On Linkages: Access To Healthy Food in A Low-Income Urban Community: A Service-Learning Experience

Service learning is difficult to define due to the wide spectrum of programming to which this term is applied. Programs range from one-shot efforts to courses that are fully integrated into a school's curriculum. Eyler and Giles assert that service learning should include a balance between service to the community and academic learning.¹ Reflection on the process of engaging with the community remains central to the value of service learning.

Service learning provides an opportunity for students to develop critical-thinking skills, gain contextual understanding of complex issues, engage in thoughtful decision-making, apply theory to practice, develop independence and leadership, and maximize the learning process through the exchange of ideas with others. Knowlton and Sharp extol these advantages, and quote Gagne:

Through this type of research and analysis, students become more adept at managing the ambiguity and volatility inherent in real-world scenarios. In fact, (this) method reinforces a “central point of education—to teach people to think, to use their rational powers, to become better problem solvers.”^2,3

Service learning provides extraordinary benefits for the student over traditional methods of instruction. Students take personal responsibility for learning in the present and develop skills for becoming active learners. Students develop skills through acquiring and critically evaluating new knowledge, as well as gain proficiency in reasoning. In addition, students further develop interpersonal skills, particularly with respect to giving and receiving constructive criticism and gaining a commitment to self and group improvement.⁴

The students' community partners will benefit from a successful service-learning partnership by acquiring information and/or resources needed to fulfill a social change mission associated with society's most complex problems such as poverty, homelessness, and hunger. Typically, community partners have few resources and limited opportunities to effectively influence structural change in the community context. Agencies are often charged with collecting quantitative data that demonstrate outcomes, as well as implementing best practices for their programs. Service-learning partnerships can facilitate these efforts for those who are dedicated to improving the quality of life for disadvantaged people.⁵

The purpose of this article is to describe a graduate-level public health service-learning course based on the following community issue: access to healthy food in a low-income urban area. Course expectations required students to interact with practitioners and community members while conducting research. In addition to the course description and community issue, this article presents data collection methods, results, and students' reflections on the project.

COURSE DESCRIPTION

The graduate-level course, entitled Public Health in Action and offered by the College of Public Health, Ohio State University, in Columbus, Ohio, is designed to offer students an opportunity to benefit from a service-learning experience. Public health practice occurs in a social context and is subject to all the complexities of a social environment. Therefore, this type of experiential learning provides future practitioners with a rich opportunity to bridge theory and practice while encouraging reflection and decision-making. Students were expected to fully participate in the team learning experience with practitioners and other students; engage in assessment activities as defined by the community partner; collect, analyze, and synthesize data; prepare and present a final report to community partner staff; and prepare and present reflections on the service-learning method and group process.

Articles for From the Schools of Public Health highlight practice- and academic-based activities at the schools. To submit an article, faculty should send a short abstract (50–100 words) via e-mail to Allison Foster, ASPH Deputy Executive Director, at afoster@asph.org.

Columbus Public Health in Columbus, Ohio, served as the community partner for this project. Columbus Public Health's Division of Planning and Preparedness is charged with providing leadership to engage communities and other health-care agencies in developing community action plans for health improvement in medically underserved neighborhoods. The assumptions underlying this effort are that successful health improvement initiatives require community involvement and the understanding that specific communities have unique needs.

COMMUNITY DESCRIPTION

The community in which this project took place is on the west side of Columbus, located close to the downtown area, and is the oldest community in central Ohio. It is also the poorest neighborhood in Columbus, with a median household income of less than $17,000 (30.0% of households earn less than $10,000). The majority of the population is white (75.5%) with 25.7% of the residents classified as part of a minority group. This area has the highest number of residents in the city who do not have a high school diploma. Only 21.0% of the residents own their own home, and one-fifth of the housing structures are vacant.⁶

