Additionally, students were asked to attend at least two community meetings that focused on some type of health care issue. The purpose of this particular assignment was twofold: 1) students would have an opportunity to meet some of the community partners that are an integral part of providing health and wellness programs for the nearby Linda Vista community and 2) students would develop a better understanding of the role of government in health policies, programs and funding.
The importance of community partners was a common theme in many students’ reflections.
Student 1: The first Family Success Center of this semester opened my eyes to the type of dedication required of those who want to be involved. The experience was a stimulating one for me and it seemed to energize the other students present as well. I believe these types of community gatherings are not only helping but essential in the improvement and well-being of local schools and neighborhoods. Higher governmental intervention is necessary as well in order to maintain standards, but only those most closely involved with the particular communities have the insight and experience with what else is needed. Student 2: I attended the Healthy Initiatives meetings in which community partners come together and use their expertise to create the best health opportunities for the community. These meetings are a good way to form a known group of individuals that are willing to help with bettering the health system within Linda Vista. It would be difficult to create this kind of service in an alternative way. Without these groups, the success of these community programs, such as the mobile immunizations connected to the libraries would not be possible.
Others commented on the connection between health care, politics and community.
Student 1: Another positive aspect of working so closely with the health community is that it shows the many aspects of the health system that I did not know before. Everything I learned in the few months of this project made me realize that if a person is outside of the health community, even if they are well educated, it is difficult to know all of the opportunities and aspects that the current U.S. health system does and does not offer. The interaction that I had with these professionals showed how important it is to have them involved in the planning of new health programs within a community such as Linda Vista.Student 2: My experiences with the Linda Vista Collaborative were very informative about the ways politics are involved in health care. The special guest speaker at one meeting spoke about the different ways in which emergency rooms were struggling. Because of laws that prevent hospitals from turning anyone away, they are used for non-emergency purposes and are struggling to perform actual emergency procedures. The speaker was coming to the collaborative to inform them of the problem and consult with members that work at local health clinics to attempt to alleviate this problem.
Below is a reaction from another student who learned at a community forum that funding for teen pregnancy prevention programs was going to significantly reduced due to budget shortfalls:
One of the questions I have for our government officials was how can funding be cut from a program, such as teen sexual health, that has been successful? These programs were created to help in pregnancy prevention and the promotion of sexual health for young adults and they have achieved that goal so far. Why take money away from programs that have done everything they were established to accomplish? I can now understand the frustrations that the health community has with the government, because they are doing everything they are being asked to do and yet they are still not receiving funds or acknowledgement of their hard work.
The global gag order and other hot political and health topics
In order for students to discover how government policies influence specific health issues, I posted articles on hotlydebated topics such as the global gag order, male contraception, Plan B contraception, and the rights of pharmacists to refuse prescriptions on moral grounds for students to read and comment. The articles discussed the current governmental policies that surrounded these issues and the benefits and barriers on each topic. Students read the articles and reported back to me about the content and their impressions.
On the issue of pharmacists student reflected on how this may impact women in particular:
The article discusses a new law the Bush administration is trying to implement about the right of health care providers to deny assistance in practices that are against their religious beliefs. This has created a stir especially in pro-life and pro-choice groups in American because of the rule’s allowance of health care providers to refuse contraceptives or abortions to women. This causes yet another barrier of health care especially for women because of the many social and cultural barriers already in existence. While religious beliefs should be respected by all employers, an employee must understand, before they decide on a health career, the requirements of the job and the implications of their work they must do. Involving the beliefs of health care providers in with an individual’s health care needs disturbs the rights of the individual to seek out appropriate care.
Another article focused on the development of a male contraceptive pill and the gender issues that are prevalent in the contraceptive debate.
Student 1: The greatest barrier for the development of a male contraceptive is our cultural love affair with the female pill. After twenty years of development, the male contraceptive is still 5 to 10 years in the future. Obviously, money is needed to develop and test new drugs, and in recent years funding for male contraceptives have been halted. Drugs companies have abandoned the project because they believe the use of a male contraceptive to be unlikely.Student 2: Another controversial issue with contraception is the fact that the majority of contraceptives focus their responsibility upon women instead of their male partners. Male birth control is an option that has been under researched for many years but there does not seem to be any progress on the production of this option.
The connection between healthcare and government policy was also identified. Due to our system of government, there is a chance that every four years policy that addresses abortion and contraception can change. Even though it would be more efficient for funding and less confusing for individuals if policy was consistent no matter who was in office, as long as there are such strong opposing views on these controversial issues, no permanent law can be created because no law could incorporate all views and all individuals equally. This is why it is important to be educated on the current policy, and for those who can vote, know where the candidates stand on the issues.
Pre- and post- survey results
At the beginning and end of the course, each student who was willing to participate in the study filled out a packet of questionnaires.
Using a condensed version of the Carnegie Political Engagement Scale (Colby, et al., 2007), students were asked a variety of questions about their political and community involvement. Using dependent t tests, students reported significant increases in the likelihood they would vote in a national, local and school election (t(9) = -2.65, p < .026). Students also reported to be better informed about politics at the end of the course (t(9) = -2.29, p < .04). One question on the survey asked students to rate how often they follow what is going on in government and public affairs. Each student reported following events more closely at the end of the semester than at the beginning.
Similarly, students at the end of the semester stated they were significantly more likely to get involved in political and community events (t(9) = -2.70, p < .02) compared to the beginning. On the other hand, even though their actual involvement in the community went up during the semester, most likely due to the projects in our class, I cannot be sure that students would maintain this behavior in the long run even though they clearly intend to be more involved. A quote from one student emphasizes this point:
Interacting with health officials has allowed me to understand everything that goes into helping a community such as Linda Vista and how important it is to volunteer. For projects to be successful there must be a lot of volunteers willing to spend a lot of time on the project. All the work that I did was welcomed and our class was always thanked for what we did. The gratitude that I received from both the health officials and the community members really showed why these projects are important. It is important to know that what we are doing is helpful and needed for the community’s well being.
