From Their Own Voices: Understanding the Impact of Pre-College Pipeline Programs Aimed at Promoting Diversity in the Health Professions

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1 From Their Own Voices: Understanding the Impact of Pre-College Pipeline Programs Aimed at Promoting Diversity in the Health Professions Diana Austria Program in Human Biology Honors Thesis Stanford University May 27, 2008 Dr. Jennifer L. Wolf School of Education Professor Catherine A. Heaney Department of Psychology 1

2 TABLE OF CONTENTS Abstract... 3 Acknowledgements. 4 List of Tables and Figures.. 5 Chapter 1: Introduction... 6 Chapter 2: Background.. 9 Chapter 3: Methodology Chapter 4: Findings I.. Program Learning Tools and Outcomes 41 Chapter 5: Findings II..... Relationship Between Program Learning Tools and Outcomes 69 Chapter 6: Discussion References 96 Appendices

3 Abstract From Their Own Voices: Understanding the Impact of Pre-College Pipeline Programs Aimed at Promoting Diversity in the Health Professions By Diana Austria Program in Human Biology, Stanford University There remains a clear under-representation of low-income and ethnic minority populations working in health fields, even in the face of research affirming for a more diverse workforce to reduce health disparities and promote cultural competency. Research has affirmed pipeline programs, which prepare students at critical educational transition points, such as high school to college, to be effective interventions in addressing health and education disparities, yet there remains a lack of qualitative research to better understand how specific program components facilitate positive outcomes that result from program participation. This study addresses these questions through a case study of the Stanford Medical Youth Science Program (SMYSP). Twenty-five semi-structured, phone and in person interviews were conducted with students who participated in SMYSP between 2001 and 2007, asking them to reflect on specific experiences and moments that impacted them academically and personally. Participants identified a number of academic-career and social-personal focused program components, as well as an array of program outcomes involving attitude changes development of academic skills, and decisions after the program. Structurally, SMYSP program components created a safe space environment characterized by simultaneous points of vulnerability and protective mechanisms. Safe space in turn facilitated internal self-reflection, which served as a gateway for attitude changes and other program outcomes. These findings have important implications for not only other pipeline programs, but also education and health care. This study emphasizes the need for challenging learning environments, continued social support and internal self-reflection in order to best prepare students to enter the health professions in turn, continue to promote and protect the health of our diverse communities. Thesis Advisors: Dr. Jennifer Wolf, School of Education; Professor Catherine Heaney, Department of Psychology 3

4 Acknowledgements This thesis is the culmination of the efforts made by many passionate and dedicated people working to improve our society and advocate for social change in a multitude of ways. Without these individuals, this tremendous learning experience would not have been possible. To the Stanford Medical Youth Science Program (SMYSP) family thank you for inspiring and motivating me. To my fellow SMYSP counselors and Class of 2006, thank you for the amazing memories of our summer that impacted me so tremendously and sparked this journey of inquiry. To Dr. Marilyn Winkleby, Dr. Judith Ned, Dr. Anh, Dale, Nell, Alana, and the entire SMYSP staff thank you for supporting me, guiding me, and trusting me to continue in this work for SMYSP. And to all the alumni who I interviewed thank you for your willingness to share your inspiring stories of courage. I hope this thesis does justice to your strength and great examples. To my thesis advisors, I am deeply humbled by the sincerity and overwhelming support you have provided me from the very beginning. To Dr. Jennifer Wolf, thank you for challenging me, guiding me, and unearthing a part of my myself that I didn t know existed. Without your many dedicated hours of mentoring and advising, I know this thesis would not have been possible. To Dr. Catherine Heaney, thank you for your patience and graciousness in advising me through this process, as well as the many other aspect of my academic and professional life. Thank you to the Program in Human Biology for granting me this unforgettable opportunity. To my community, my second home on campus: Anne, Edith, my many amazing fellow staff members: Takeo, Soo, and David for sharing this thesis-while-staffing journey together, and Alice, Tammie, Bryan, Charlie, and Stanford for your support all along the way. My Okada residents for putting up with my busyness spring quarter! To my mentors, community leaders, and countless friends who supported me all along the way, came out to my presentations, and always reminded me why I was doing this work: Cindy, Shelley, Faith, my drawmates, my fellow A3C/SAAAC/PASU and student group members. And of course, thank you to the amazing A3C computer cluster where 75% of my thesis was written and to all those joined me there to witness my multiple late nights and writing blocks. To Jackie, Mary, Stephanie, my fellow PSSP Class of 2008, and the Haas Center thank you for all that you are and have given me through this thesis process. Thank you for inspiring me, sustaining me, and never letting me forget the faces of those I hope to serve with my thesis. To my family thank you for trusting me to complete this work and supporting me in every way possible. Without you in my life, I would not be the person that I have become. And to Takeo Rivera. Thank you for unearthing the humanity within me. Than you for helping me realize time and time again that we as humans as connected in this struggle for social change and social justice. Thank you for loving me, sustaining me, and healing me throughout this journey of searching, learning, and growth. Diana Austria, May