COMMUNITY ISSUE

The student project focused on access to and cost of healthy food in this underserved, urban area. Research indicates that location, nutrition, cost, culture, weight control, taste, and convenience are factors that influence dietary and lifestyle choices. The physical availability of healthy foods is particularly important when considering socioeconomic status and race. Morland et al. report in their study of several census tracks that supermarkets were four times as likely to be in predominantly white neighborhoods and that the small corner grocery store is most likely to be located in the predominantly African American, poor neighborhood.⁷ The lack of availability of healthy food in small grocery stores located in low-income neighborhoods and the higher cost of the healthier food items may be a deterrent to eating healthier among very low-income consumers. Algert et al. note that access to supermarkets and other stores offering fresh produce and other healthy foods is often different between impoverished and wealthier neighborhoods. These researchers conclude that providing access to low-cost fresh produce and foods in low-income neighborhoods could substantially reduce the risk of chronic illness and other health-related complications.⁸

METHODS

Students enrolled in Public Health in Action met with the health planner of Columbus Public Health and were introduced to “Improving Access to Healthy Food: A Community Planning Tool.”⁹ This document was designed to enable community residents to find ways to bring healthier foods into their neighborhoods by implementing one or more food access strategies. These strategies included working with corner grocery stores, working with existing supermarkets, bringing new supermarkets to a neighborhood, food cooperatives, buying clubs, food kiosks, farmers' markets, and community gardens.

Students were expected to conduct an environmental scan of the designated area, noting community assets as defined by Kretzmann and McKnight as well as community deficits.¹⁰ Students also conducted visual food item surveys of the 12 food stores located in the designated area, based on recommended healthy food items from the U.S. Department of Agriculture and its Women, Infants, and Children Program. The students recorded the availability and quantity of healthy food, product placement, access to public transportation, and general environmental conditions. None of the food stores were associated with major grocery chains. Key community informants—including citizens, community leaders, and city personnel working out of the Neighborhood Pride Center—were interviewed regarding their perceptions about access to healthy food and about residents' eating and food purchasing habits, as well as their opinions regarding the feasibility of the healthy food access strategies outlined in “Improving Access to Healthy Food: A Community Planning Tool.” The class also visited the food pantry that served this area.

RESULTS

Students noted a number of assets. This community is located in close proximity to downtown, providing access to major thoroughfares and bus routes. A library, community center, parks, schools, and churches are also found in the area. Services are abundant and include child care, summer programs, food pantries, clothing and household goods, free clinics, and government housing. However, many of the key informants felt that community assets were underutilized.

Community residents also experience a variety of barriers. Many residents do not have personal transportation and must rely on friends and family, buses, or taxis to purchase groceries. All of the large supermarkets in the area are closed, so many residents rely on the corner stores, which typically lack fresh produce. The corner stores stock and advertise snack foods, alcohol, cigarettes, and lottery tickets. Owners of these businesses often do not live in the area and therefore are perceived as not invested in the health of community residents. In addition, community streets are lined with fast food establishments.

Key informants identified generational poverty as a major issue. Informants also surmised that many residents may not understand the correlation between eating habits and current and future health issues. Key informants almost universally rejected the strategies outlined in “Improving Access to Healthy Food: A Community Planning Tool.” The strategies rely on community readiness, which was described as unlikely in this area at this time.

One informant indicated that some residents had to choose between food and “a roof over their heads.” Healthy food is often considered expensive and difficult to prepare, making fast food a more attractive alternative. Nonworking appliances and insect infestation become formidable barriers to healthy food storage and preparation as well.

Students surveyed 12 food stores in the area and found that the smaller the establishment, the less likely that fresh produce was available for sale. The majority of stores carried canned fruits and vegetables, and breads and grains. Prices were universally lower at the larger stores. The cost of a loaf of white bread ranged from $0.79 to $2.79; milk from $1.99 to $3.59 a gallon; and a dozen eggs from $0.69 to $1.59. In many locations, students noted dairy products such as yogurt and cheese for sale that were a month past their expiration dates. Alcohol was sold at every location and typically placed in the front of the store. Store windows were often covered with alcohol and cigarette advertisements and lottery signs.

Findings were consistent with research previously conducted in low-income, urban areas. The high cost and limited availability of healthy food, along with other identified barriers, increase the difficulty of consuming a nutritious diet.

