WATCCH: a multiprofessional approach to widening participation in healthcare careers

ABSTRACT

Background

Students from lower socioeconomic backgrounds are underrepresented in higher education and healthcare careers. Whilst most healthcare-related widening participation schemes focus on one healthcare profession, the Widening Access to Careers in Community Healthcare (WATCCH) programme at Imperial College London supports participation in a range of community healthcare careers. We aim to evaluate the impact of WATCCH on students’ perceptions and aspirations towards community healthcare careers.

Method

WATCCH provides educational and application support to 16–18 year-old students interested in a variety of community healthcare careers via work experience, educational workshops and mentoring. The programme was evaluated by focus groups using semi-structured questions to explore the impact of WATCCH on students’ healthcare career perceptions and aspirations.

Results

Five themes were identified from the focus groups: increased awareness and understanding of a range of community healthcare careers; improved insight into the realities of healthcare careers enabling reflection on career aspirations; altered perceptions of healthcare professionals and acquisition of new role models; increased confidence in achieving a career in healthcare; and valued access to previously inaccessible work experience.

Discussion

WATCCH is a multi-professional widening participation programme that has supported students from lower socioeconomic backgrounds interested in entering healthcare careers by increasing insights into varied healthcare careers, provision of role models, and increasing students’ confidence of ability to enter healthcare careers. Similar programmes in other institutions could support large numbers of aspiring students to enter varied community healthcare careers in the future.

KEYWORDS:

• Widening participation
• widening access
• healthcare careers
• primary care careers

Introduction

Students from lower socioeconomic backgrounds are under-represented in UK higher education (HE) [1], and students from neighbourhoods with low participation in HE are less likely to apply for some healthcare careers including medicine, dentistry, audiology, speech sciences, physiotherapy, and nutrition and dietetics [2]. In medicine, students from lower socio-economic classes are both less likely to apply and less likely to obtain a place [3]. Barriers to HE participation, and subsequently healthcare careers, for students from lower socioeconomic backgrounds has significant impact on student social mobility, and results in a workforce unrepresentative of the society it serves [2]. Diversity of healthcare staff contributes to improved quality of care for patients and staff wellbeing [4,5].

The reasons behind the under-representation of students from lower socioeconomic backgrounds in HE and healthcare courses are complex and often related to wider societal inequalities [5,6]. Contributing factors include parental education levels [5], social networks [7], limited access to work experience [2,8], differences in academic and pastoral support from peers, family, and schools [6] and reduced access to role models [1]. Students may not identify with existing HE cultures [6] or aspire to HE [5], underestimate their academic ability [7], experience differential attainment at school, and face financial barriers [7]. The Widening Participation (WP) agenda aims to enable those from disadvantaged groups to be proportionately represented in HE [5].

WP is a global issue and different countries' historical, political, and social issues determine the focus of WP activities [9]. This article discusses a UK WP programme. Disadvantaged access to the UK professions for those from less privileged backgrounds was highlighted in a 2009 report [10]. The WP agenda in the UK aims to reduce disparities amongst different demographic groups, particularly minoritized ethnic and lower socioeconomic groups, entering HE through WP programmes led by HE institutions [9]. In healthcare, WP is a government mandate [11] and the state-funded National Health Service (NHS) and HE institutions aim to increase entry to healthcare careers for students from under-represented groups [12]. Many groups, however, remain underrepresented [1].

Most WP programmes support access to one healthcare course in isolation [12]. Many students, however, may be undecided about their choice of healthcare career, have limited awareness of the range of patient-facing career options, and limited chances of successful application to more competitive courses. We describe WATCCH (Widening Access to Careers in Community Healthcare), a programme, which supports students to access a range of community healthcare careers through its multi-professional approach. We evaluate the impact of WATCCH on participants’ perceptions and aspirations towards community healthcare careers.

Method

WATCCH is a year-long Imperial College London WP programme supporting 16–18-year-old students from lower socioeconomic backgrounds interested in community healthcare careers. The aim of the programme is to empower students to make informed career choices, raise aspirations and expectations, and support students in healthcare career applications. WATCCH provides education on a range of healthcare careers including medicine, nursing, physiotherapy, pharmacy, and physician associates, particularly focusing on careers in community services. Although there are many WP programmes in the fields of medicine and dentistry, there are fewer supporting a variety of healthcare careers with a strong community career focus. This is important as many students might possess the relevant attributes and skills to work in healthcare but have uncertainty about career suitability and choices, lack awareness of the variety of health professional careers, and do not meet the entry requirements for some courses. Moreover, there is a need to promote community healthcare careers. Within the NHS, patient care is increasingly being delivered within community settings with expanded community healthcare teams and a greater emphasis on community preventive medicine [13]. The WATCCH programme provides a series of educational workshops (Figure 1) including opportunities to meet multi-professional healthcare professionals, primary care work experience with opportunities to shadow multiple multi-disciplinary healthcare professionals, and mentoring from undergraduate medical students. An overview of the programme is in Box 1.