5 List of Tables and Figures Figure 1 Health Professions Educational Pipeline 9 Table 1 Nonvognitive Minority Admissions Variables 12 Table 2 Elements of SMYSP Weekly Schedule 24 Figure 2 Figure 3 Race and Ethnicity of Stanford Medical Youth Science Program Alumni, Educational and Career Status of Stanford Medical Youth Science Program Alumni, Table 3 Demographic Overview of SMYSP Alumni Sample 32 Figure 4 SMYSP Alumni Sample by Year of Participation 33 Figure 5 SMYSP Alumni Sample by Race and Ethnicity 34 Table 4.1 SMYSP Program Learning Tools Identified by Cohort 42 Table 4.2 SMYSP Program Learning Tools Identified for All Cohorts ( ) 42 Table 4.3 SMYSP Program Learning Tools and Example(s) 43 Table 5.1 SMYSP Program Outcomes Identified for All Cohorts ( ) 49 Table 5.2 SMYSP Program Outcomes and Example(s) 49 Figure 6 Relationships Between and Among SMYSP Program Outcomes 63 Figure 7 Program Experience of a SMYSP Participant 70 Figure 8 Student Experiences and Resulting Program Outcomes of SMYSP Participation 87 5

6 Chapter 1: Introduction The United States population is rapidly becoming increasingly diverse: the United States Census predicts that by 2050, nearly fifty percent of the U.S. population will be non-white (US Census Bureau, 2004). These demographic trends call for increased attention to the health needs of our diverse communities, including more culturally competent and equitable healthcare. Although the overall health of the United States population has substantially improved over the past decades, disparities in health status, healthcare access, delivery, and quality of care still exist and are worsening. Low income and ethnic minority populations have historically, and still do, suffer an overwhelming burden of these disparities, across almost every single health condition or disease and in much larger gaps than ever before (Johnson & Smith, 2002). Thus emerges a great need for increased diversity in the health professions, a diversity that is essential to effectively and adequately address the unique health needs of our nation s communities and eliminate health disparities. A more diverse workforce translates into increased cultural competency (understanding of and sensitivity to different beliefs, cultures, and backgrounds that influence the provider-patient interaction and experience); improved access to health care, especially for the underserved; strengthened medical research agenda; and ensured optimal management of the healthcare system (Association of American Medical Colleges, 2006; Cohen, Gabriel, & Terrell, 2002; Scharff & Kreuter, 2000; Sullivan Commission, 2004; Terrell & Beaudreau, 2003). Individuals from underrepresented minority (URM) groups who pursue health careers are also more likely to serve in physician shortage areas, where most patients are of similar backgrounds (low-income and ethnic minority) and who suffer from chronic and multiple diagnoses (Bergen, 2000). 6

