Dental schools continue to face major challenges

Parental Involvement in Recruitment of Underrepresented Minority Students Rose O. Wadenya, B.D.S., M.S., D.M.D.; Naty Lopez, Ph.D. Abstract: Recruitment of underrepresented minority (URM) students to dental schools has had limited success, so dental schools need to reach out to high school students with programs to extend the pipeline. The Short Term Enrichment Program (STEP) of the University of Pennsylvania School of Dental Medicine adds a new dimension to these efforts by involving parents, who directly or indirectly impact their children s career decisions. The program consists of an introductory two-day course that includes presentations of the dental profession, laboratory, and virtual classrooms. Biannual follow-up workshops are conducted for both children and parents. Outcomes are measured through pre- and post-program surveys, focus groups, and interviews. STEP attendance has increased over five years, with a total of 163 students participating and 56 percent of their parents attending the program. Eighty participants have graduated from high school, twenty-three of whom are enrolled in a predental program or dental school; twelve are in other prehealth programs. Students in predental programs or dental school have the highest percentage of parents who participated in STEP (96 percent) and engaged them in discussions over career goals (100 percent). Dr. Wadenya is Director of Minority Affairs and Assistant Professor of Pediatric Dentistry, Department of Preventive and Restorative Sciences, University of Pennsylvania School of Dental Medicine; Dr. Lopez is Assistant Dean for Admissions and Diversity, University of Minnesota School of Dentistry and was Assistant Dean of International Relations/WHO Collaborating Center, University of Pennsylvania School of Dental Medicine during the first three years of implementation of the program. Direct correspondence and requests for reprints to Dr. Rose O. Wadenya, University of Pennsylvania School of Dental Medicine, 240 S. 40 th Street, Philadelphia, PA 19104; 215-573-2650 phone; 215-573-4497 fax; wadenya@dental.upenn.edu. This program was funded by the Provost s Diversity Fund, University of Pennsylvania. Key words: underrepresented minority students, recruitment, dentistry, parental involvement, high school students Submitted for publication 12/13/07; accepted 4/4/08 Dental schools continue to face major challenges in enrolling underrepresented minority (URM) students at rates commensurate with their proportion in the general population. 1 The Sullivan Commission reports that African American, Hispanic, and American Indian individuals make up more than 25 percent of the general U.S. population but only 5 percent of its dentists. 2 In an effort to increase matriculation of URMs in dentistry, dental schools have conducted various activities, including enrichment and recruitment programs that focus on college students to strengthen their academic skills in the sciences and other subjects. 3,4 These programs have resulted in slight increases from 10.5 percent URM dental applicants and first-time enrollees in 2000 to 12.4 percent applicants and 11.6 percent firstyear enrollees in 2004. 5 However, these modest gains are not enough to provide adequate representation of URMs to mirror their number in the population. An additional challenge is that dental schools have been competing with each other and, with minimal success, with other health professions education programs to recruit from the same pool of qualified URM college students. 6 One fundamental reason that the percentage of URMs remains low in health professions education, including dental school, is that the overall applicant pool of African American, Hispanic, and American Indian students who seek a career in one of the health professions is small. Therefore, one strategy to enhance the participation of URMs in health professions education is to expand the applicant pool that is available by targeting young URMs as early as high school. Early exposure to dentistry and to dentists has been identified as an important pathway to recruit students. 7 Although URM dental students report that their decision to enroll in dentistry was made in college and that dentistry was not considered as a career option in high school, 8 early recruitment in high school presents two advantages. First, it provides young students with early exposure to minority role models in the community. 9 This is especially critical for first-generation college-bound students who may not have family members or friends as role models to emulate. Role-modeling and mentoring by minority dentists and dental students offer the type of encouragement and direction necessary for these students to make important choices about their careers. 10 Second, high school students are able to participate in mentoring and referral to college preparatory programs to augment their study and test-taking skills, enabling them to be more competitive college applicants. En- 680 Journal of Dental Education Volume 72, Number 6

