Effective Recruitment and Retention Strategies for Underrepresented Minority Students: Perspectives from Dental Students

Critical Issues in Dental Education Effective Recruitment and Retention Strategies for Underrepresented Minority Students: Perspectives from Dental Students Naty Lopez, Ph.D.; Rose Wadenya, D.M.D., M.S.; Peter Berthold, D.M.D., Ph.D. Abstract: This study was designed to identify reasons underrepresented minority (URM) dental students select a dental school and to determine the factors that contribute to their resolve to complete their programs. A survey questionnaire developed from interviews with URM students was sent to Minority/Admissions Officers or deans of dental schools that enrolled URM students for distribution to their minority students. A total of 198 questionnaires were received from minority students in all levels of dental school. The results were that 74 percent said they selected a school for its reputation, and 49.5 percent chose a dental school even if the financial aid package was less than what was offered in other schools. African American, Hispanic, and Native American students prefer integrated interview days with nonminority applicants and disapprove of special days designated for URMs. The presence of other minority students was not an important factor in the selection of a school but is an important source of support while attending dental school. Dental school minority alumni also play a significant role in the selection of a school. Results of the study can be useful in planning recruitment and retention programs. Dr. Lopez is Assistant Dean, International Relations and Adjunct Associate Professor, Department of Community Oral Health; Dr. Wadenya is Director of Minority Affairs and Assistant Professor, Department of Community Oral Health; and Dr. Berthold is Professor and Chair, Department of Community Oral Health and Associate Dean for International Relations all at the University of Pennsylvania School of Dental Medicine. Direct correspondence and requests for reprints to Dr. Naty Lopez, Office of International Relations, WHO Collaborating Center, University of Pennsylvania School of Dental Medicine, 240 South 40 th St., Philadelphia, PA 19104; 215-898-0558 phone; 215-573-2087 fax; lopeznb@pobox.upenn.edu. This paper was a winner in the Oral Presentation competition at the 2003 ADEA Annual Meeting. The study was funded by the Provost Diversity Fund, University of Pennsylvania. Key words: recruitment, retention, underrepresented minority Submitted for publication 5/16/03; accepted 8/8/03 Current demographic estimates project that by 2050, 48 percent of the U.S. population will be comprised of minority groups. 1 These groups experience a disproportionate level of oral health problems and restricted access to health care. 2 One of the means proposed to reduce the problem of access in these groups is to have a workforce that reflects the diversity in society. Unfortunately, the current number of underrepresented minority (African American, Hispanic, and Native American) dentists/oral health care providers is far below the desired level. In spite of efforts by dental schools to recruit underrepresented minorities (URM), the American Dental Education Association (ADEA) reports that, among the fifty-five U.S. dental schools in 2000, half had one or no Black/African American first-year enrollees while 43 percent had one or no Hispanic/Latino enrollees. 3 As shown in Table 1, considerable numbers of individuals from each ethnic group apply to dental school, but only a small percentage manage to enroll. In 2001, only 11 percent of African American, 8.5 percent of Hispanics, and 11 percent of Native Americans in the applicant pool entered dental school (Table 1). As a result, the percentage of URM enrolled in dental schools does not approach the percentage of underrepresented minorities in the population (Table 2). The need to attract, recruit, and retain underrepresented minorities continues to be a challenge. The Institute of Medicine report Dental Education at the Crossroads recommends that dental schools should initiate or participate in efforts to expand the recruitment of underrepresented minority students, faculty, and staff. 4 The IOM study further states that the creation of a dental workforce and faculty that reflect the nation s diversity is a goal only partially achieved at this time. In 1999/2000, URM students constituted 10.5 percent of dental school enrollment, while underrepresented minorities comprise 25.5 percent of the U.S. population. 5 The vast ma- October 2003 Journal of Dental Education 1107

