Carline, Jan D. PhD; Patterson, Davis G. PhC
Despite a 30-year history of extensive programs to interest and support college students in health professions, the pool of qualified underrepresented minority students entering health careers remains inadequate.1 A number of studies identified the major issue that problems with the pipeline into health careers start much earlier in the education of students, namely in the earliest levels of public school education.2,3
The Health Professions Partnerships Initiative (HPPI) was begun in 1996 to address the underrepresentation of certain racial/ethnic minority groups in the health professions. Health professions schools were challenged to improve the curricula and educational programs of partner school districts and colleges in order to increase the numbers of African Americans, Hispanics, and Native Americans in health professions. These improvements would increase the academic achievements of many more minority students and assist them to enter and progress through the educational pipeline towards health care careers. The impetus for this program came from the work of the Association of American Medical Colleges (AAMC) to increase the numbers of underrepresented minorities in medical schools started in its Project 3000 by 2000, and was initially funded by The Robert Wood Johnson Foundation (RWJF). The first grants were awarded in 1996 to ten schools of medicine. Six additional grants were awarded in 1998, with funding from the RWJF and the Kellogg Foundation (WKKF), to a variety of health professions schools, and ten in 2000, including five schools of public health. The Association of American Medical Colleges initiated the program and continues to act as the National Program Office (NPO) for the HPPI project, assisted by the Association of Schools of Public Health (ASPH) in dealing with public health programs.
The HPPI project is based on the notion of equal partners working together to achieve the goal of increased representation in health careers. The application instructions for the third round of awards state, “Since it is the colleges, K–12 schools systems and communities themselves that are primarily responsible for the education of prospective minority health professional students, their active involvement as full partners is critical to the success of the HPPI.” A successful program will have all partners involved in conducting needs assessments, setting goals, planning and conducting programs, and governance. Starting with the second round of grants, awardees were required to include a community-based organization as a member of the partnership.
A typical partnership consists of a health professions school that received the grant, one or two other health professions schools, one or two undergraduate colleges, several public schools in one school district, and one or more other organizations. These partners represent the educational path from public school through college and health professional school. The public schools usually involve one or two high schools, two or three middle schools, and—in several instances—several elementary schools. The public schools may be limited to one geographic area of a city, or may be spread across a much wider area and include several school districts. Other organizations have included business partners, hospitals, and clinics, housing authorities, African American business associations, Area Health Education Centers, public health departments, and science museums. Partnership members at one site vary over time, and are not equally involved in all activities. The partnerships have undertaken professional development for teachers, curriculum improvement, enrichment programs in science and math, career counseling, and support of career aspirations.
Developing effective partnerships is not a simple task. A major difficulty in forging effective professional school–public school partnerships exists because of the very different cultures among these institutions. The divergent cultures and organizational imperatives of public schools and universities are thoroughly documented.4,5,6,7,8,9 These discontinuities between higher education and the public schools can lead to problems in setting up partnerships and can engender continuing distrust; if these difficulties are not overcome, failure ultimately occurs. School–university relationships may be loaded with the historical weight of past problems in working together.4,9 Public school personnel may feel threatened by outsiders or be skeptical about what a university has to offer and how committed it is to long-term involvement, since programs come and go and funding is unstable.10
In October 2000, we in the Department of Medical Education and Biomedical Informatics received a grant to perform an assessment of the HPPI program from the RWJF, the WKKF, and the AAMC with the intention of informing the foundations about aspects of the funded projects that might help guide the management and construction of similar programs in the future. As part of the assessment, we conducted a review of the literature focusing on professions school–public school partnerships. The results of that review, reported elsewhere, helped focus questions addressed by other assessment activities.11
While a number of broad questions were proposed for the overall assessment, the present report focuses on our study to identify those characteristics of health professions schools, public school systems, and community-based organizations associated with successful partnerships. We collected information in an attempt to answer the following question: What is the nature of the partnerships that have developed between the health profession schools, colleges, and school districts? For this study, we defined success in partnering in terms of how members perceive the partnership to be functioning; the perceived benefits and satisfaction gained from the partnership; and the relevance and quality of partnership-sponsored activities in achieving the partnership's goals.
On the basis of this definition, the information gained from our site visits and interviews allowed us to judge the success of HPPI programs at individual sites. The design of the assessment did not include collection of outcome data such as numbers of underrepresented students entering health care training or even the numbers of children and parents participating in programs.
This assessment required a series of qualitative methods to obtain information necessary to answer the study questions we posed. The methods we used are briefly described in the following paragraphs. This study was reviewed and approved by the human subjects committee of the University of Washington.
A semi-structured telephone survey of all HPPI program directors at the 26 health professions schools was completed. Ten schools of medicine received HPPI awards in 1996. Six awards were made in 1998 to six schools of medicine (two schools of medicine jointly applied as one site) and one school of nursing. Ten health professions schools received awards in 2000, including five schools of public health, four schools of medicine, and one school of nursing. Questions focused on their programs' activities, successes, and barriers to activities and their perceptions of the relationships between all partners. Interviews with directors of third-round award sites included questions about the types of indicators the the ten site directors expected to use to evaluate their successes and the efforts and support needed to collect this information. In telephone interviews with the program directors at the five schools of public health, we inquired about the nature of the public health career pipeline and specific problems in mounting this type of program in a school of public health.
