American Indian populations experience decreased health outcomes and a disproportionate disease burden when compared with other ethnic populations in the United States. Additionally, they have higher mortality rates for a number of health conditions, including chronic liver disease and cirrhosis (368% higher), diabetes mellitus (178% higher), unintentional injuries (138% higher), and intentional self-harm and suicide (65% higher), among many other public health challenges (Centers for Disease Control and Prevention, 2014). Overall, American Indians born today have a life expectancy that is 4.2 years less than the general US population (Indian Health Service, 2015).
American Indian students are severely underrepresented among healthcare professionals, which presents significant challenges to addressing the higher rates of illness and mortality, and to improving the healthcare in Native communities (Agency for Healthcare Research and Quality, 2013; Sequist, 2007). There is a dire need to increase the number of American Indians in health professions because clinicians who understand the language, culture, and traditions of their patients and communities are able to offer culturally effective care (National Rural Health Association, 2013). Further, when the workforce reflects the diversity of the population that it serves, there is an increase in health equity and clinicians are better equipped to meet the unique needs of their people (Duffus et al., 2014).
In 2004, American Indian students represented 0.6% of medicine graduates, 0.3% of dentistry graduates, 0.3% of public health graduates, and .1% of registered nurses (Mitchell & Lassiter, 2006; American Association of Colleges of Nursing, 2015; Health Profession Occupation Grants, 2015). Studies have shown that minority physicians are more likely to treat minority and indigent patients, and to practice in underserved communities. Recent research from the Association of American Medical Colleges (2004) showed that 41% of American Indian medical students indicated they were likely to practice in underserved areas, compared to 18% of Caucasian graduates. Furthermore, American Indians are the least represented of all ethnic minorities in nursing schools and the overall nursing workforce (Chapman, 2011).
There are numerous reasons for the disproportionately low enrollment of American Indian students in health professions. These reasons range from financial restraints to the lack of mentorship. Many American Indians share the belief that a career in medicine or a health profession is not an achievable goal, which leads them to self-doubt their perceived abilities (Sequist, 2007). In addition, there is a lack of positive role models for the students, as many do not observe family members succeeding in higher education. Even if the students are highly motivated to enroll in a health professional program at nearby universities, they still face the personal barriers of leaving their homes, communities, and families to study in an environment where they may feel culturally isolated (Sequist, 2007; Brown, 2003). Efforts to promote community health education and professional health careers need to consider the unique barriers of this population and create innovative programs that enable students to overcome these obstacles.
In 2007, after two years of discussion, faculty from the Icahn School of Medicine at Mount Sinai (MS) in New York met with the president and faculty of Cankdeska Cikana Community College (CCCC) in Spirit Lake, North Dakota, to address the health needs of the local American Indian population. Given the endemic poverty, the numerous health disparities, and the lack of Native professionals, the college president sought to improve understanding of public and community health and how tribal members could impact change on the reservation. Based on concerns generated from the community and local stakeholders, the group established a mission to improve overall community health through recruitment of American Indian students into the health professions, with the intent that they would ultimately become providers of culturally concordant care in the tribal nation. In 2008, faculty from the Columbia University Mailman School of Public Health (CUMSPH) in New York, joined the partnership and devised the initial educational intervention—a three-week college course. This multicultural course enabled MS physicians and medical students to learn about American Indian health and Dakota culture while tribal members learned about community and public health, including career opportunities. In 2009, MS and CUMSPH faculty, medical students, and public health students taught the first course to four CCCC staff and students. In 2012, faculty from the North Dakota State University School of Nursing (NDSU) joined the collaboration, adding considerable resources to the project both in the form of exposure to local health professionals and through the financial support of the University and Community Partnership Health Profession Opportunity Grant (Weintraub et al., 2015).
The content and format of the course was based on an understanding of local health needs and concerns, as well as culturally appropriate educational styles. As such, topics were chosen based on the most common or concerning health issues of the community. The course was divided into three topical sections: 1) public health: determinants of health, global health, health disparities, obesity, diabetes, malnutrition, substance abuse, maternal/child health, environmental health, dental health, Indian Health Service, built environment, depression, suicide prevention, domestic violence, infectious disease, unintentional injury, health literacy; 2) research: introduction to research design, research ethics, questionnaire design, community-based participatory research, quantitative methods, and public health interventions; and 3) health careers: public health, medicine, nursing, dentistry, dental hygienist, and emergency medical technician (Weintraub et al., 2015).