7 The task of promoting a more diverse health care workforce, however, remains challenging. Low-income and ethnic minority students still face many barriers in pursuing careers in health, despite numerous interventions. The underrepresentation of minorities matriculating to medical school, for example, was worse in 1990 than in 1975, despite progress in the 1960 s and 1970 s (Terrell & Beaudreau, 2003). The Sullivan Commission on Diversity in the Healthcare Workforce (2004) report, Missing Persons: Minorities in the Health Professions, reveals that although African Americans, Hispanic Americans, and American Indians comprise nearly 25 percent of the U.S. population, these populations make up less than 9 percent of nurses, 6 percent of physicians, and only 5 percent of dentists. These findings make clear the continued underrepresentation of these populations in the health workforce. Interventions that improve the quality and diversity of the healthcare workforce must address the root economic, social, and structural factors. In 1991, the Association of American Medical College (AAMC) launched their 3000 by 2000 objective to increase the medical school enrollment of URM students to 3,000, by the year 2000, with a strong emphasis on unique collaborations and partnerships target the educational pipeline - the crucial junction between two educational institutions, such as high school to college (Terrell & Beaudreau, 2003). Many interventions aim to increase the matriculation of low-income and ethnic minority students into health profession schools by targeting downstream factors, such as admissions and affirmative action policies of medical schools. However, Cohen et al. (2002) affirm that, in order to promote a more diverse healthcare workforce, one particular pipeline must remain a priority: first and foremost, disparities at the precollege level must be addressed (p. 99). Inequalities in access and opportunity at the pre-college level continue to impact students at all educational transition points, including the rigorous process of applying to health and 7

8 medical professional schools. Thus, many students who have the desire and potential to work as health professions face a sustained lack the resources, support, and knowledge to successfully entering the health field, beginning with their K-12 education and into their transition to college. These trends deprive the nation a much-needed diverse health workforce that may more effectively and better serve our diverse communities. Thus, the challenge remains for health and education policymakers to develop and implement interventions that best address these multifaceted barriers to academic and career success faced by students who will undoubtedly impact the future health of our communities. 8

9 Chapter 2: Background Access and Opportunity at the Educational Pipeline Many low-income and ethnic minority students face challenging economic, environmental, educational, and social barriers in access to higher education. Many of these barriers continue to exist as students attempt to enter graduate or medical school and prepare for careers in the health professions. This disparity in basic educational opportunities, support, and achievement is the fundamental problem leading to underrepresentation of [low-income and ethnic minority students] in the health professions (Grumbach et al., 2003). Figure 1. Health Professions Educational Pipeline Source: Strategies for Improving the Diversity of Health Professions, The California Endowment, Previous literature has identified the multiple stages that exist along the health professions educational pipeline, as displayed with Grumbach et al. s (2003) model (see Figure 1). Educational disparities are most evident at three crucial transition points of this pipeline: 1) K-12 education; 2) post-secondary education; and 3) health professional education and beyond (Sullivan Commission, 2004). These educational inequalities exist beginning at the earliest point of entry, elementary school, and continue to worsen over the course of K-12, post-secondary, and professional levels of education (Grumbach et al., 2003). Present and consistent in K-12 is the distinct achievement gap between disadvantaged and minority students and affluent white 9

10 students at every educational level and nearly all scholastic indicators, namely reading and math skills, learning outcomes, high school completion rates, college enrollment rates, and graduation rates (Sullivan Commission, 2004). Much research has revealed the many countless barriers to access and possible explanations for these gaps. The list is long and involves both systemic and personal factors: inequalities in available educational resources at school; shortage of qualified teachers; lack of motivation or self-esteem; absence of role models and mentors; financial barriers; availability of advanced placement courses; and more (Sullivan Commission, 2004). After examining outreach program literature, Hayward, Brandes, Kirst, & Mazzeo (1997) identified eight frequently cited barriers to access by disadvantaged students: 1. Information: Parents and students often lack and have less access to information about higher education, financial aid, and the college application process. 2. Counseling and advisement: Disproportionate availability of counselors in schools, coupled with lack of adequate support from existing school counselors. 3. Tracking: Students are often placed in academic tracks that stratify opportunity and resources with group ability. 4. Test requirements: Many students do not take the required standardized tests for college admissions and if they do, overall scores show large gaps in comparison to their white counterparts. 5. Courses: Because of many school factors like tracking, students are not enrolled in courses sufficiently demanding to prepare for college level courses. 10

