Health Professions and Cooperative Extension: An Emerging Partnership

Introduction

Rapid changes in healthcare are raising concerns about access to and cost and quality of care. Disease prevention and health promotion continue to be important programmatic needs. And, while healthcare makes an important contribution to the local economy, concerns about healthcare infrastructure in rural areas and access for minorities and limited resource individuals and families remain important challenges.

The Cooperative Extension System in partnership with the Cooperative State Research, Education and Extension Service (CSREES) has increased its engagement with the community to identify and ameliorate community health problems, but Extension as a resource is still underutilized within the university. The USDA-CSREES funded pilot project entitled "Health Professions and Cooperative Extension: An Emerging Partnership" is part of the "Healthy People...Healthy Communities" initiative. This project works to bridge the gap between the university and community by offering a community-based service-learning experience for health professions students across disciplines.

The "Healthy People...Healthy Communities" initiative is guided by three main goals:

1. Educate and empower individuals and families to adopt healthy behaviors and lifestyles,
2. Educate consumers to make informed health and healthcare decisions, and
3. Build community capacity to improve health.

The pilot project, "Health Professions and Cooperative Extension: An Emerging Partnership," placed health science interns in community-based education and outreach programs in partnership with county Extension faculty and staff. Each project contributed to one or more of the "Healthy People...Healthy Communities" goals and provided students with service-learning opportunities.

Funding was awarded to seven students in Illinois, Missouri, Ohio, and West Virginia during the summer of 2000, providing them with a rare opportunity to learn in mostly rural community settings. Learning goals for the students included working at the community level to assess community healthcare needs and to develop and deliver a health education program to a high-priority audience. Long-term effects expected as a result of the grant include placing health professions students in underserved rural areas; enhancing the capacity of Extension to deliver health education and outreach to underserved populations; and fostering the integration of research, higher education, and Extension.

This article evaluates the success of this grant in meeting three specific goals:

1. Provide service-learning experiences for students,
2. Develop community-based and university partnerships, and
3. Enhance Extension's capacity to deliver health education and outreach programs.

The diversity of projects and methods undertaken throughout this project provide for a rich understanding of how Extension can better its own efforts in expanding partnerships and providing community-driven programs.

Methods

At the end of the internship, students reflected on their experiences in written reports to the project team. These reports were studied to determine the extent of student learning, new partnerships created or enhanced, and improved Extension capacity to deliver health promotion and education. Second, grant applicants (Extension administrators and specialists) and the Extension agents/educators at the county level were administered a telephone survey that further evaluated the experience of Extension faculty and staff in implementing this grant project to meet its objectives.

This article discusses the projects that were created or enhanced, and the target client populations reached by each of the projects. Further, the extent to which collaborations were built and what students learned through service in the community-based setting are discussed. Finally, this article assesses the outcomes of the pilot project and makes recommendations for its further implementation.

Findings

Overview of Projects

Five disciplines, including medicine, nursing, social work, physical therapy, and nurse midwifery, were represented in this grant project. This range of disciplines allows for diverse perspectives and skill sets to guide project development in the community. The grant program was flexible in terms of which kinds of projects could be developed so that students could easily match their learning objectives to community-identified needs and existing Extension projects. Student involvement ranged from observation to active participation and leadership in service delivery and project development.

The Extension educator at each site worked to oversee community projects; assist the student in making contacts with community members, leaders, and organizations; and to provide education and limited supervision.

Projects developed by the students in conjunction with Extension agents include the safe-sitter program, Dining with Diabetes, recycled medical equipment, nutrition and health for young mothers, food safety workshops, and the development of a rural health clinic. Through these projects, a variety of client populations were reached, including low-income teens, geriatric women, diabetics, children, food vendors, the medically uninsured/underinsured, and young parents (Table 1).