The purpose of this study was to explore if this three-week college course for American Indian students and community members increased their knowledge about public health issues and their interest in pursuing health professions.
A pretest/posttest design was used to measure the difference in students’ knowledge of public health issues and health careers. Students were recruited from those enrolled in the three-week summer course, “Introduction into Community and Public Health,” offered at CCCC. Twelve students completed the pretest and the posttest.
A resolution was obtained from the tribal council, granting permission to conduct research and evaluation projects. Additionally, two university institutional review boards reviewed this study. To ensure the confidentiality, pretests and posttests were numbered to retain participant anonymity.
Mount Sinai, CUMSPH, and NDSU faculty developed the 31-item pretest/posttest questionnaire. The questionnaire consisted of 1) two short answer questions on the definition of public health and the top public health issues, 2) twelve true/false and multiple choice questions regarding public health issues, and 3) seventeen questions related to their consideration of careers in health-related fields. Demographics such as age, gender, level of education, ethnicity, family size, and household income were also collected.
The primary author distributed the consent forms and questionnaires to the students before the course began and at the conclusion of the final class. Each questionnaire included a cover page explaining the purpose and procedure of the study. The primary author remained in the room to answer questions and to collect the completed questionnaires.
Students were described by demographics (age, gender, education, and family size). Students reported on a one to four Likert-type scale detailing how much encouragement they thought they would receive from family and friends for entering any of the nine healthcare careers, including emergency medical technician (EMT), licensed practical nurse (LPN), registered nurse (RN), nurse practitioner (NP), physician’s assistant (PA), physician, dentist, mental health professional (counselor), and optometrist. These nine ratings were totaled to produce three encouragement scores: one for family, one for friends, and a grand total. Five questions were asked regarding barriers, including the duration of both nurse and physician training, the cost of a healthcare career, family responsibilities, and the stress of studying for a career in healthcare. These questions were also measured on a one to four Likert-type scale and averaged for a total barrier score. The demographics of family size and income, six measures of barriers, and three measures of encouragement were averaged to obtain one measure for each student.
The analysis for this paper focuses on three areas of the questionnaire. The first area includes the 12 questions related to public health issues. The questions focused on definitions of public health, the top three public health issues in the tribal nation, and other public health issues.
The second area includes the series of 15 questions on whether the respondents had ever considered a specific healthcare career. These careers were divided into two groups: 1) careers requiring a technical degree: Certified Nurse Aide (CNA), LPN, dental technician, EMT, home health aide, medical assistant (MA), and phlebotomist—or 2) a university degree: RN, NP, PA, physician, dentist, counselor, optometrist, and public health. The number of careers considered from these two groups were totaled into one score for technical careers, one for university careers, and then combined for a total of all careers considered.
The third area relates to the nine healthcare careers presented in the questionnaire (EMT, LPN, RN, NP, PA, physician, dentist, counselor, optometrist, and public health). Students were asked to rate on a Likert-type scale of one to four if they thought those nine healthcare professionals were people like them, if they currently worked on the reservation, and if they understood the health needs of their community on the reservation (regardless of race). These ratings for the nine careers were summed into one score for each of the three questions. The three scores were then totaled, measuring identification of the students to healthcare professionals working in the tribal nation. The students’ total ratings for the three questions and identification total were compared from the beginning to the end of the course. It was noted if each student’s ratings had improved.
Twelve students completed all questions related to public health issues and health careers on the pretest and posttest. All self-reported their ethnicity as American Indian. Eight were female and four were male. Four were under 20 years of age, six were 20 to 29, one was 40 to 49, and one was 50 to 59. Three had completed high school or a GED, two had completed technical college, six were enrolled in the tribal college, and one had a bachelor’s degree. Seven of the students were single parents with children. All reported registering for this course to learn about public health issues and health career options. Six of the students were undecided about future career choices; five were enrolled in the pre-nursing program at the tribal college.