richment programs implemented for college-bound students have been proven to improve the chances of URMs to get into dental schools, as experienced by one dental school s increased enrollment of 325 percent over three years. 11 A strategy that is often underutilized in early recruitment programs is the involvement of parents who, particularly in family-oriented African American and Latino cultures, directly or indirectly influence their children s behaviors and career decisions. A study conducted by Crawford et al. found that parental support and participation in health careers orientation programs are the two most influential factors in a student s decision to pursue a career in the health professions. 12 URM dental students have reported that they have used family members as sounding boards when they made career decisions. 13 Other studies show that parental support is a major factor in sustaining career interest and aspiration of students from low-income and minority groups. 14,15 Providing parents with the knowledge and skills needed to interact with their children on future career decisions may strengthen and reinforce students interest in dentistry. The purposes of this article are 1) to describe the components of one private dental school s early recruitment program that emphasizes parental involvement and 2) to report preliminary outcomes obtained over a five-year period by pre- and postprogram surveys, focus groups, and interviews, as well as tracking data to determine the educational pursuits of program participants. Program Description The Short Term Enrichment Program (STEP) of the University of Pennsylvania School of Dental Medicine is an outreach program to high school underrepresented minority students with the goal of increasing the pool of URM applicants to dental school. The program is conducted by the Office of Minority Affairs and is part of a schoolwide effort to increase enrollment of URM students. Through hands-on experiences, interactive seminars, and mentoring, both students and parents are introduced to the field of dentistry and helped to gain awareness and knowledge of responsible oral health behaviors. Three important features of the program are the strong emphasis on parental or family involvement; the leadership of minority faculty, alumni, and students in activities; and consistent follow-up with participants. STEP starts with a two-day program in June of each year, followed by another two-day program in January. Students are asked to return for second- and third-year follow-up sessions. High school students are recruited into STEP from local high schools in underserved areas. High school principals and guidance counselors are contacted via mail, followed by telephone calls to identify and recommend students with general interests in the sciences and careers in the health professions. Students and their parents are then invited to the initial two-day program at the School of Dental Medicine. During this time, students take part in the following activities: a presentation of the different disciplines of dentistry and discussion of stereotypes of dentists and the profession; discussions on admission requirements and financial aid; a laboratory session in which students take alginate impressions of their teeth and pour models; a visit to a virtual realitybased classroom where students practice drilling a tooth on a virtual patient; and discussions with URM dental students and faculty. Parents participate in the discussions and presentations and spend time with the directors of admissions and student affairs to learn about the application process and financial aid. Students receive a certificate of completion and are encouraged to attend subsequent six-month follow-up sessions. During the follow-up STEP session in January, high school students spend structured mentoring time with URM dental students while their parents discuss with faculty and school administrators perceived barriers to their children attending college. Knowledge of the dental profession and responsible oral health behavior are reinforced through a game in which both parents and students participate. A highlight of STEP phase 2 occurs when students perform an oral screening on their parents under supervision of a faculty member. Activities during the second- and third-year follow-up sessions include presentations of specific fields of dentistry, shadowing of minority faculty or providers in the community, and mentoring by URM dental students. These sessions are intended to keep participants connected with their mentors and role models in the dental school and the community while the program administrator keeps track of participants. Measures Students complete a pre- and post-program survey (Figure 1) to evaluate the impact of STEP on their June 2008 Journal of Dental Education 681

1. Grade in high school 2. Age 3. Gender: 1.. Male 2. Female 4. Race/ethnicity (check one that applies to you) 1. African American 3. Black, non-hispanic 2. Hispanic 4. Native American 5. Other 5. Do you visit a dentist for regular checkups? 6. How often do you see a dentist? 1. Every year 2. Every 6 months 3. Every 2 years 4. Whenever I have a problem 7. Does your family have dental insurance? 8. How often do you brush your teeth? 1. once a day 3. once every other day 2. 2-3 times a day 4. other 9. Do you floss your teeth? 10. If yes, how often? 1. once a day 2. 2-3 times a day 3. once every other day 4. other 11. I plan on going to college after high school. 12. I have thought about going to college to study a health profession. 13. I have thought of becoming a dentist. 14. My parents and I have ongoing discussions about college. Figure 1. STEP survey for high school students interest in health professions and dentistry, as well as changes in oral health awareness. Focus groups are conducted and taped with permission from participants. Two minority faculty facilitate discussions to gain students perspectives on college preparation and matriculation and their continuing interest in dentistry. One-year follow-up telephone interviews with parents are conducted by a minority faculty member to gain parents perspectives on the challenges their children face with regard to staying competitive for college and their fears and concerns about college. In addition, the program administrator tracks former participants to determine subsequent graduation from high school, application to and matriculation in college, majors selected, and participation in the ongoing shadowing and mentoring activities. 682 Journal of Dental Education Volume 72, Number 6