Figure 1. WATCCH students participating in a workshop with mentors.

WATCCH students are from WP backgrounds as defined by criteria in Box 2. Places are randomly allocated if the programme is over-subscribed. A total of 158 students have completed the programme in four cohorts between 2017 and 2021.

Box 1. WATCCH Programme Overview

Educational Workshops	Primary Care Work Experience	Mentoring
Monthly structured workshops co-delivered by faculty and medical students.	3 day primary care work experience in North-West London.	Provision of monthly group mentoring from Imperial College London medical students guided by workshop topics.
Opportunity to meet and participate in a Question and Answer session with a multi-professional healthcare panel. Sessions supporting reflective skills and coaching.	Opportunity to shadow multiple healthcare professionals from diverse backgrounds. Supervision from a named General Practitioner.	Group and 1:1 mentoring via an online platform across the duration of the programme. Mentors trained in safeguarding, mentoring skills and coaching.
Sessions supporting entry to higher education including personal statement workshops, interview skills and multidisciplinary mock-interviews.	Practices quality assured as Imperial College London undergraduate teaching practices.	Some mentors themselves participated in widening participation programmes prior to entering higher education.
Provision of career summary guides and university application guides for multiple healthcare professions.

Box 2. WATCCH student participation criteria

Attend a non-selective state school and one of the following: Receive free school meals or a means-tested bursary or have in the past Neither parent has a university degree Currently, or have previously been, in care Carer with significant and sustained caring responsibilities Student or one of the parents is an asylum seeker or refugee

The application process is competitive and the programme is oversubscribed each year.

The WATCCH programme was evaluated using focus groups with students on the final day of two programme iterations in 2017 and 2018. Ethical approval was granted by the Imperial College London Education Ethics Review Process (EERP1617-018) and students provided a written consent to participate.

33 students participated in six focus groups lasting between 40 and 60 minutes. Semi-structured questions focused on motivations for joining WATCCH, learning from the programme including awareness of community healthcare careers, access to role-models, and impact on career aspirations. Focus groups were audio-recorded and electronically transcribed verbatim with anonymisation. Transcripts were analysed independently by two researchers (ND, KS) using inductive thematic analysis as described by Braun and Clarke [14]. ND and KS firstly familiarised themselves with the data, with repeated readings to gain an overall sense of the data. Codes were openly generated in alignment with evaluation aims and important features described by participants and recorded by hand. The code was sorted, and ND and KS searched for potential themes pragmatically, focusing on those that occurred frequently or were deemed important. The themes and sub-themes were then reviewed, and finally themes were named reflecting the crux of the data. ND and KS shared their themes with the other authors and discussed interpretations to reach consensus on the final themes.

Results

Five themes were identified from the analysed data. The themes, sub-themes, and example quotations are in Table 1.