11 6. Under-prepared and under-qualified teachers: Teachers serving in school with large populations of URM students are also more likely to be the most underprepared, many serving with emergency credentials and often teaching courses outside of their fields of expertise. 7. Personal factors: Issues of motivation and expectation arise and are compounded by a lack of adult mentors and role models. 8. Financial costs: Increasing tuition prices make access to and feasibility of college more difficult especially for low-income, minority students. For students who do overcome these challenges, the barriers continue, and perhaps are even exacerbated, at the college and post-graduate levels. This is especially the case for first generation college students (Sullivan Commission, 2004). Certain factors also influence whether or not disadvantaged students can and do overcome personal and structural barriers to educational success. Students whose social contexts are characterized as academic risk factors being a minority student, low-income, attendance at an inner-city or rural school, or coming from a home where English is not the first language are strongly correlated with academic risk behavior, such as dropping out of school or gang involvement. Together these circumstances translate into difficult academic barriers. Despite these barriers, however, personal assets have also been linked to positive academic outcome, including self-esteem, confidence, motivation, personal discipline, and resiliency (Finn & Rock, 1997). Based on supporting literature, Sedlacek & Prieto (1990) and Tracey & Sedlacek (1985) proposed a system of eight noncognitive, nontraditional admission variables that may predict a minority student s success in medical school. These variables are identified and defined in Table 1 and include the following: positive self concept or confidence; realistic self-appraisal; 11

12 understanding of and dealing with racism; preference for long-term goals; availability of strong support network; leadership experience; community service involvement; and knowledge acquired from a field. Additionally, student self-perception and academic/behavior outcomes are not in isolation from the larger context around them, including family, peers, and overall school environment (Finn & Rock, 1997). Much research has also shown the positive effects of family involvement and support on student academic achievement, across all racial, ethnic and socioeconomic backgrounds and many academic disciplines, including mathematics, science, reading and language arts (Smith & Hausfaus, 1998). Theoretical Frameworks A number of theories have been developed to explain the multi-faceted processes that occur with adolescent cognitive development, particularly in the context of learning and academic achievement. Understanding these theories is also important in exploring how specific 12

13 program components may or may not impact student learning and achievement. In this discussion, I will explore theories relevant to pre-college pipeline programs and their impact on students academic/professional, social, and personal selves. Social and Emotional Learning Research has suggested that students academic success is best achieved when all aspects of learning are addressed collectively, including academic, social, and emotional learning (Zins, Bloodworth, Weissberg, & Walbreg, 2007). Elias et al. (1997) defines social and emotional learning (SEL) as the process through which children and adults develop the skills, attitudes, and values necessary to acquire social and emotion competence, and this social and emotional competence, defined as one s ability to understand, manage, and express the social and emotional aspects of one s life, is crucial to students development. Although there is general consensus that SEL is important in a broad sense, Zins et al. (2007) and Elias et al. (1997) affirm that SEL also plays a crucial and direct role in promoting students overall academic success: when schools attend systematically to students social and emotional skills, the academic achievement of children increase. Other outcomes of SEL-focused learning also include decreased behavioral problems, the development of positive relationships, and preparation as responsible member of society. Research has also affirmed SEL s strong association with neuropsychology and successful development of thinking and learning activities the fusion of both cognitive and social/emotional learning. Because personal challenges are oftentimes rooted in social and emotional issues that carry over into the academic context, interventions to promote social and emotional competence play a significant role in helping direct youth away from risk behaviors, such as violence, drugs, and teen pregnancy (Elias et al., 1997). 13