Participants Since its inception in 2002, STEP has enrolled a total of 163 students. Of these, African Americans predominated (78 percent), with sixteen Hispanics and eight American Indians (Table 1). Since recruitment of high school students into STEP was low (seventeen participants) in the first year, guidance counselors from twelve local high schools were contacted by telephone and invited to a one-day workshop to introduce STEP and the role they could play in recruiting students. In the second year, guidance counselors recruited students from their schools, resulting in a 100 percent increase (thirty-four participants). The low numbers of Hispanics and American Indians are due to the racial makeup of the local schools, which are predominantly African American. Participant ages range from thirteen to eighteen years, with 64 percent in the fifteen to sixteen-year age group and 76 percent female. Various grades are represented, with 71 percent in grades 10 and 11 (Table 2). Fifty-six percent of the parents participated in the program; the majority were mothers of the participating students. The age of parents ranged from thirty-six to fifty-four years. Approximately 35 percent of the parents had the equivalent of a high school education, and 65 percent had graduated from college or had completed a portion of college education. Forty-two percent of the parents reported an income of less than $30,000, while 58 percent reported an income of more than $30,000. Results The data were analyzed by the Stata statistical program. The pre-test survey showed that 50 percent of the students planned to pursue a career in health care but only 6 percent considered dentistry. Postprogram surveys showed an increase in participants interest in health careers with 74 percent interested in the health professions and 64 percent of these interested in a dental career (Figure 2). There was an increase in parent-child discussions about college from 39 percent before STEP to 68 percent Table 1. STEP participants 2002 06 (N=163) Participants 2002 2003 2004 2005 2006 Total African American 15 27 35 26 25 128 (78%) Hispanic 2 3 1 4 6 16 (10%) American Indian 0 1 2 3 2 8 (5%) Other 0 3 5 2 1 11 (7%) Total 17 34 43 35 34 163 (100%) Table 2. Grade level of STEP participants (N=163) Grade Level 2002 2003 2004 2005 2006 Total Grade 9 7 1 9 7 6 30 (18%) Grade 10 5 12 16 17 18 68 (42%) Grade 11 2 13 15 9 8 47 (29%) Grade 12 3 8 3 2 2 18 (11%) Total 17 34 43 35 34 163 (100%) after the program. Post-program surveys showed major improvement in oral health practices, with 85 percent brushing twice daily and 57 percent flossing daily compared to 40 percent brushing twice daily and 10 percent flossing two to three times a week pre-step. The program is now into its fifth year with support from the Provost s Diversity Fund. Fortynine percent of the 163 participants who were due to graduate have graduated from high school (N=80). Of these eighty students, 76 percent are currently enrolled in four-year colleges, and 24 percent are in vocational training. Thirty-eight percent of those in college (n=61) are in predental/dental programs, while 20 percent are enrolled in other prehealth programs (Table 3). Students in predental programs or dental school have a higher percentage of parents who participated in STEP (96 percent) compared to students enrolled in other programs (44 percent). Fifty-two students have discussions with their parents regarding their college careers. All of the students enrolled in predental/dental programs had parents discuss their college careers with them. Correlation analysis shows that parents who participated in the STEP program tend to discuss college careers with their children (r=.5) and there is a strong correlation between such discussions between parents and children and decisions on college careers (r=.61). A total of 150 students (thirteen students were lost to follow-up) participated in sixteen focus groups with an average of eight to ten participants per group. The focus groups aimed to identify perceptions of June 2008 Journal of Dental Education 683