We also conducted telephone and in-person surveys with leaders in the sponsoring agencies (WKKF, RWJF, AAMC, and ASPH) to ascertain their understanding of the project history and goals, and of the specific questions they hoped to have answered in the assessment.
We visited a sample of program sites to help inform us about successful methods used to build partnerships and identify issues that either foster or hinder productive partnerships. On the basis of the interviews and consultation with the sponsoring agencies, ten sites to be visited were chosen for their perceived “richness” and diversity of information about the nature of relationships between partners. We visited two sites that received awards in the first round, four in second round, and four in the third round of awards.
Both of us conducted the site visits. In most cases, we both attended all meetings and took extensive field notes. At each site, interviews were scheduled with leadership personnel from all partner organizations, teachers, counselors, family members, and students. Questions focused on perceptions of the success of the site's activities, how the partnership was developed and the types of relationships between partners, and the perceived changes and benefits the partnerships had brought about.
Semi-structured interviews were used during site visits. Items included in the interviews were based on issues identified during the telephone surveys, and from the literature review of partnership programs. After the completion of several visits, questions and the structure of the visits were modified as themes and issues appeared. For example, since we had learned a great deal from parents and students in earlier visits and their comments and ideas were being repeated in each subsequent visit, we allotted more time in later visits to teachers and school system administrators to capture their important insights into programs and how partnerships were formed and maintained.
We combined the transcriptions of the site-visit field notes and telephone surveys into a master document for each site. We then reviewed the documents and extracted content based on type of organization—professional school, public school, community-based organization—and the general nature of partnership development and maintenance. These comments were then reviewed to identify major themes that both supported and detracted from partnership development and functioning.
Partners' Characteristics Associated with Successful Partnerships
The four tables summarize the major categories of the comments we recorded during our site visits; the comments describe characteristics of organizations or other factors that affected the functioning of the partnerships. The tables are arranged by the partner type, the positive or negative nature of the influence, and the number of sites in which the influence was recognized. Table 4 includes general issues that apply to any organization or relationship within a partnership.
The comments included in these charts were gained from a variety of individuals encountered at site visits, including leaders of the health professions school (e.g., dean, department chair); health professions school staff associated with the project; health professions school and university students providing services to HPPI; health care system personnel, such as hospital staff or representatives of Area Health Education Centers (AHECs), personnel in public health departments; other representatives from professional schools or colleges, including faculty participants; leaders of the public school district/system; principal of a partner school; teacher from a partner school; parent and child participants; representatives from community-based organizations not previously included; and representatives from corporate partners.
Although we attempted to speak with as many individuals as reasonable, not all categories of individuals were included at each site visit, and the number of any one type of representative varied from site to site. Consequently, it is unreasonable to attempt to quantify the responses to our questions by the types of individuals and the partner organizations they represented. The tables include the number of sites at which a characteristic or factor was voiced.
Characteristics of Health Professions Schools Associated with Successful Partnerships
The major characteristics of health professions schools in successful partnerships were vision, a listening and respectful attitude toward partners, specific characteristics of leaders and staff that fostered the program, and prior experience in diversity programs. Each of these is discussed in the following sections. Table 1 displays the numbers of sites at which these characteristics were discussed.
Vision and commitment to community
Perhaps the best examples of vision and commitment to the community are the HPPI sites at the University of Massachusetts, Yale University, and the University of Alabama at Birmingham. In all three, the university's vision includes a commitment to the community directly surrounding the institution. The racial and ethnic makeup of these communities consists of members of underrepresented minorities, many of whom are also economically disadvantaged.
The University of Massachusetts School of Medicine, in a document titled “UMMS Vision 2000,” asserted that it would act to “be a major asset to the City of Worcester and Central Massachusetts in the areas of economic growth and K–12 science education.” This statement, one of six goals, clearly places the medical center and the school in the business of helping improve education and the career aspirations of children in K–12 education. This vision is further supported by the expectation of the school's dean that individuals occupying major administrative roles will have a strong presence in the community by serving on the boards or in leadership roles of educational and social organizations in the community, attending community functions, and if at all possible, living within the city and sending their children to community schools. Commitment to the community is an expectation, if not a requirement, of leaders. This school has been so successful in its involvement that the community now expects the medical school to be involved in major community organizations.
The medical school had not always held this commitment. At the time that the present dean was named in 1989, the school was perceived as elitist by the community, and its actions were not always thought to be in the community's best interest. There was mounting pressure from the state legislature to reconsider the funding of the school. In the dean's words, the future of the school depended on having the school “valued by the community.”
Another major impetus for working with the educational system in the community was the recognition that the great majority, if not all, of the health care system staff, including physicians, nurses, and technical staff, came from communities outside Worcester. The fact that the school and health care system together were the largest employer in central Massachusetts but did not draw employees from the local community was a further basis for distrust and suspicion in the community. Efforts to improve K–12 education in Worcester and to ensure that community high school graduates would be able to enter and succeed in medical technical fields at local community and four-year colleges were critical to the success and longevity of the medical school and medical center. Commitment to the community and education comes out of a sense of justice and altruism as well as the political necessity of being a good neighbor.