Most importantly, to highlight the impact of the course on their civil and political engagement, students were asked to rate their willingness to advocate for people to receive cultural-specific care and care based on their cultural beliefs (t(8) = -3.50, p < .007). The results of the pre/post comparisons were encouraging. At least in the short term, my students had become more aware, accepting, and knowledgeable about the role of culture in health care and were more willing to advocate for a person’s beliefs about their health.
A comment from one student made this clear:
One of the greatest failures of the healthcare system is when individuals do not continue treatment because of the service provided clashed with their cultural needs. Specialized community organizations are more likely to be culturally sensitive and desirable to many groups.
Conclusions
In the final reflection paper, I asked students to write about whether they had a better understanding of the role politics play in health care. I also asked them questions about whether they believe they would become more politically involved due to their experiences.
Student 1: For the most part, the corruptness of politics disturbs me to the point of not wanting to care. However, in the end I realize that it is a privilege to vote and be a part of the democratic process.Student 2: Personally, I can make a difference with others by voting in the upcoming election. Also, I plan to enter the health care field myself, so this will pertain to me personally. Therefore, I will be able to personally help others and my voice will be important in helping to change the current health care system.
Overall, I believe the course was successful in increasing awareness as well as short-term behavioral change. My students reported being more conscientious about the issues and paying closer attention to what was happening politically and socially at the end of the course. I would be cautious however in making any statements about igniting long-term behavioral change. I would suggest that if universities want to truly make civic (and even political) engagement part of their core values, training for faculty on how to do this work is necessary. As more faculty become better prepared to incorporate these themes in their courses, students will have more opportunities to become engaged throughout their academic career. Additionally, universities and colleges should offer opportunities outside the classroom to reinforce what is happening in class. Therefore students will not only have a chance to learn theory and content but apply the information to real world situations including their own political and civic behavior.
Finally, I asked students to list a number of ways in which they identify themselves. One key way that most students listed was whether or not they considered themselves to liberal or conservative. USD has a fairly conservative student body and I found it interesting that a third of the students labeled themselves as liberal. It was also interesting that most of the conservative students in the course reflected on some of the topics covered in class and in their writings (birth control, gay marriage and Nader’s universal health care plan) in a manner that was contrary to how they reported they were raised or exposed to in the past. I believe the course material got these students to think about these issues in a way they never really had before. The research they did into these issues opened their eyes in many respects. Although many of them realized they were still struggling with these issues, they also recognized the other side of the story. Keeping a nonpartisan perspective and presenting both sides (or in some cases multiple sides) of an issue is key to making informed decisions as an electorate. I have to admit that this was probably the most challenging part of the fellowship but the most rewarding. From readings, assignments and interaction with the community, the layers in which the information was presented I believe was key. One student summarized it well:
Before this class I did not know that politics played a large role in how health care systems function, but this experience made me more aware of the large amount of influence that politics have on every aspect of the system. Our current health care system is full of disparities that put poor and lower middle class and minorities at a disadvantage. I learned that community health organizations are trying to create programs for the community, but without proper funding from the government, not much can be done. It is important to know the proposed policies of the individuals running for office because they will be defining where the funding will be focused.
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| Department of Psychology, University of San Diego, 5998 Alcala Park, San Diego, CA 91911 emch@sandiego.edu |
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| This article was supported in part by Award No. 06LHHCA001, granted by the Corporation for National and Community Service, Learn and Serve America Higher Education through California Campus Compact. The opinions, findings, and conclusions of recommendations expressed in this article are those of the author(s) and do not necessarily reflect the views of the Corporation for National and Community Service, California Campus Compact, or the Carnegie Foundation for the Advancement of Teaching. |
References
American Civil Liberties Union. Toward a New Health Care System: The Civil Liberties Issues Brief at http://www.skepticfiles.org/aclu/health_s.htm.
Campbell, C. & Murray, M. (2004). Community Health Psychology: Promoting Analysis and Action for Social Change. Journal of Health Psychology, 9, 187, 195.
Colby, A., Beaumont, E., Ehrlich, T., & Corngold, J. (2007). Educating for Democracy: Preparing Undergraduates for Responsible Political Engagement. Jossey-Bass: San Francisco.
Cook, B.L. & Manning, W.G. (009). Measuring Racial/Ethnic Disparities across the Distribution of Health Care Expenditures. Health Services Research, 44(5), 1603- 1621.
Cooper, R., Cutler, J. & Desvigne-Nickens, S.P. , et al.(2000). Trends and disparities in coronary disease, stroke, and other cardiovascular disease. Circulation, 102, 3137- 3147
Gaskin, D.J., Price, A., Brandon, D.T., & LaVeist, T.A. (2009). Segregation and Disparities in Health Services Use. Medical Care Research & Review, 66(5), 578-589.
Smedley, B.D, Stith, A.Y. & Nelson, A.R. (Eds)(2003). Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Institute of Medicine Report : Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.
About the Author
Dr. Sgoutas-Emch is a professor of psychology and director of the Center for Educational Excellence at the University of San Diego. She has been a professor at the university since 1992. During her tenure at USD, she has also been the director of the gender studies program. She teaches courses in health psychology and biopsychology. Dr. Sgoutas-Emch has research interests in the efficacy of alternative medicine, the impact of stress, and women’s health issues.
Dr. Sgoutas-Emch received the Innovation in Experiential Education award at the University of San Diego and most recently a two-year fellowship with the California Compact-Carnegie Fellowship in Implementing Political Engagement.