Table 1. Dental school applicants and enrollees by racial and ethnic background African American Hispanic Native American Year Applicants Enrollees Percent Applicants Enrollees Percent Applicants Enrollees Percent Entering Enrollees Enrollees Enrollees 1995 2,011 235 11.69 2,558 160 6.25 295 25 8.48 1996 2,321 224 9.65 2,718 156 5.74 312 26 8.33 1997 2,219 233 10.50 2,991 140 4.68 448 31 6.91 1998 2,115 181 8.56 3,199 160 5.00 267 19 7.12 1999 2,020 191 9.46 2,837 168 5.92 268 26 9.70 2000 2,102 221 10.52 2,802 236 8.42 198 17 8.59 2001 2,265 253 11.12 2,987 253 8.47 151 17 11.26 Source: American Dental Education Association, Official Guide to Dental Schools, 2001. Table 2. Minority enrollment in U.S. dental schools Black Hispanic Native American Asian Percent U.S. Population (U.S. Census 2000) White = 75 percent 12.3 percent 12.5 percent 0.9 percent 3.6 percent Percent Total Dental Enrollment 4.88 percent 5.89 percent 0.42 percent 23.54 percent Source: American Dental Education Association, Predoctoral First-Year Minority Enrollment in U.S. Dental Schools 1995-2001, 2001. jority of U.S. dental schools have consistently failed to enroll students from underrepresented minority groups at rates commensurate with their proportion in the general population. 3 Many factors may have contributed to the low enrollment of URM students in dental school. Dental schools may be competing with other health professions schools for the same pool of URM applicants. It is also assumed that students may prefer to enroll in schools where other minority students are enrolled, so dental schools that do not have minorities may find it more difficult to attract these applicants. Published literature on the recruitment of minority dental students tends to focus on trends in enrollment and on recruitment programs. 6 Other than a study conducted at the University of Kentucky that surveyed African American students in health professions schools, 7 there is no other known study that examines the issues from the perspective of minority dental students. Methods The descriptive study used a self-administered questionnaire survey constructed from data based on issues raised during focus groups and interviews with African American, Hispanic, and Native American dental students. The fifty-eight-item questionnaire included factual items (demographics), attitudinal items (such as preference for types of admission procedures), and behavioral items (such as where to find support when faced with a problem in school). Students indicated their agreement/disagreement on a five-point Likert scale of statements covering topics about their experiences while applying to dental school and during dental school. Face validity was obtained through a pilot test of the questionnaire with a random sample of ten URM students from two dental schools. The questionnaire format, questions, and scales were revised after the pilot test to incorporate suggestions from the students. A list of schools where URM students are enrolled was acquired from ADEA. 8 Copies of the questionnaire were sent in spring 2002 to faculty or staff in charge of minority students in dental schools where URM students are enrolled (except historically black schools) according to the ADEA report. The number of questionnaires mailed to each school was based on the report. A cover letter explaining the survey, consent form, and a stamped return envelope were mailed with the questionnaires. Individuals who received the package were asked to distribute the questionnaires to URM students in their school. Three schools returned the questionnaires because no URM students were enrolled in their schools. Because the 1108 Journal of Dental Education Volume 67, Number 10

names of the URM students were not released to the investigators for confidentiality reasons, it was difficult to follow up with students who did not return questionnaires. Personal follow-up was made with directors of minority affairs at a meeting that resulted in a second mailing in October 2002. Results A total of 198 students from dental schools in twenty-two states returned their questionnaires. Data from the questionnaires was analyzed using descriptive statistics and chi-square analysis to compare responses of the three groups: African Americans, Hispanics, and Native Americans. Percentage of return is difficult to assess since it is not known how many students actually received the questionnaire. Responses were received from all year levels (21 percent freshmen, 30 percent sophomores, 34 percent juniors, and 14 percent seniors). Among the 198 respondents, forty-two (21 percent) were African American, ninety-seven (49 percent) Hispanic, sixteen (8 percent) Native American, twenty (10 percent) African/Caribbean, and fifteen (7.6 percent) Asian-Pacific Islanders. Only the responses from the African American (AA), Hispanics (HP), and Native Americans (NA) who are considered underrepresented are included in the analysis. The mean age of the respondents was 25.8 years, 56 percent were females, and 31 percent were foreign-born. Respondents reside and study in dental schools located in twenty-two states with the majority coming from California, Florida, Massachusetts, Pennsylvania, New Jersey, New York, Oklahoma, Tennessee, and Texas. Forty-nine (25 percent) had nondental careers prior to dental school ranging from business jobs to