RECOMMENDATIONS

Like many other low-income, urban neighborhoods, this Columbus community has seen better times. In recent years, all major supermarkets in the area have closed, leaving the small corner store as the only option for residents without transportation. These stores offer a small inventory of healthy food choices, promote alcohol and tobacco products, and are often sites for illegal drug trade. Small markets and corner store operators are not interested in and see no cost benefit to offering more healthy food options in their establishments. Although key informants generally expressed a desire for a supermarket in the area, the students felt that research into why the big chains pulled out should precede any effort to recruit a new one into the area.

Key informants expressed doubt as to whether any of the strategies outlined in “Improving Access to Healthy Food: A Community Planning Tool” would be successful, as many had been tried before but not sustained. However, churches and schools were mentioned as trusted institutions that could be utilized as vehicles for community education.

Behavior change is unlikely without attention to some of the environmental constraints such as lack of transportation, pest infestation, unsafe neighborhoods, and a high concentration of alcohol outlets. Policy changes that address some of these issues might have a positive impact.

In sum, students felt that community planners should proceed carefully when addressing the issue of availability of and access to healthy food. Government intervention is viewed with distrust, and many efforts designed to improve the area have not been sustained or have failed. Instead of attempting one of the strategies from the “Community Planning Tool,” existing trusted institutions such as churches and schools should be mobilized to influence food purchasing, preparation, and consumption behaviors. Attention to environmental barriers should be considered as well. Research into efforts that have been successfully implemented in demographically similar communities might offer insight into how best to proceed.

LESSONS LEARNED

Practical experience intertwined with classroom learning offers a new perspective to students and allows them an opportunity to apply classroom knowledge. The field of public health is based on a social justice philosophy. Many public health problems disproportionately affect some groups. This course exposed the students, most of whom had limited personal experience with diverse neighborhoods, to the disparity in the availability of healthy food in an underserved area. These students' comments included the following:

My experience in class has given me insight into how difficult public health actually is. In class, we always have the right answers, always have the ideas that will “work,” and I've always pictured myself educating people about how to be healthy with the result that all of a sudden they will be. This class sort of shattered those thoughts for me.

It made me think, and gave me the chance to look at the bigger picture, instead of assuming we have all the answers.

I know that I have developed a new way of looking at societal problems, and I will carry these lessons with me into the future.

Student course evaluations revealed a high level of satisfaction with this experience, especially regarding the community engagement aspect and the opportunity to work with a local health department. However, many students became invested in the community and expressed concern that the assessment and recommendations would not be acted upon:

I have a fear in the pit of my stomach that the information we came up with may be presented, filed away, and never developed into something that could truly help the community.

I really hope to see this project go somewhere after the information is presented. I wish as a graduate student I could devote more time to the issue after being involved and observing a community that I never knew too much about. There's a big part of my heart that goes out to the people.

Although the focus of a course such as the one described in this article will change according to the issue and the partners, faculty attempting to engage students in community-based research would be well advised to consider some general issues in advance. Some measure of control is sacrificed when the community becomes the classroom. Partnering with the community should be viewed as a process as opposed to a discrete event. Faculty would benefit from recognizing that all parties bring liabilities and assets, and from acknowledging the complexity of social organizations. To reduce sources of tension, roles and responsibilities of all participants and the final product should be agreed upon prior to course initiation. Finally, students should be advised to recognize political realities that may impede their ability “to get the job done.”

CONCLUSION

Service learning encourages what Eyler and Giles refer to as a “connected view of learning,” allowing the student to link personal and interpersonal development with academic and cognitive development.¹ The student learns the subject matter while engaged in the process of acting and reflecting, thereby “learning to be effective while learning what to be effective about.”¹¹ When reflecting in their journals and final papers, all of the students noted that what they learned and observed could be combined with their skills to impact a public health issue.

Although this article describes one class with a small number of students, this method of teaching and learning is promising. Community-based, service-learning research is an underutilized form of scholarship that has the potential to prepare students to become active and committed citizens and practitioners in our diverse society.