What are the features of targeted or system-wide initiatives that affect diversity in health professions trainees? A BEME systematic review: BEME Guide No. 50

Abstract

Background/purpose: There is interest to increase diversity among health professions trainees. This study aims to determine the features/effects of interventions to promote recruitment/admission of under-represented minority (URM) students to health professions programs.

Methodology: This registered BEME review applied systematic methods to: title/full-text inclusion review, data extraction, and quality assessment (QA). Included studies reported outcomes for interventions designed to increase diversity of health professions education (HPE) programs’ recruitment and admissions.

Results: Of 7225 studies identified 86 met inclusion criteria. Interventions addressed: admissions (34%), enrichment (19%), outreach (15%), curriculum (3%), and mixed (29%). They were mostly single center (76%), from the United States (81%), in medicine (45%) or dentistry (22%). URM definition was stated in only 24%. The dimension most commonly considered was ethnicity/race (88%). The majority of studies (81%) found positive effects. Heterogeneity precluded meta-analysis. Qualitative analysis identified key features: admissions studies points systems and altered weightings; enrichment studies highlighted academic, application and exam preparation, and workplace exposure.

Discussion/conclusions: Several intervention types may increase diversity. Limited applicant pools were a rate-limiting feature, suggesting efforts earlier in the continuum are needed to broaden applicant pools. There is a need to examine underlying cultural and external pressures that limit programs’ acceptance of initiatives to increase diversity.

Acknowledgments

The study team would like to sincerely thank and acknowledge the following individuals for their contributions to this review as follows: librarian research assistant Lana Atkinson (20% data extraction review, gray literature searches and retrieval of literature published since initial search), Alberta Research Centre for Health Evidence research assistants Sanjaya Dhakal and Annabritt Chisholm (second reviewers for quality analysis), and research assistants Joanna Czupryn (author contacts, second reviewer quantitative descriptive analysis, assistance with preparation of Supplementary Table 3, and with development of glossary) and Maria Tan (data extraction, quality analysis, and assistance with preparation of Supplementary Table 3 following the update to the search). We would also like to acknowledge the University of Alberta, Faculty of Medicine, and Dentistry Office of Education who provided support for Kristen Simone’s Summer Studentship in Health Professions Grant.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Glossary

Acceptance: A formal offer of entry into a school or program.

Affirmative action: A policy or program that favors populations that have historically been discriminated against or disadvantaged, such as underrepresented minorities, in order to increase their representation in the workplace or student body. Affirmative action programs may provide benefits, such as guaranteeing entry into an academic program.

Application: A formal request to seek entry into a school or program.

Complimentary selection criteria: Outlined by O’Neill (2013), as using criteria, such as personal attributes, to widen medical school access to applicants from diverse backgrounds. Complimentary selection criteria can include attributes, such as verbal or written communication skills, interpersonal skills, and the ability to cope appropriately with stress.

Conditional acceptance: Defined by Stagar (1998), as reserving a seat in a medical school class for a specific person based on an assumption that they will meet pre-determined criteria by the start of the next academic calendar year.

Diversity: Diversity within health care systems and educational programs refers to ensuring greater inclusion of those populations that are under-represented in the health professions relative to their numbers in the general population. Diversity includes such dimensions as race/ethnicity, religion, gender, sexual orientation, geographic origin, and socioeconomic status (Bediako et al. 1996).

Educational Disadvantage: Discontinuity between the competencies a learner brings and the competencies valued by an educational institution (Kellaghan 2001).

Graduate entry program: A program that requires that applicants obtain an initial university degree prior to entry.

Matriculation: The process by which a student acts on an acceptance offer to formally enter a particular health professions training program.

Minority: A category of people that are considered different from the majority, based on one or more observable human characteristics.

Pipeline programs: Programs whereby high achieving students from disadvantaged or underrepresented backgrounds are identified at the secondary or postsecondary school level and receive focused educational support and mentorship as they pursue medical school (Reiter et al. 2012). These initiatives vary in the number of students recruited for each program and range from several months to several years in length.

Post-baccalaureate program: A short-term program of study that takes place after the initial Bachelor’s degree has been earned. Post-baccalaureate programs can target minority and disadvantaged students, who have previously applied unsuccessfully for admission to medical school, and provide enrichment experiences with the aim of making these students more competitive medical school applicants (Grumbach 2006).