teaching. Eighty-three (42 percent) had worked in a dental-related job; 63 percent of this group worked as dental assistants. Thirty (15 percent) had family members who are dentists. There were no significant differences in the responses based on gender. Selected results appear in Table 3. Choice of Dentistry as a Career and Choice of Dental School Fifty-two percent of the respondents made dentistry their career choice while in college; 56 percent reported that they did not consider dentistry as an option in high school. Forty-six percent were influenced by their family dentist to choose the dental profession, but all groups (AA, HP, NA) report that they were influenced by dental school alumni in their selection of dental school (p=0.3730). All three groups also indicated that their parents were not an influence in their choice of dentistry as a profession (p=0.9305). A majority of parents (96 percent), however, were supportive of the decision to enroll in dental school. Reputation of the school was identified by 74 percent of the respondents as the reason for their choice. Chi-square analysis showed that there was no significant difference in the response of the three groups to this issue. As seen in Table 3, scholarships and financial aid were not the primary reason for the choice of a school for Hispanics and Native Americans, but the African Americans were divided 50-50 over this point (p=.0026). Overall, only 30 percent of all respondents indicated that they chose the school because of scholarship and financial aid; 50 percent of African Americans cited this as a primary reason in contrast with 26 percent Hispanics and 14 percent Native Americans (Table 3). Forty-nine percent chose a dental school even if the financial aid package was less than what was offered in other schools. Presence of Other Minority Students Respondents to this study indicated they preferred integrated interview days with non-minority applicants rather than special days for minority students only. Most had good experiences during the interview; 88 percent felt welcomed and wanted; and 83 percent said they were treated the same way as the non-minority applicants. The presence of other minority students in the school was an important factor for choosing a dental school for African Americans (53.4 percent), but not for Hispanics and Native Americans (p=.0004). Overall, only 34 percent indicated that the presence of other minority students was an important factor in their decision. However, during dental school the presence of other minority students was one of the major sources of support for 62 percent of the respondents. Seventy-four percent of the students felt that a minority student association among their ethnic group was an important source of support. Minority students also felt that there was someone in school they could go to for support and felt that support was stronger if there was strong leadership commitment. They also reported that they received support from faculty regarding academic courses, and October 2003 Journal of Dental Education 1109

Table 3. Comparison of responses among ethnic groups Statements African Americans Hispanics Native-Americans Chi-Square Top: Disagree Top: Disagree Top: Disagree Bottom: Agree Bottom: Agree Bottom: Agree A. On recruitment I chose the school where I am currently enrolled 50 percent 74 percent 86 percent 0.0026 because of scholarship and financial aid they offered. 50 percent 26 percent 14 percent The presence of other minority students was an 48 percent 66 percent 87 percent 0.0041 important factor in my decision to choose my 52 percent 34 percent 13 percent current dental school. I preferred having a separate interview day for 97 percent 91 percent 100 percent 0.7889 minority students. 3.4 percent 9 percent 0 percent My parents influenced me in my choice of dentistry 79 percent 77 percent 80 percent 0.9305 as a profession. 21 percent 23 percent 20 percent I was influenced by alumni of the school to choose 5 percent 3 percent 0 percent 0.3730 my current dental school. 95 percent 97 percent 100 percent My decision was dependent on the scholarship and 71 percent 78 percent 86 percent 0.7357 financial aid the school offered. 29 percent 22 percent 14 percent B. On retention There is someone in the school that I could go to 24 percent 16 percent 7 percent 0.1152 for any difficulty and s/he would give concrete help. 76 percent 84 percent 93 percent I usually feel that I am constantly being watched in 57 percent 73 percent 87 percent 0.0187 class. 43 percent 27 percent 13 percent I blend in well and do not feel different. 50 percent 21 percent 7 percent 0.0001 50 percent 79 percent 93 percent I was born and raised in this country, so I feel part 72 percent 37 percent 7 percent <.00001 of the majority. 28 percent 63 percent 93 percent The Office of Minority Affairs at my school is one 36 percent 52 percent 27 percent 0.8095 of my sources of support. 