Table 1. Focus Group themes, sub-themes and example quotations

Theme	Sub-theme	Example Quotations
1. Increased awareness and understanding of a range of community healthcare careers	Increased awareness of new healthcare careers Increased awareness of roles and responsibilities of healthcare professionals	“I learnt you don’t need to be a specific healthcare professional to be with patients… for example, doctors and nurses. You could be various other things such as physiotherapists and still get the patient contact that you might want.“ “before, I had this… perception that it’s just doctors. Then I find about so many other things, like (physician) assistants, nurses, training nurses and other areas… like social services.” “I think the role of the nurse was really surprising because…there is a big stereotype going on that nurses are just following behind the doctor, but this wasn’t the case at all. At a baby clinic session, the nurse was looking at the babies and actually doing the vaccination and seeing what’s wrong.” “to be honest, I don’t really know what the role of the pharmacist was before I went there. And then I saw what they were actually doing every day.”
2. Improved insight into the realities of healthcare careers enabling self-reflection on career aspirations		“I learnt that I have no patience because I was…in some consultations, and people would just get so rude…So I know that I definitely do not want to be a doctor because I’m not willing for people to be rude to me when I’m helping them.” “(the doctors) would just stay late into the hours, because they love their job and love their patients so much. And I want … that kind of… involvement and dedication.” “through this programme it kind of like taught me what type of…doctor I want to be. And if I was a patient, what type of doctor would I want.”
3. Altered perceptions of healthcare professionals and acquisition of new role models		“I didn’t expect…a variety of characters. I… expected it to be more serious people.” “I was expecting most Doctors to be…from (an)… advantaged background…They didn’t necessarily have to come from…(a) private school and like all this money put into them to like get into med school. It was really helpful… because, I (was thinking I’m) not going to get in because I don’t go to the best school.” “The nurse that I was shadowing…she came from a very underprivileged background and she’s been through a lot of…hard times. And she overcame them… and it was… really encouraging…she never let like all these bad things get to her.“
4. Increased confidence in achieving a career in healthcare	Confidence from meeting successful healthcare professionals Confidence in ability to overcome barriers Preparation for career goals	“It gave me confidence that if they can do it, my abilities are just as strong… I can do it too.” “I feel like it gives you a sense that its achievable because someone else has done it.” “It was quite reassuring as I think two or three (healthcare professionals) actually switched career paths. And so it…reminded me maybe that it’s not set in stone. And whatever happens you can in the end do something you love but it may take some time, but in the end you will get there.” “I feel like for me so many opportunities have been offered to me, so many… workshops… work experiences, lectures, and it’s really made me feel prepared for what’s coming. So I think in that sense, yes, it’s achievable, hopefully.”
5. Valued access to previously inaccessible work experience	Difficulties due to a lack of access to a contact working in healthcare Perceived benefits of work experience for applications to healthcare courses	“Most of them (friends) found it (work experience) through family friends and… neighbours… Because I’m from a less privileged background with… less people around me that are in this healthcare profession… most of the times they don’t come back to you, they don’t reply.” “Having done this work experience I feel like it’s even more achievable now because before I didn’t have any work experience related to healthcare. So this work experience was very valuable for my personal statements.”

Theme 1: increased awareness and understanding of a range of community healthcare careers

Students described a new awareness of different community healthcare careers, many of which they had not previously known about. Some considered these as possible future careers. Students also described a better understanding of the roles and responsibilities of a range of community healthcare professions, some of which they had preconceived incorrectly, or had limited understanding of.

Theme 2: improved insight into the realities of healthcare careers enabling self-reflection on career aspirations

Students described better insight into the realities of community healthcare careers, including both positive and negative aspects, and the skills required of a community healthcare professional. This included understanding the realities of workload and time pressures and managing difficult patient interactions, alongside the rewards of working with patients and communities. This enabled self-reflection of personal strengths, capabilities, and qualities, and how this aligned with career aspirations. For some students, career aspirations were strengthened, whilst for others new careers were considered, including considering their suitability for alternative healthcare professional careers, but also careers out with healthcare.

Theme 3: altered perceptions of healthcare professionals and acquisition of new role models

WATCCH challenged some students' preconceived notions of the ‘types’ of people that enter healthcare professions. This included perceptions on cultural background including socio-economic status, ethnicity, and personality traits. Some students, for example, expected that healthcare professionals would be privately educated or from financially privileged backgrounds, while others were encouraged to meet healthcare professionals who had overcome personal adversity. For some students, meeting community healthcare professionals with similar traits and backgrounds to themselves led to the acquisition of new relatable healthcare role models that were previously difficult to access.

Theme 4: increased confidence in achieving a career in healthcare

Students described improved confidence in their ability to apply for and enter desired healthcare careers and overcome perceived barriers. This resulted from meeting peers and successful professionals from similar backgrounds, improved understanding, and preparation for admission processes, and increased ability to make informed career decisions.

Theme 5: valued access to previously inaccessible work experience

Students valued access to primary healthcare work experience that had previously been inaccessible, sometimes due to limited social networks. This is valuable for gaining insights into careers and necessary for some HE admission processes.

The data also highlighted how the WATCCH project could be improved. Some students suggested they would have preferred work experience more relevant to their chosen career for example, in a hospital setting for students interested in surgery or time spent shadowing a healthcare professional that is not present in General Practice. In addition, some students felt that the travel times to work experience placements were too long.

Discussion

This evaluation of multi-professional WP programme suggests WATCCH has supported students interested in healthcare careers via increasing students’ awareness of different community healthcare careers, providing access to work experience and relatable role models, increasing students’ confidence, and providing students with knowledge to make more informed choices about future HE applications and careers.