Pre-admission program: A program designed to assist non-traditional applicants in strengthening their academic credentials in order to enter a health professions program. Pre-admission programs can also act as pipeline programs that target undergraduate students for mentorship and exposure to the healthcare professions (Vela 2010).

Representation: The difference in the proportional population of a certain racial/ethnic or otherwise underrepresented group from the proportion of health professionals of the same race/ethnicity or underrepresented group (Bailey 2013; Brown et al. 2009).

Special admissions: A school initiative whereby a student can be considered for academic admission if he/she meets a set of criteria. Criteria for special admission might include factors such as minimum GPA or entrance exam scores. Cornely (1999) describes examples where race or origin can also be included as a factor for admission.

Under-represented minority (URM): Any recognized minority group whose representation in healthcare is disproportionately lower when compared to the group’s proportion in the general population. Minorities are often defined using categories of ethnicity/race but can also include other categories such as gender, geographic location, and socio-economic status.

Widening access: A school or program initiative designed to change entrance criteria in order to increase access for specific applicants or groups. Watson (2005) describes examples of widened access that include criteria such as educational experience, ethnic background, age, marital status, disability, and socio-economic background.

Additional information

Notes on contributors

Kristen Simone

Kristen Simone, BSc (Hons), MD, is a first-year Obstetrics and Gynecology resident at the University of Alberta. As a medical student, she was a recipient of a Summer Studentship in Health Professions Education grant at the University of Alberta.

Rabia A. Ahmed

Rabia A. Ahmed, MD, FRCPC, is an Associate Professor and consultant in the Division of Infectious Diseases, Department of Medicine at the University of Alberta. She works with underserved communities and has completed a BEME on promoting research among clinical educators.

Jill Konkin

Jill Konkin, BA(Hons), MD, CCFP, FCFP, FRRMS, is a Professor in the Department of Family Medicine and the Associate Dean and Division Director, Community Engagement. Her portfolio includes Indigenous, inner city, global and rural and regional health as well as community-engaged research. Initiatives of the Division are oriented to social justice and health equity. She has developed, implemented and continues to support significant undergraduate medical education interventions, including a longitudinal integrated clerkship and the delivery of a second year undergraduate course in communities in Northern Alberta. Her research is focused on longitudinal integrated clerkships, professional identity formation, and social accountability. She is currently a co-PI for a systematic review of the literature on social accountability and another on Indigenous health curricula. Her clinical work is as a locum for comprehensive rural family physicians.

Sandra Campbell

Sandra Campbell, BA, MLS, AALIA (CP), is a Public Services Librarian at the University of Alberta John W. Scott Health Sciences Library and library liaison to the School of Public Health and the Faculty of Medicine and Dentistry. She is also an expert database searcher and information literacy instructor. She has recently coauthored and provided librarian support and consultation on recent BEMEs on musculoskeletal Clinical Skills, Audience Response Systems, and Team-Based Learning.

Lisa Hartling

Lisa Hartling, MSc, PhD, is an Associate Professor in the Department of Pediatrics and is the Director of the Alberta Research Centre for Health Evidence and Director of the University of Alberta Evidence-based Practice Center. In this role, she oversees approximately 20 staff in the production of systematic reviews, health technology assessments, and methodological research for evidence synthesis. She is a reviewer with The Cochrane Collaboration (Acute Respiratory Infections, Anesthesia, Injury, Wounds, Heart, and Infectious Diseases Groups). She has coauthored more than 30 systematic reviews. She has also coauthored a BEME on Musculoskeletal Clinical Skills, a BEME on Audience Response Systems, a BEME on Team-Based Learning, and a BEME on promoting research among clinical educators.

Anna E. Oswald

Anna E. Oswald, BMSc, MD, MMEd, FRCPC, is an Associate Professor in the Division of Rheumatology, Department of Medicine at the University of Alberta. She is a consultant rheumatologist, co-director of pre-clerkship education, and director of competency-based medical education at the University of Alberta. She has a Masters in Medical Education degree from the University of Dundee. She is a Clinician Educator for the Royal College of Physicians and Surgeons of Canada. She has coauthored a systematic review on problem-based learning and has been the team lead for a BEME on musculoskeletal Clinical Skills, a BEME on Audience Response Systems, a BEME on Team-Based Learning, and a BEME on promoting research among clinical educators. She is the team lead for this review.