Students were asked the question, “What is your definition of public health?” Before the course, four students were unsure of the definition while eight students reported it as helping the community as a whole. After completing the course, all identified public health as the health of the community or the people. Figure 1 indicates the number of students who correctly answered questions related to public health issues before and after completion of the course. The number answering correctly significantly increased from four to eight (<p = .033).
Students were also asked the question, “In your view, what are the top three public health issues on your tribal nation?” As shown in Figure 2, their initial responses were healthcare in general (n=8); drugs, prescription and illegal (n=7); and alcohol abuse (n=6). After the course, they listed diabetes (n=12), drugs (n=6), and cancer (n=3). The awareness of diabetes as a health issue increased from four students to 12. The students also became more specific in their responses after the class, with only two respondents referring to healthcare in general as a problem.
Before the course, students were asked to rank the top 10 leading causes of deaths among the American Indian population in North Dakota. From the highest to the lowest, the top 10 leading causes of death included are: cancer, unintentional injury, heart disease, diabetes mellitus, chronic liver disease and cirrhosis, intentional self-harm (suicide), chronic obstructive pulmonary disease, stroke, Alzheimer’s disease, and influenza or pneumonia (U.S. Census Bureau, 2010). Figure 2 shows the number of students who correctly ranked one to five causes. The students ranking of American Indian causes of death improved after the class (p = .031).
Encouragement from family and friends were rated on a four-point Likert-type scale for nine healthcare professions: EMT, LPN, RN, NP, PA, physician, dentist, counselor, and optometrist. The average encouragement rating from these two sources and total (friends and family together) are shown in Table 1. Encouragement scores ranged from 20 to 36, with family encouragement being slightly higher (x̅ = 29.8) compared to friend encouragement (x̅ = 29.5). This is slightly above students scoring three out of four possible points (27 out of 36 total) or “somewhat encouraged.”
Table 2 displays how students rated, on a four-point scale, five barriers to health careers (time for nurse training, time for physician training, cost, family responsibilities, and stress) and their total. “Family responsibilities” was the highest indicated barrier (mean 3.0) while “time for physician training” and “cost” were the lowest (x̅ = 2.0 and 2.2, respectively). The overall average was 2.5, suggesting barriers were between “somewhat disagree” and “somewhat agree.”
Students were asked if they had thought about 15 different careers in healthcare. These were defined by three groups: 1) careers requiring a technical college degree, 2) careers requiring a university degree, and 3) all 15 careers. At the end of the course, five students chose more technical careers than at the beginning, five students selected additional university careers, and six students specified new careers. The median number of careers chosen by students at the beginning and end of the course is shown in Figure 3. The median number of careers increased by one for each category (mean increase of 0.64 for technical, 0.45 for college, and 1.10 for total). This was not a significant change in median for technical (z=.095, p=.171) or university (z=.816, p=.207) careers. For all 15 careers the median increase was also one career (z=1.36. p=.088). Some students did not increase in this area while others increased the number of career options by 12.
Students were further asked to rate how they identified with nine healthcare professionals in the tribal nation. Figure 4 shows the median scores of the 12 students before and after the course for these four questions. The students who believed that healthcare professionals were like them had their median increase by three (z=1.39, p=.083). The median of students who held the belief that healthcare professionals worked in the tribal nation decreased by one (z=-0.045, p=.517). Their belief that healthcare professionals understood the health needs of their community showed a median increase of two (z=0.224, p=.589). Overall, the median value for identification that students had with healthcare professionals on the reservation increased by one (z=0.758, p=.224).
The findings of this study demonstrate that the implementation of a three-week community and public health course positively impacted the American Indian students’ knowledge of public health and potential health career options. There was a significant increase in the knowledge level of the students, specifically in their understanding of public health, public health issues, and leading causes of death for American Indians in North Dakota. At the end of this course, the study’s findings showed a promising increase in students’ thoughts about various health careers. Throughout this course, students interacted with Native and non-Native health professionals, and learned about the health careers listed in the survey, the speakers’ personal experiences, length of schooling required, salary, and career paths.
When recruiting American Indian students to attend four-year institutions and enroll in health professional programs, recruiters need to be aware of potential barriers or challenges they may encounter when leaving their tribal community. Family is the most important factor for American Indian students to pursue their college education (Guillary & Wolverton, 2008). As in this study, families serve as a motivating source for Native students thinking about enrolling in a health profession at an area university. Additionally, students believed their friends in the tribal nation would offer encouragement if they chose a career in the health professions.