Table 1.
Overview of Projects

Student Discipline	Project	Audience	Skills	New/Enhanced Partnerships
Nursing	Safe-Sitter	Lower income adolescents, children, and parents	Networking, community organizing, grant writing	Local community hospital, nurses, & Girl Scouts
Social Work	Recycled Medical Equipment Project	Community members, elderly, service providers	Project development, network building, community organizing, grant writing	Rural Health Education Partnership, Regional Health Promotion Specialist, local hospitals
Physical Therapy	Dining With Diabetes	Diabetics, their families, and caregivers	Public relations/outreach, group facilitation, program evaluation	County health department, churches, service providers
Medicine	Rural Community Health Clinic	Underserved rural families, local service providers, low income individuals	Networking, hands-on experience working with limited resource clientele, program development	Community members, health department, government officials
Medicine	Food Safety, Dining with Diabetes, 4-H	Diabetics, factory workers, youth	Healthcare assessment, teaching, video and Web site production, nutrition education	Healthcare community
Medicine	Geriatric Health	Geriatric women	Program evaluation, survey development	Health professions schools
Nurse Practitioner	Geriatric Health	Senior adults	Rural health evaluation, patient rapport	Health professions schools

Service-Learning Benefits

Increasingly, universities are turning to service-learning as a method of engaging campuses with surrounding communities. Extension, rooted in community involvement, is the ideal vehicle for providing opportunities in student learning through community involvement.

It is useful here to provide a working definition of service-learning. A recent review of the literature devoted to university service-learning models reveals that most scholars and practitioners identify several major learning components. These learning components include orientation and reflection, reciprocal learning, interdisciplinary learning, community partnerships, needs and assets assessments, and social change.

Orientation and reflection are interdependent and crucial to implementing service-learning. First, orientation should work to define the goals and to clarify the role of each party (students, Extension, and community), including types of activities involved, evaluation criteria, and hours of work (Cauley, 2000). Reflection is a tool used throughout and at the completion of a project or activity to evaluate and re-evaluate the roles and expectations of each party and comes in many forms, both formal and informal (Eyler, Giles, & Schmeide, 1996). It is also useful in connecting community work to the health professions.

Reciprocal and interdisciplinary learning are also central to service-learning. In this framework, the student, community, and organization all benefit from the project, learn from the project, and bring valuable resources to the project. This idea holds true in interdisciplinary learning as well, where each health profession brings different, but equally valuable, knowledge to the project.

The pilot project succeeded in meeting these service-learning objectives. Concerning orientation and reflection, all students were required to write a report documenting their activities, successes, and suggestions for future development. Many students had not before heard of Extension, and much of their orientation centered around familiarizing themselves with Extension and the community to be worked in. A medical student wrote, "the first two weeks of the internship were dedicated to learning about healthcare needs in this area and also in some surrounding areas. It also involved learning what services Extension provides to the community."

However, the majority of respondents reported that there was not a proper introduction to project responsibilities. This was in part due to the newness of the project, but also due to the desired flexibility to carry out community-based projects. Still, the majority of the students report that, although they were somewhat autonomous in carrying out their responsibilities, they were always able to obtain the needed guidance from the local Extension educator.

The interdisciplinary and reciprocal nature of the internship experience was invaluable to student learning. Extension agents provided a link to the community, and they helped with the development of learning objectives while the students implemented the projects. Not only were different disciplines, such as diet, nursing, and medicine represented, but different types of community agencies offering their own expertise were utilized to further the students' learning objectives as well as the goals of the communities. And all parties brought their own expertise to the projects. As one Extension educator said of working with a nursing student, "it was good to have someone come into the office and give us a different viewpoint."

Students essentially worked for social change in the area of healthcare. Each project in some way enhanced efforts to improve access to healthcare with community input and involvement, the third goal of the "Healthy People: Healthy Communities" initiative. One administrator responds "we met this [goal] by making more resources available through the recycled medical equipment project. The goal of adopting healthy behaviors and lifestyles was also met."

Each project developed out of a community-identified need and built upon community strengths. Two students organized focus groups and community meetings to determine the desire for the respective projects, and a research study was done to determine the need for another project. One Extension agent reported, "the student really helped to organize the social reconnaissance meeting so that we could get input from the community to determine their interest in pursuing being a federally qualified health center in our county."

Concrete service-learning activities included project development, outreach, observation, grant writing, assessment, public relations, and community organizing. At a minimum, students gained an enhanced understanding of community practice and the diversity of rural healthcare needs, the impact of which cannot be underestimated. At most, sustainable projects were developed and initiated. Perhaps the most noticeable service-learning benefit was the creation of new or the enhancement of existing community partnerships.