14 Learner-Centered Classrooms and Learning Building upon theories of social and emotional learning, the learner-centered model was developed as a means to balance both academic and social-emotional aspects of learning. McCombs & Whisler (1997) define learner centered as a perspective that focuses both on an individual learner s assets, needs, and experiences, and on how available knowledge about learning and teaching practices can promote the highest levels of motivation, learning, and achievement for all learners. This model incorporates a holistic understanding of student learning and academic success in which both individual level and larger, systemic levels are taken into account. McCombs & Miller (2007) argue against claims that SEL and learnercentered models take away from schools academic missions focusing on cognitive and academic outcomes, but rather help to balance all aspects crucial to student learning within a larger living system. Theories of Motivation Theories of achievement motivation not only predict behavior, but they are also crucial in explaining why individuals behave the way they do in achievement settings (Stipek, 2002). Previous research has identified motivation as fundamental to this field of pipeline interventions, given the many previously studied and existing pipeline programs that incorporate a form of motivation component to their program structure. The dominant model in the field of motivation until the 1960 s was reinforcement theory, which claims that student behavior in academic and other settings is the result of previously reinforced or rewarded behavior. Reinforcement techniques in the classroom today are still utilized in classroom settings, but as 14

15 Stipek (2002) affirms, this theory was thought to be mechanistic by not taking into account student beliefs, feelings, aspirations, or any other psychological variable, and instead directly linking behavioral consequences and the likelihood it would be repeated with (or without) reinforcement. After the 1960 s, theories built upon reinforcement theory to develop cognitive motivation theories that not only consider reinforcement mechanism s role in achievement, but also how one s cognitive or psychological beliefs serve as mediators to behavior. From these theories, Stipek (2002) defines a motivated person as someone with cognitions or beliefs that lead to constructive achievement behavior, such as exerting effort or persisting in the face of difficulty. Additionally, intrinsic motivation theories were developed not only to explain cognitive elements of achievement motivation, but the role of emotion the intrinsic pleasure one feels from achieving higher levels of mastery and learning. Two additional and related motivation theories include self worth theory that students are naturally motivated to preserve a sense of personal worth and self-system theory, which affirms individuals intrinsic human need to feel socially connected to others. In understanding motivation, however, Stipek (2000) also highlights the need to look beyond the system and recognize students individual motivation with factors in the context of larger academic and social influences, such as pedagogical practices, classroom environment, and lack or presences of support. Pipeline Program Interventions There exist a number of interventions that aim to both eliminate the educational barriers faced by low-income and ethnic minority students and provide the necessary resources crucial along the path towards higher education. A wide array of titles refers to pipeline interventions, 15

16 including, but not limited to, pre-college programs, college access or preparation programs, outreach programs, and enrichment programs. The title of the intervention is important to consider because it often suggests the focus or strategy for intervention. For example, Hayward et al. (1997) explains that the term outreach suggests an intervention originating on a college or university campus reaching out into K-12 schools and thus, most outreach programs utilize a student-centered, or learner-centered, approach. The term program not only usually references a specific funding source, whether government or private, but suggests a initiative that utilizes certain actions and strategies towards an established goal, such as increased minority access to the health professional pipeline (Grumbach et al., 2003). Interventions can be categorized as school-centered and/or student-centered (or learnercentered). School-centered refers to interventions that aim towards larger structural change of the educational system and improvement of existing policies that have resulted in unequal access and resources in schools (Grumbach et al., 2003). Examples of these interventions include teacher-training and professional development programs (Hayward et al., 1997). As previously discussed, learner-centered interventions focus on the individual student and consider his or her specific background, experiences, capacities, needs, etc, in the context of complex living environments (McCombs & Miller, 2007). Given the large expanse of existing interventions, this discussion will focus on primarily learner-centered, pre-college programs that target students during the transitional stage between high school and college. These programs, which I will primarily refer to as pre-college and/or pipeline programs, address the multi-faceted needs of students at this critical educational juncture by providing personal, social, as well as academic support. 16