The students reported that the most significant barrier for a career in a healthcare profession was their family responsibilities, and according to Guillory and Wolverton (2008), many American Indian students care for their family members and are primary caretakers of their parents and grandparents. Students also reported the length of time required to be a nurse as a stronger barrier than the time to become a physician. In this course, none of the students indicated an interest in becoming a physician. However, five students were enrolled in pre-nursing at the tribal college, which does not offer a nursing program. For these students to continue to pursue their nursing careers, they must leave their tribal community to enroll in one of the area community colleges or universities to complete their degree. As single parents, this can be a major barrier because of the loss of the family support system and the resulting problems such inadequate child care and finding time to study while balancing time with their children. Additionally, while the students in this study perceived their families as supportive of their educational goals, they can also be seen as a barrier, especially in situations where the family members are dependent on the students for financial and emotional support (Guillory & Wolverton, 2008).
Besides family support, there are other factors that contribute to the shortage of health professionals in tribal nations, including financial constraints. In 2012, nearly one in three American Indians was living below the Federal Poverty Line and that number increases to 38.6% for those living on reservations (Health Profession Occupation Grants, 2015). The students in this study rated the financial cost of higher education as a low priority barrier. This finding could be attributed to the Health Profession Occupation Grant titled, “Next Steps: An Empowerment Model for Native People Entering Health Professions.” As a tribal grantee, this program is distinct from the non-tribal grantees because its aim is to integrate training programs in health professions with culturally informed models of learning and practice. The Next Steps Program provides financial, academic, social, cultural, and psychological services to students planning careers in health professions (Health Profession Occupation Grants, 2013).
During this study, students gained an in-depth knowledge of health professional careers which lead them to think about an increased number of health career opportunities. The content and guest speakers provided during the course did not significantly change students’ views of health careers. Overall, the students believed the healthcare professionals practicing in the tribal nation understood the healthcare needs of their community. The students’ understanding of healthcare careers increased, especially when they identified with health professionals in the tribal nation.
In conclusion, it was determined that the American Indian students’ knowledge of public health issues and health careers increased due to their participation in this three-week community and education course taught at the tribal college. Because of the perceived barriers to health education and limited interest pursuing health careers, these findings highlight the need for a future curriculum modification along with revision to the survey. Although the small size of the sample is a limitation, the findings demonstrate the positive impact the course had on the American Indian students’ knowledge of public health issues and health careers. Future research needs to be conducted on this multiple-year education program.
Editor’s Note: For a related article, see “To Empower and Educate: Bringing Native Students into the Healthcare Professions” by Marielle Christine Leilani Young.
Loretta Heuer, Ph.D., R.N., F.A.A.N., is a professor in the School of Nursing at North Dakota State University; Marielle Christine Leilani Young is a medical student at the Icahn School of Medicine at Mount Sinai; Cynthia Lindquist, Ph.D., is president of Cankdeska Cikana Community College; Marilyn G. Klug, Ph.D., is an associate professor at the University of North Dakota’s Center for Rural Health; Ann Wadsworth, A.D., is the Next Steps assistant program director at Cankdeska Cikana Community College; and Jonathan Ripp, M.D., M.P.H., is an associate professor of medicine at the Icahn School of Medicine at Mount Sinai.
The authors would like to thank the following individuals and organizations for their participation in course development and implementation: Leander “Russ” McDonald, Ph.D., Phillip Longie, B.S., Lane Azure, Ph.D., Marisa Oishi, M.D., M.P.H., Alexander Lloyd, Lauren Macewicz, M.D., Evan Pulvers, M.D., Pesha Rubinstein, M.P.H., Amitha Sampath, M.D., M.P.H., Emily Sorg, Linda Cushman, Ph.D., Amanda Nordick, United Tribes Techical College, Cankdeska Cikana Community College, Oberon Elementary School, Mount Sinai School of Medicine Master of Public Health Program of the Mount, Mount Sinai Hospital, Columbia University Mailman School of Public Health, and North Dakota State University School of Nursing. This project was funded by the University Partnership Research Grant for Health Professional Opportunity grant # 90PH0019, Office of Planning, Research, and Evaluation, Administration for Children and Families.
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