Partnership Development

The value of community partnerships was apparent to the participating health professions students. As a logical first step in implementing a community-based project, students identified collaborating with their community as a learning objective. One grantee described one of her objectives while initiating the Safe-Sitter program as identifying "potential relationships between healthcare and Extension." Her work reflects this goal, as she "developed a community-based coalition for project collaboration." To promote the Dining with Diabetes project, one student wrote, "county Extension educators will work with health departments, hospitals, community dietitians, and other diabetic support groups." Another student, working with the Recycled Medical Equipment Project wrote, "planning meetings were held which brought together the county Extension agent, the Rural Health Education Partnership site coordinator, the regional community health promotion specialist, representatives from two rural hospitals, and a community member.... Many community leaders were brought together that had never met each other."

Although many students reflected that they had not before heard of Extension, they described it as an invaluable resource for community collaboration in promoting health and health education. A theme of many students' responses was the idea that Extension was a "best kept secret." Students learned about Extension in general, but also learned about the role of the Extension agent as a community leader and facilitator of change. Through this project, the Extension agent took on a new role, that of a facilitator of learning for health professions students.

Local Extension offices gained new partners through the collaborative work of the students in the community. An agent reported, "I was able to network with some organizations that I hadn't been able to get into before." To do this, some students arranged public meetings where community members and social and health service administrators came together to assess community needs and provide direction to projects. Examples of new partners identified by the agents/educators included the county health department, local nurses, the Girl Scouts, local hospitals, local citizens, and government officials. However, two agents reported that students used existing community partnerships rather than making new community ties.

For administrators, this project served as an opportunity to gain new partners in health professions schools, including schools of social work, medicine, nursing, and physical therapy. Although there were only five disciplines represented in the pilot project, these connections led to additional linkages with other health science programs such as the schools of pharmacy in two states. Through this pilot project, as one Extension applicant indicated, "we are learning to talk the same language with the health professions."

This grant program also expanded Extension's partnership with communities. One Extension specialist reported, "the contacts that were made will really enhance the efforts of other educators and help them get similar contacts in place." Another applicant reflected, "...although many organizations may have known about each other, they had not worked together in a partnership like this before these projects." Partnerships were also reportedly strengthened at the state level.

Benefits to Extension

The benefits to Extension were many and varied. One obvious benefit is that Extension programs were developed at little or no cost to local offices, and students provided the energy and mobilization to initiate community projects. All parties indicated that the internship provided an atmosphere that fostered a mutual relationship among student, agent, and community. A variety of new and old target groups were reached through these joint efforts, providing a valuable service-learning experience for the students. Additionally, the health professionals provided a new perspective on program delivery at the community level.

This project brought higher visibility of Extension to the community by creating and strengthening partnerships. At the same time, students, some who previously had not heard of Extension, learned the value of Extension as an educational resource. These efforts undoubtedly worked to expand the mission of Extension to include healthcare and to become more engaged with the university through facilitating learning experiences for students.

It should be noted that, although this program was targeted at health professions, its aims are perfectly suitable for working with other disciplines within the university such as engineering, public administration, economics, and more. Extension could partner with these departments to provide community-based service-learning experiences for students, while using the skills of these students to contribute to the expanding mission of Extension.

Project Challenges and Recommendations

A majority of the challenges faced by all participants were logistical in nature. Some felt that the 2-month timeframe for the project limited the opportunities for the student to become really involved in the community. The short time allotted and the short notice of the project to agents created problems in finding a "good fit" between agents and students, especially when students have such a structured program.

Another major challenge to implementing the project was the lack of orientation to the project in terms of expectations for the student and the agent. Proper orientation is essential in ensuring that the student has a meaningful learning experience in the field and that the project itself is successful without creating an additional burden to the agent.

Despite the challenges to implementing this project for the first time, benefits of the project were realized in health professions education programs, Extension, and underserved rural communities. There was unanimous agreement that the project should continue providing more opportunities for health professions students to learn in the community setting and for Extension to be the link to the community.

The "Health Professions and Cooperative Extension: An Emerging Partnership" pilot project resulted in the development of various community projects that have worked to expand the role of Extension in the community and in the university. With limited seed money, community-based projects have been initiated whose benefits are still being realized. In turn, Extension has become more visible and more effective in partnering with communities.

For more information about the "Healthy People...Healthy Communities" initiative, visit the National Network for Health Web site at http://www.nnh.org/.

References

Cauley, K. (2000). Integrating student learning objectives with community service objectives through service-learning in health professions schools curricula. Paper presented at the Community-Campus Partnerships for Health's Annual Conference, Washington, DC.

Eyler, J., Giles, D.E. Jr., & Schmiede, A. (1996). A practitioner's guide to reflection in service-learning. Nashville: Vanderbilt University.