Service Learning in Public Health: A Critical Assessment of Potential Benefits and Unintended Consequences

Abstract

Service learning is a pedagogical strategy in which students complete a project at a community-based organization where they can apply classroom skills in a real-world context. Service learning can benefit student learning outcomes and continues to expand in public health education; yet there is the potential for ethical concerns. In particular, service learning may reinforce inequities between academic institutions and community organizations by positioning academic institutions as holding significant power and resources and inadvertently promoting this dynamic to students. This perspective provides an overview of service learning in public health and related fields, discusses the benefits of service learning as well as the gaps in standardization and evaluation, and highlights situations in which inequities may emerge. Recommendations are provided, with the goal of helping future health promotion professionals better meet the objective of fostering social justice through public health.

Service learning is increasing across universities and has been described as integral to public health education ( Sabo et al., 2015 ). This perspective discusses the goals and role of service learning in public health and health promotion training, the benefits of service learning, and the potential ethical concerns that should be addressed for service learning to meet its intended outcomes. Specifically, the power structures on which service learning was built, and how this pedagogical approach may result in the promotion of problematic dynamics between students and the communities they intend to serve, will be discussed. Recommendations will be provided to ensure that service learning can continue to be advantageous for students while making sure that community members do not face unintended harm.

Service Learning in Public Health

Service learning was first defined in 1993 as an educational tool to promote civic responsibility and strengthen both communities and students’ skills, wherein students participate in activities to meet community needs as a part of their academic curricula ( Pritchard & Whitehead, 2004 ). Since then, service learning courses have become widespread and have even become a tool in university ranking systems ( Chupp & Joseph, 2010 ). Key stakeholders involved in the development and implementation of service learning are the university, faculty, students, and community partners. The university provides structure for service learning and faculty to oversee service learning activities, ideally offering opportunities for students to engage in meaningful and structured reflection. Students expand their classroom knowledge and gain experience to benefit their future careers, while community partners acquire university resources they might not otherwise have, such as access to faculty, materials, and student labor. In public health education, service learning is one modality to meet the Council on Education for Public Health (CEPH) criteria for applied experiences ( CEPH, 2021 ).

Service learning can take three forms: direct service, indirect service, or advocacy, examples of which are provided in Table 1. Substantial research has identified diverse benefits of service learning, including in public health and health promotion education. Service learning can enable students to gain real-world experience, increase career readiness, contextualize topics taught in class, and improve perceptions of their ability to link theory to practice ( Brown, 2017 ; Gasparis et al., 2017 ; Hart, 2015 ; Salam et al., 2019 ). Service learning in allied health fields has also been shown to increase students’ cultural competence and perceptions of civic responsibility, aid in their professional development, improve their understanding of the delivery of ethical care, and increase their ability to intervene on health equity related issues ( Bill & Casola, 2016 ; Lohr et al., 2022 ; Ylitalo & Meyer, 2019 ). However, one study found that adding a service learning component to a class did not improve test scores, compared to the class without the service learning component ( Lambright, 2008 ). Additionally, another study found that students’ level of involvement in service learning and the type and quality of in-class discussions and reflections impact students’ intrinsic motivation and civic skills ( Levesque-Bristol et al., 2011 ). In the first author’s personal experience as a service learning instructor, service learning has aided students in recognizing career paths of interest and developing their skills in both public health research (e.g., conducting data analysis) and the provision of public health services (e.g., facilitating cooking classes); however, students who did not have direct contact with priority populations sometimes stated that they did not see the relevance of the content being taught in class (e.g., public health theories and frameworks like the social-ecological model) to their service learning work.

Table 1.

Types of Service Learning and Examples in Public Health.

Type of service learning	Definition	Example
Direct service	Providing direct health services to priority populations	Conducting food recall surveys among individuals being screened for dietary services
Indirect service	Supporting the provision of services, without directly interacting with priority populations	Analysis of existing program data to determine strategies for improving reach
Advocacy	Supporting a given cause or policy	Conducting research to present to a government entity, to describe a public health concern and offer evidence-based approaches