64 percent 48 percent 73 percent The presence of other minority students like me 24 percent 30 percent 77 percent 0.0053 provides a strong support for me. 76 percent 70 percent 23 percent The minority student association (of my ethnic 21 percent 43 percent 46 percent 0.0283 group) is a source of support and encouragement 79 percent 57 percent 54 percent to me. I feel that majority students at my school are 12 percent 8 percent 0 percent 0.1608 accepting of minority students. 88 percent 92 percent 100 percent I feel that faculty have the same academic 27 percent 15 percent 0 percent 0.0109 expectations from minority students. 73 percent 85 percent 100 percent 82 percent felt that faculty have the same expectations from minority and non-minority students in their academic performance. Forty-three percent of African Americans indicated that they felt they were constantly watched in class. Dental practitioners provided another source of support to the students: 79 percent of African Americans found encouragement from practitioners from their own ethnic group, but only 27 percent of Native Americans were of this opinion. The feeling of being able to blend in with other students and not feeling any different varied among the three groups (p=.004), with 93 percent of Native Americans agreeing with this sentiment compared to 63 percent of Hispanics and 50 percent of the African Americans. Although all groups reported having friends among other ethnic groups, all groups differed significantly (p=.0014) in their responses. Twenty percent of African Americans limit their friends to fellow African Americans. 1110 Journal of Dental Education Volume 67, Number 10

Discussion It is commonly believed that financial aid and scholarships are one of the main factors in attracting underrepresented minorities to dental school. While finance is an important factor, URM students in the study selected a dental school for its reputation first. As one student explained, graduating from a highly recognized school provides an additional weight that will be needed in their future dental careers. It is thus important for dental schools to present the strengths of their curriculum when recruiting URMs. This does not make financial aid less important. One respondent pointed out that many minority students are first-generation health professionals in their families and may therefore not have other sources for funding their education. The burden of the high cost of dental education can be discouraging especially to those who do not have anything to begin with. As the results reveal, 66 percent worked prior to dental school, most probably to support themselves. According to comments in the questionnaires, many URM students chose other professions such as teaching and social work because the course of study is shorter and there is no huge financial burden to pay back after graduation. Although URM students often need scholarships and other forms of financial aid, the general feeling is that any form of aid should be given because they are deserving and not just because they are minority students. As one respondent commented, Any effort to single me out as a minority, even if deemed positive (e.g., providing scholarships), has done little more than make me uncomfortable. One interviewee remarked that she was completely turned off when one school offered scholarships and financial aid even before they saw her for the interview. One common practice for recruitment is the holding of a minority day where URMs are scheduled for interviews and tours of the school. It is clear from this study that URMs prefer integrated interviews with majority students. Having special days tends to isolate them. One respondent called this practice a source of civil separation. The presence of other minority students is important in attracting African Americans as indicated in the responses to the survey and supported by comments made in the focus groups and interviews. Having a group to identify with makes it easier for these students to fit into the particular school and gives them a sense of belonging. But it is different for Hispanics and Native Americans who commented in focus groups that they do not feel the presence of other minority students is important since they feel they are able to blend in well with other students and they do not feel any different. However, for retention purposes, the presence of other minority students becomes a significant source of support for all three groups. Having a critical mass gives the students a voice and a sense of empowerment, and they in turn become more involved in the recruitment process to encourage applicants from their own ethnic group. In contrast, in schools where there are few URM students or at times one minority student, respondents have commented that there is a general feeling of not belonging or homelessness in spite of fair treatment from faculty and classmates. A respondent from a school where she was the lone minority student wrote, It has been a hard four years without a support group, but it is doable. An