# S t u d e n t s 140 120 121 100 80 82 78 Pre-test 60 Post-test 40 20 9 0 Health Professions Dentistry Figure 2. Pre- and one-year post-tests: number of students expressing an interest in the health professions and dentistry students regarding college and dentistry. Discussions lasted sixty to ninety minutes and explored the following questions: What fears and concerns do minority students have about college? How do minority students schools prepare them for college? How do minority students describe the current environment in schools they attend? What role do parents play in minority students interest in college or dentistry? What role do minority dentists play in students interest in college or dentistry? How does a program such as STEP affect minority students thoughts about college? A primary concern of all the students was going into debt in order to finance their college education. Eighty-seven percent of the students expressed concern that their schools did not prepare them well and, therefore, they may not be adequately primed for college, while 83 percent expressed concerns that they may not be able to keep up with college work. A majority of the students were concerned about being away from their parents and not being socially accepted by classmates and teachers due to their race. Despite such fears, 87 percent of the students reported that they maintained ongoing discussions with their parents regarding college and dental school. Surprisingly, a very low number of students reported that they had discussed college and dentistry as a career with their dentists. Focus group responses are summarized in Table 4. Forty-nine parents (53 percent of those who initially attended STEP) participated in a one-year follow-up telephone interview. Forty-seven percent of parents could not be reached during the follow-up telephone interview. Parents reported similar concerns as their children about financing college and dental education. A majority of parents also reported fear of racism in college and not being able to protect their children against discrimination especially if the children went to college in a different state. Other concerns expressed by parents included the level of their children s preparedness for college, their chil- Table 3. Current status of 2002 06 STEP participants who have graduated from high school (N=80) 2002 2003 2004 2005 2006 Total Currently enrolled in predental programs or attending dental school. 4 6 5 4 4 23 Currently enrolled in other prehealth (medicine, nursing, pharmacy) programs 4 3 4 1 0 12 in college. Currently enrolled in general studies or undecided on major. 4 7 6 7 2 26 Currently enrolled in two-year vocational training. 5 6 6 2 0 19 684 Journal of Dental Education Volume 72, Number 6

dren s level of confidence, negative peer pressure, and lack of role models and mentors (Table 5). Parents commented that URM students are not usually encouraged by science teachers and/or guidance counselors to pursue health professions. To strengthen recruitment programs, parents recommended that there should be systematic dissemination of information on career options in the health professions to increase students awareness, along with provision of enrichment programs in conjunction with local schools, inclusion of parents in programs and activities that expose students to different careers, and ongoing mentoring of high school students by minority dental students, faculty, and alumni. At the start of STEP, a majority of the students had minimal knowledge and numerous misconceptions about dentistry and optimal oral health. This was determined through an oral health basketball game in which participants were divided into two teams and each team scored points for right answers to questions on oral health knowledge and practices. Through hands-on experiences, interactive seminars, and mentoring, STEP students gained knowledge, awareness, and a new appreciation for the dental profession. This is evident in the shift of interest in dentistry from 6 percent at pre-program to 64 percent post-program and over 100 percent improvement in oral health practices. Discussion This study examined the effects of parental involvement in a program designed to enhance URM high school students interest in enrolling in dental school. Although only 59 percent of parents of the post-high school students participated in STEP, results of this study (as in other studies) show students whose parents are involved in decisions on college or Table 4. Responses expressed in focus group discussions with STEP participants (N=150) Fears and concerns about college Number Percent Going into debt to pay for college and later on dental school. 150 100% Worried that school did not prepare me for what lies ahead. 130 87% Discussions with parents help me stay focused. 130 87% Fear of not being able to keep up with the work. 124 83% Functioning without parents, doing things on your own. 117 78% Worried about not being accepted due to my race. 103 69% Worried about not being accepted due to poor grades. 81 54% My dentist has talked to me about college. 22 15% My dentist has suggested/encouraged me to consider dentistry. 9 6% Table 5. Responses expressed in one-year follow-up telephone survey of parents (N=49) Fears and concerns about college Number Percent Financial concerns; cannot afford college. 49 100.0% Fear of being away from my child if my child is in another state. 42 85.7% Not having mentors or role models for my child. 40 81.6% Fear of not being able to protect my child from discrimination. 39 79.6% Racism in colleges and universities. 32 65.3% Children falling into peer pressure, hence low grades. 30 61.2% Don t know how to make my child feel confident that he or she 28 57.1% can make it through college. career and who receive family support are better able to overcome perceived barriers to their school and career aspirations. 