Power Structures and Ethics

The beliefs students forge from their service learning experience regarding academics, the public health and health promotion fields, and social justice are formative to their careers. Therefore, alongside the benefits of service learning, potential ethical concerns are also consequential. We discuss several of these potential problems below based on our experiences and the extant literature focused on community partners. Although there is minimal and dated literature on the experiences of community partners, some authors do discuss an imbalance of power whereby academic institutions hold resources of value to communities, which the latter believe are only accessible if they agree to accept service learners at their organizations ( Stoecker et al., 2009 ). This may place an undue burden on community partners to host students and devote valuable resources to student training and support, in the hopes of gaining access to academic capital. At minimum, this enables one-sided relationships that are not mutually beneficial. At a greater extreme, there may be ethical violations, whereby certain vulnerable populations, like children or those marginalized due to their race or ethnicity, may be inadequately protected, such as through students providing health education they are not adequately trained to deliver ( Chapman, 2018 ). More generally, many frameworks for implementing and assessing service learning largely neglect existing power structures due to the historic exclusion of many minority groups from academia, and do little to disrupt faculty and academic institutions from holding power over community organizations ( Cashman & Seifer, 2008 ). Additionally, situations where cultural competency training may have been lacking during service learning activities may reinforce neocolonialist power dynamics, where it is expected that those from higher income countries or communities have the resources and responsibility to provide health-related services for those in lower income countries or among communities with fewer resources ( Brown, 2017 ). We have seen how service learning is often met with praise without critical reflection, and when it can create a dependent relationship, which may negatively affect movement toward capacity building and sustainable efforts. This may further reinforce the notion that academies hold the knowledge and expertise and may undervalue the experience of those working at community organizations and individuals within communities themselves, reinforcing a power dynamic, rather than a truly equal partnership.

A challenge that has also arisen in our own experiences is that unfortunately not all community organizations promote equitable or just services. Hence, it is crucial that universities be selective in their partnerships and place students with organizations that follow evidence-based practices and uphold values of justice and equity. This once occurred, for example, when a student partnered with an organization that promoted individual-level weight-loss solutions for cardiovascular health improvement, but did not consider ramifications related to fatphobia and systemic factors. Hence, it was challenging for the student to balance content being taught in class (i.e., stigmatization, social determinants of health, white supremacy, and related implications for body size), and their service learning work.

It can also be challenging to unpack students’ positionality related to their service learning, which may be dependent on their own backgrounds and identities. For students of color attending a predominantly white university, the service learning experience may be different than for white students. In general, some students may see service learning as an opportunity to work with communities very distal to their own, whereas for other students, this may mean working in their own community. Discussing this in a classroom setting can be difficult, as it requires instructors to explore the many systems of oppression that exist within society, without placing added labor on the shoulders of students and faculty who themselves experience structural oppression. For example, some concepts taught in class, such as racism and homophobia, may be hypothetical to some class members, while the lived experience of others. Hence, explaining the important ramifications of these oppressive structures, while ensuring that students are not traumatized (or re-traumatized), can be an especially difficult balance to strike. Further, as the first author has experienced, instructors of color or instructors who are a part of other marginalized groups, may shoulder an undue burden by needing to explain these concepts to their students or engage in correcting student misperceptions, wherein instructors may have to revisit traumatic experiences (e.g., microaggressions), in an effort to help students understand these critical issues.

Rethinking the Paradigm of Service Learning

Considering the many strengths and continued growth of service learning in public health and related fields, it is imperative that institutions examine their current approaches to yield the best outcomes for both students and community organizations alike. Based on both the literature and our experience, we believe this may be best achieved through the following: standardized training for all stakeholders; expanded evaluation practices; contributions from academic institutions to the community beyond service learning; further research; resource development and distribution; and systemic change within the academy. These strategies are listed and expanded upon in Table 2.

Table 2.

Existing Service Learning Concerns and Recommendations to Address Them.

Concern	Possible solution	Relevant resources*
Imbalance of power between academic institutions and communities	- Offering other services through universities, such as training or collaboration opportunities, that do not require hosting a service learner - Hosting community conversations to address the historic impact of universities on communities, and to aim to improve relations - Participation in equity, diversity, and inclusion trainings, facilitated by compensated members of the community with relevant expertise - Consideration of community collaboration in faculty tenure and promotion criteria	Provision of equity, diversity, and inclusion resources online, so that individuals can engage with content most relevant to their learning needs. Example: - UCLA Equity, Diversity & Inclusion (https://equity.ucla.edu/edi-education-series-learn-more-ad/)
Inadequate protection of vulnerable populations	- Adequate training of service learners by the university - Review of service-learning positions to determine if students have adequate training before interacting with priority populations (e.g., training in working with youth for youth-based interventions) - Evaluation of changes to training over time, to ensure this problem has been resolved (specifically evaluations of community organizations’ feedback)	Online ethics training resources. Examples: - CDC Public Health Ethics Training (https://www.cdc.gov/os/integrity/phethics/trainingmaterials.htm) - CITI Training courses for those in research (https://about.citiprogram.org/course/essentials-of-public-health-research/)
Reinforcement of neocolonial power dynamics through service learning	- Adequate classroom discussion around the origins of public health in relation to colonialism, sufficient training of faculty to moderate these discussions, and support of underrepresented faculty when leading such discussions - Increased training from the university on cultural competency, and assessments to ensure students meet certain standards prior to beginning their service work	Conversations unpacking neocolonialism at the university level. Examples: - Yale University Conversation about Neocolonialism (https://ysph.yale.edu/news-article/neocolonialism-and-global-health-outcomes-a-troubled-history/) - Packard, R. M. (2016). A history of global health: Interventions into the lives of other peoples. Johns Hopkins University Press.
Unpacking student positionality relative to service learning activity	- Classroom exercises to address student positionality and lived experience	Privilege walk or similar exercise. Example: - McIntosh, P. (1990). White privilege: Unpacking the invisible knapsack. JSTOR (https://psychology.umbc.edu/wp-content/uploads/sites/57/2016/10/White-Privilege_McIntosh-1989.pdf)

*

The resource examples provided are not specific to service learning; however, tailoring these to be specific to service learning would be beneficial to the advancement of the field.