encouraging finding is the feeling that students have someone in the school they can turn to when they need help. In schools where there are few minority students, faculty and staff regardless of ethnic background can provide the support needed by URM students. Another encouraging finding is the feeling of URMs that majority students are accepting of their presence. This study highlights the role of the family dentist and alumni in recruitment. A significant number of the respondents were influenced to choose dentistry by their family dentists. Alumni also played an important role in mentoring and supporting students through their dental education. These two groups may need to be involved more in recruitment programs and in encouraging minority students to continue in dental school. Recruitment programs also need to include parents of minority students. The study showed that only 15 percent of the respondents have family members who are dentists, so they may not have the role models to encourage them to consider dentistry for a future career. One respondent wrote that dentistry is not presented as a viable option to minority families; hence few consider entering the profession. Even guidance counselors in high schools do not encourage minorities to consider the dental profession. Instead, minority students may be told to think of vocational or technical careers. It is possible that not all dental schools have an office designated for minority affairs. Even if there is such an office, underrepresented minority students may not know of its existence or may not fully utilize the services it offers. The Office of Minority October 2003 Journal of Dental Education 1111

Affairs may need to be made more visible, relevant, available, and supportive to students. The school also needs to be supportive of its own Office of Minority Affairs and provide necessary funding. One respondent commented that the Director of Minority Affairs in her school takes money from his own pocket to fund their programs. Conclusion The results of this study may be useful in the planning of recruitment and retention programs for minority students. A successful recruitment and retention program needs to include the following components: an integrated interview/applicant orientation program where underrepresented minorities are mixed with other applicants; a consistent mechanism that will provide scholarship and financial aid throughout dental school; and the involvement of alumni and other practitioners in the community who will actively encourage young students to choose dentistry. URM students enrolled in a school can be part of the recruitment and retention program by giving the orientation tour of the school or serving as mentors to new students. Dentistry as a career option must also be presented to parents and children of minorities. Recruitment programs should start early, even before students start thinking about going to college, so that both parents and children can begin to consider dentistry as an option. URM families should likewise be informed about resources available to them such as HCOP programs that will prepare the students for dental school and other sources of help to enable them to negotiate the application process. Overall, it takes a strong commitment from the school and its leadership to increase the number of underrepresented minority dentists, so that the student population reflects the true diversity of society. Acknowledgments We would like to thank the Directors of Minority Affairs/Student Affairs who distributed the questionnaires and encouraged students to participate in the study. We also thank the minority students in the dental schools who participated in the interviews and completed the questionnaires. We would also like to thank Pamela Godbolt of Temple University who recruited students in the pilot study. It is with their participation that this study was made possible. REFERENCES 1. Sinkford JC, Harrison S, Valachovic RW. Underrepresented minority enrollment in U.S. dental schools: the challenge. J Dent Educ 2001;65:564-70. 2. Oral health in America: a report of the surgeon general executive summary. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. 3. 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. 4. Institute of Medicine. Dental education at the crossroads: challenges and change. Washington, DC: National Academy Press, 1995. 5. 2000 update: losing ground underrepresented minority dental student enrollment shifts. Washington, DC: American Dental Education Association, 2000. 6. Chalkley Y. A survey of minority student recruitment and retention efforts in dental schools. J Dent Educ 1995;59:645-8. 7. Wiggs JS, Elam CL. Recruitment and retention: the development of an action plan for African-American health professions students. J Natl Med Assoc 2000;92(3):125-30. 8. The official guide to dental schools. Washington, DC: American Dental Education Association, 2003. 1112 Journal of Dental Education Volume 67, Number 10