A key valued component of WATCCH is the provision of work experience, which students reported was highly valuable for university applications. Research [8] suggests a lack of access to work experience is a significant barrier to entering healthcare courses, and students from higher socioeconomic groups, private and grammar schools are more likely to have been able to undertake primary care work experience [15]. Our evaluation confirmed accessing work experience, particularly in general practice, was difficult, often due to reduced relevant social networks. In view of the need to increase capacity in primary care, the provision of such work experience may increase student interest in primary care careers, which is reported in the literature [15] and serve to improve primary care workforce diversity [16]. Moreover, medical students who attended state schools are more likely to enter careers in General Practice and work in deprived communities, which often face the biggest recruitment challenges [17].

Research suggests that some students from lower socioeconomic backgrounds have stereotypical perceptions of doctors, which can act as a barrier to entering medicine [18]. WATCCH challenged some students’ stereotyped perceptions of healthcare professionals by providing access to role models from multiple professions and backgrounds, allowing students to perceive their career aspirations as achievable. This is consistent with research suggesting that role models contribute to raising career aspirations and are beneficial for WP students in forming more accurate perceptions and challenging stereotypes of HE students [1].

Our evaluation indicated WATCCH supported students’ confidence to apply for HE consistent with findings from other WP programmes [1]. This is important, as some students underestimate their ability to enter HE [18] which acts as a significant barrier to applications.

There are challenges to providing a multi-professional community healthcare widening participation programme. It is difficult to ensure the programme is relevant to students’ varying career aspirations, particularly given the organisers of the programme are doctors, mentors are medical students, and students may not be able to meet a professional from their chosen career. Multi-professional mentors from different institutions will be introduced in future iterations to better support a variety of career choices. A co-ordinated effort between community healthcare service providers and local HE institutions may further support this. Finally, the programme supports students for one academic year, however students who are not successful in initial HE applications may require longer-term support, and it may be advantageous to encourage aspiration towards community healthcare careers from a younger age.

A limitation of this evaluation is that the destination of all the participating students in entry to HE healthcare careers was not recorded. For future iterations, this will be measured using national datasets for HE entry, however it is difficult to ascertain the specific impact of WATCCH alongside other variables. Another limitation is that, participants may have felt obliged to be positive about the programme. We minimised this by having focus group facilitators that were not involved in programme delivery. Finally, the provision of medical student mentoring was not explicitly evaluated. It would be interesting to understand the role of mentoring on confidence, aspirations, and role-modelling. It would also be beneficial to understand the individual impacts of educational sessions and work experience placements. This would be particularly relevant to institutions considering commencing a similar programme.

Conclusion

The multi-professional nature of WATCCH is key in broadening students’ understanding of the wide range of careers within community healthcare and prompting participants to consider new careers in relation to their interests, aspirations, and capabilities. WATCCH addresses some of the underlying factors that impede students from under-represented and diverse backgrounds entering healthcare careers, such as exposing students to role models, access to work experience, and developing confidence and self-belief, all of which serve to empower students to enter healthcare courses.

Despite increased WP efforts, a worrying trend of underrepresentation in healthcare careers remains. To make meaningful progress in tackling some underlying factors in underrepresentation in healthcare, whilst also making progress with the primary care recruitment crisis, we suggest that WP programmes acknowledge the following when designing and delivering programmes: the impact of support and role modelling in improving student self-efficacy and increasing HE applications; the role of multi-professional WP programmes in offering wide-ranging healthcare career options; programmes with a community focus may increase uptake of community-based healthcare careers in the future; benefits of contextual-grade offer; and the need for transparency of WP programme evaluation with published data on destinations to understand if programmes are successful in improving HE entry.

Programmes such as WATCCH can make an important and positive contribution to current WP strategies, supporting entry to healthcare careers, social mobility, and a diverse healthcare workforce. This is vital at a time where healthcare systems, including primary care, face a recruitment and retention crisis, with under-representation of individuals from diverse socioeconomic backgrounds.

Author Contributions

Nina Dutta - conceptualisation, methodology, investigation, writing - original draft preparation

Katie Scott - investigation, writing - original draft preparation

Jo Horsburgh - conceptualisation, methodology, writing- reviewing and editing

Farahnaz Jamil - conceptualisation, methodology, writing - reviewing and editing

Rumbidzai Chandauka - investigation, writing- reviewing and editing

Samantha J Meiring - investigation, writing - reviewing and editing

Sonia Kumar - conceptualisation, methodology, writing - reviewing and editing

Disclosure statement

This article presents independent research commissioned by the National Institute for Health Research (NIHR) under the Applied Health Research (ARC) programme for North-West London. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health.

Additional information

Funding

The WATCCH programme was supported by the Health Education England North-West London.