Service learning training often exclusively involves students receiving an orientation at their community placement related to their service learning project. However, this traditional training model neglects the needs of those who support students: namely the community organizations and service learning course faculty. Universities can support capacity building for community organizations to ensure that they are able to host a student, without depleting their own resources, by providing checklists for resources community-based organizations would need to host a student (e.g., expected time demands of supervision), working with organizations to understand qualifications students should possess to meet stated needs, and providing organizations with a stipend to cover the cost of training if possible. Many institutions have university-wide service learning program managers; investing in these positions and ensuring that these individuals either possess a background in health equity, or receive training in this area, is essential. Additionally, faculty must also have adequate training in cultural competency, pedagogies of oppression, and an understanding of social justice, to be able to support their students in meaningful personal and classroom reflection, which is a known service-learning benefit ( Levesque-Bristol et al., 2011 ). Curricula for training faculty in service learning have been published ( Hollander et al., 2020 ), but the extent to which they have been adopted or evaluated is unclear; thus, more work can be done in this area, such as implementing trainings for service learning faculty, including social justice principles, and disseminating model programs that have been found to be effective. Moreover, though dedicated equity, diversity, and inclusion curricula exist (Table 2), modifying these to be specific to service learning, could help address the specific ethical concerns that arise through this pedagogical strategy.

Expanding evaluation around service learning is also crucial to improving its effectiveness and making it more equitable. Evaluations from all stakeholders, not just students, are generally recommended, but it is unclear the extent to which this is done, or, if it is, how and by whom the data are compiled and analyzed. Time should be dedicated to assessing trends in evaluations annually by service learning program managers or other identified individuals at the university level. By regularly tracking student satisfaction and especially student developmental outcomes, universities would have the ability to assess the extent to which service learning is beneficial across multiple learning domains. Additionally, efforts should be made to obtain meaningful feedback from community organizations, a commonly untapped source of input, in the form of both qualitative and quantitative feedback ( Stoecker et al., 2009 ). To date, only a few sources have shared such findings ( Blouin & Perry, 2009 ; Pellerano et al., 2023 ; Stoecker et al., 2009 ). In doing so, gaps in student capacity and university or faculty support would become clearer and could be addressed. Faculty could also offer insight into which concepts around ethics and justice students are, or are not grasping, and offer suggestions for curriculum revisions, as well as their own self-identified areas for growth and ideas for ongoing training. Of note, institutions may be doing this internally, though disseminating these processes and findings more widely would be helpful in supporting the further development of service learning as a field.

Finally, service learning as a pedagogical strategy should exist in a context where resource sharing between academic intuitions and community organizations is normalized outside of service learning to minimize power imbalances ( Stoecker et al., 2009 ; Wilson, 2023 ). Possible examples of resource sharing from our own experiences include hosting trainings in intervention or research methodologies for community organizations seeking to create or evaluate programs, developing partnerships, wherein faculty collaborate on community-based projects with local organizations, and ensuring that that relevant publications (e.g., manuals, toolkits, articles) are broadly available, including open-source or accessible journals. One mechanism for enabling resource sharing may be through rewarding community engagement and applied research in faculty tenure and promotion criteria. Although there appears to be increasing attention in higher education around the potential to better recognize these traditionally undervalued areas, administrative support and systematic change will need to occur for this to happen. Moreover, tools for building equitable academic-community partnerships, justice-focused service models, and study results pertaining to service learning should be disseminated in both scholarly and mainstream outlets, to strengthen existing approaches in the field.

Conclusion

With public health student enrollment and service learning both increasing nationally, the impact of service learning among students and communities must be continuously and critically assessed. This includes the comprehensive effects of service learning as a pedagogical strategy, including both intended and unintended outcomes, and implications for the public health profession. Although service learning can have beneficial learning outcomes, it may also produce a power imbalance between academic institutions and community organizations that may have negative ramifications for students’ public health careers and community members. Though some academic institutions may be taking steps to address this given more recent attention to health equity and social justice, these efforts have largely not been shared, though doing so could benefit the public health and health promotion education communities. The strengths and challenges of service learning must therefore be considered and addressed in their totality, and best practices must be disseminated, for public health and health promotion professionals to truly fulfill our commitment to equity and social justice.