16 The parents role is important in sustaining career interest and aspiration of students, as reflected in the responses of both parents and students at the one-year post-program evaluation. STEP provided a forum for parents to gain knowledge and skills needed to interact with their children on future career decisions; this improved communication may strengthen and reinforce students interest in dentistry. Encouragement from parents has been demonstrated to be a stronger predictor of aspiration compared to encouragement from teachers and friends and social status. 17 The increase in parent-child discussions and qualitative evidence obtained from discussions with the parents demonstrate that parents who participated in the program have high aspirations for their children and actively seek enrichment programs to introduce their children to the college environment. The parents background (65 percent reported some form of college education) suggests that STEP attracts a unique group of parents and students who are already college-oriented or that parents educational background may have contributed to their involve- June 2008 Journal of Dental Education 685

ment in STEP. However, parents education does not seem to be predictive of their children s college career decisions (r=.28). Parental support is also important during times when a student may feel ostracized by peers due to race or socioeconomic status. Students and their parents expressed similar concerns about college such as financial debt, inadequate preparation of students to handle college-level courses, lack of role models and mentors, and race/discrimination issues. Many of the students come from families with significantly lower incomes and economic resources than non- URM students. Although a majority of the parents report an income above $30,000, students and parents alike express concern about financial debt associated with college. They tend to view costs associated with college and professional education as insurmountable and may be unaware that they could apply for grants or qualify for financial assistance. Students and parents are greatly concerned about taking out loans for both college and graduate school, which they would have to pay back with interest. Recruitment programs need to provide detailed discussions about grants, loans, and scholarships or some assistance that could eliminate the financial barriers that discourage so many minority students and their parents. Many of the students participating in STEP report that they have a family dentist and regularly received dental care from these individuals; however, only 6 percent reported having received encouragement from their dentist to consider dentistry as a career. The findings from the program evaluation indicate that the majority of students learned about dentistry from STEP. According to parents and students, there seems to be minimal outreach from dental alumni and other practitioners in the community and, as such, most URM students and their parents do not perceive them as role models or mentors. Nonetheless, dentists in the community are in key positions to mentor and influence students by actively engaging them in discussions about college and dentistry. In addition, their presence in the communities provides them with visibility as role models anchored in the neighborhoods in which students reside and go to school. Conclusion Parental support and participation in recruitment programs are important in sustaining the career interests and aspirations of students. Students who have proceeded to college and enrolled in predental programs or dental schools have their parents involved in their career plans. On the other hand, while parents play a central role in the support and encouragement of high schoolers, minority faculty, alumni, and dental students can provide the rolemodeling, skills, knowledge, and resources that are needed for students to stay focused on dentistry, especially because very few URM students may have family members who can provide this support for them. The special role that minority alumni/dental practitioners can play in motivating high school students to be interested in dental education needs to be explored further. Despite the consistent follow-up with participants, this program is not without its challenges, including losing participants to follow-up and sustaining students interest throughout high school and college. Financial realities associated with the cost of a college and health professions education pose an overwhelming and insurmountable barrier to many low-income students. In order to continue to create awareness and motivate students about careers in dentistry, the program plans to increase parental participation in STEP to exceed the 56 percent involvement reported here; recruit minority dentists and alumni to provide mentorship to participants; provide students and parents with information about financial loans, grants, and scholarships; and assist students and their parents, through training workshops, with ways to apply for and receive these sources of economic support. The School of Dental Medicine, with support from the Provost s Diversity Fund, is also involved in efforts to increase the number of underrepresented high school students in a more intensive four-week recruitment program that will be run in collaboration with other pre-health programs of the University of Pennsylvania. REFERENCES 1. Weaver RG, Haden NK, Valachovic RW. U.S. dental school applicants and enrollees: a ten-year perspective. J Dent Educ 2000;64(12):867 74. 2. 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