17 Grumbach et al. (2003) identifies five categories of pipeline programs based on their sponsorship source: private and non-profit; higher education partnerships (between schools and colleges); government-sponsored; K-12 sponsorship by public school systems; and community based. Additionally, pipeline programs target a range of student populations and/or professions; programs exist for students at the K-12, post-graduate, graduate, and professional levels, in addition to programs that focuses on specific careers, such as science, engineering, dentistry, and nursing (Matsui, Lui, and Kane, 2003; McKendall, Simoyi, Chester, and Rye, 2000; Yates et al., 2003). These categories in turn influence the mission, goals, and design of each respective program. Because of this wide array of focus and sponsorship, pipeline programs for low-income and ethnic minority students differ tremendously in structure, content, and design. Thus, it remains a challenging task to compile an exhaustive list of all existing programs and their different programmatic components. Nonetheless, many authors have attempted to identify key program components consistent across most pipeline programs. Key components include academic enrichment and support, mentorship and career counseling, motivation, and social support, all of which are manifested in different forms for each program. Collectively these components attempt to address the multiple social, personal, environmental and academic needs of students, according to the learner-centered model (Grumbach et al., 2003; Hayward et al., 1997; McCombs & Miller, 2007). Much research has also assessed and confirmed the effectiveness of these forms of program interventions. A meta-analysis of 60 college programs for high-risk and disadvantaged students (Kulik, Kulik, & Shwalb, 1983) confirms the positive effect of such programs on students, particularly in increased grade-point average and persistence in college. 17

18 Among this body of program interventions are those that target students interested in science, medical, and health professions. Pre-college science education programs have been established to address the educational, social, and cultural gaps and needs of many low income and ethnic minority students who want to pursue a career in health, science, or medicine but who often lack the resources to do so. Successful programs serve as a valuable intervention to even the playing field of educational resources and opportunities for disadvantaged students. However, it is important to remember that such programs are secondary to necessary structural changes in education that address the root causes of inequality in access and opportunity (Tekian, 1998). Pipeline programs aim not substitute or replace, but to complement critical education reform measures. Research on Pipeline Programs Over the past few decades, research has been conducted on the nature and effectiveness of a number of pre-college and undergraduate programs that aim to promote diversity in the health and medical professions, all of which are uniquely structured and designed. Research has been able to confirm the effectiveness of specific programs through largely quantitative measures, such as college admissions rates and SAT scores, but there remains a lack of qualitative research to better explain these measures of effectiveness. Most research in this field has relied primarily on varying quantitative data and varying evaluation methods to confirm the effectiveness of such programs. One such program is the Minority Medical Education Program (MMEP), a six-week summer residential program for minority college students and graduates established in 1989 by the Robert Wood Johnson Foundation and now administered by the Association of American Medical Colleges (AAMC) 18

19 across the nation (Cantor, Bergeisen, and Baker, 1998). Using data from sources like medical school applications and Medical College Admission Test (MCAT) scores, Cantor et al. (1998) affirmed the program s effectiveness on increasing the probability of its participants being accepted into medical school, particularly among younger participants. This finding suggests that MMEP and similar programs may have this same positive effect in shap[ing] the way its participants prepare for medical school application[s] well after the summer experience and may remain an important strategy in diversifying the health workforce. Matsui et al. (2002) examined the Biology Scholars Program (BSP) at the University of California at Berkeley, a program that aims to promote the study of the biological sciences among students from historically underrepresented economic, gender, and cultural groups. Student participants were found to have higher grade-point averages than non-bsp-scholar counterparts, suggesting again the beneficial effects of such programs but also, raising important questions. In trying to answer the question, What possible role has BSP had in their success?, Matsui et al. (2002) identifies that the single greatest challenge is to go beyond simply describing what we have done to explaining why it has worked, in applicable ways/formats that we can share with our colleagues. The quantitative results of this study were able to affirm effectiveness of BSP, but were unable to explain the mechanisms that result in this form of impact, thus confirming again the need for assistance from qualitative [research] to help us understand (beyond the numbers) those factors that affect student success (p. 121). As of yet, there exist only a few studies in this field that utilize any or some form of qualitative data. A mixed-methods approach was utilized by McKendall et al. (2000) to examine the Health Sciences and Technology Academy (HSTA) program in West Virginia. Using quantitative data (GPA, major, etc) and qualitative data (telephone interviews consisting of a 19

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