The dean of Yale University School of Medicine voiced a similar commitment to improving the community in which his school is located. He stated that programs aimed at improving access to education and health careers for underrepresented minorities and breaking down health disparities are at the “core of what the school does.” Faculty and students of the school are actively involved in a number of community-based projects aimed at improving education and health care.
Equally impressive is the overall commitment of Yale University to programs in the community. Yale has had a history of town–gown disputes between the community of intellectuals at the university and the working people of New Haven. The community perceived Yale as aloof from its problems, which were related in part to white flight from the city to richer suburbs and increasing economic and educational disparities between whites and other community residents. In 1995, with the advent of a new university president, increasing resources and efforts were allocated to work within the community and the state. The office of New Haven and State Affairs was created as a vice presidential office to act as a “front door to Yale and its resources for the people and organizations of greater New Haven,” where members of the community work with Yale in partnerships for “economic development, neighborhood revitalization, education and human development.” Yale has made a significant commitment to the community and provides over $2,000,000 a year in services and grants to community organizations. A major component of these activities focuses on improving K–12 education, including efforts that had begun in the School of Medicine with its partnership with Hill Career High School.
A third example of commitment to the community is found in the University of Alabama at Birmingham (UAB), specifically in its Center for Community Outreach (CORD). A former UAB president founded CORD in 1998 “to establish an effective interface between UAB and the City of Birmingham in order to identify and constructively address critical areas of need within the community.” It has focused on early academic intervention in partnership with the Birmingham City Schools. CORD, in conjunction with teachers and leaders in the school district, has developed curriculum for use in middle and high schools, and provides significant professional development activities for teachers and laboratory experiences for students. CORD has a core of professional science staff and a large facility with laboratories for use by community children in science education. It is funded through contributions from the university and grants from the National Science Foundation, the Howard Hughes Foundation, and other agencies.
A second major focus of CORD has been to assist individual faculty and staff in developing effective community outreach programs. It coordinates the efforts of a number of faculty members throughout the university in outreach to the educational community of the city. Graduate students interested in teaching are placed in CORD on fellowships provided by grants given to other units of the university. While this organization is funded primarily from external sources, it represents a major effort of the university to extent its resources to the community.
These three institutions have all worked toward a vision of improved community education and health. Institutional leaders developed the vision and found ways to support significant community efforts. In two of the schools, senior administrators lead these efforts. Two programs work out of centralized offices with consistent goals, allowing combined efforts of programs from around the campus to jointly improve program activities.
Community programs may originate, in part, out of a university's need to respond to community perceptions and diminish distrust of the university, medical school, and health care system. In several of our site visits, we observed communities that did not trust the intentions of the medical school or university. These institutions had reputations, justified or not, as primarily majority institutions, unfriendly toward the minority communities in which they were located, and coming to the community members only to do research of little perceived benefit to the community. These attitudes made it difficult for programs to develop effective partnerships with the schools and other organizations. While the three outreach programs mentioned above may have been developed, in part, to overcome political problems, they have contributed to the education of students in the communities while meeting the institution's need to be a better community member.
Health professions schools may be rewarded through community programs by improved reputation and increased community support. But how are individuals within the institution rewarded? Some are rewarded by virtue of being employed to lead these programs. The HPPI director at the University of Kansas negotiated with her dean and chair for a significant amount of release time from other responsibilities after she realized that the program needed her direct attention. Other individual faculty members may receive external support to develop curricula and professional development activities aimed at secondary schools, as seen in CORD at Alabama. At some institutions, community participation may be seen as a positive component on a resumé, particularly if the faculty member has been able to produce a scholarly manuscript about his or her efforts in the field.
Faculty members, already active in research and service, who volunteer time to mentor students or sit on community boards may participate out of the “good feeling” it gives them, as was stated at two of the most successful programs. But good feelings alone may not be sufficient. At two of the sites we visited, where diversity programs were not well established and faculty were heavily supported on outside research funds, it was very difficult for HPPI directors to identify faculty willing to participate in programs other than giving a single presentation or offering a tour of a laboratory.
The University of Massachusetts and Yale represent environments in which community involvement is an expectation of employment, although not financially rewarded. Chairs, deans, and other university leaders at Yale are now hired with the expectation that they, too, will have a commitment to the community. In other words, partnership activities became routine in the university culture. How can an institutional culture supporting the expectation of community involvement be developed? Certainly, dedicated leadership is a component. Leaders of the successful programs we visited have had a long history of involvement in community programs and success at gaining outside support. They have also felt a strong political need to respond to the interests of the community. Our observations lead us to believe that the combination of leadership and vision, experience in these programs, a history of having community involvement be a factor in hiring and promoting faculty members, administrators committed to community involvement, and a political necessity to respond to community needs may be critical in building a successful partnership program.
Willingness to listen to partners and respect them
At almost every site we visited, the ability of the professional school leadership and staff to listen to the needs and concerns of partners was an essential characteristic for developing successful programs.
The first HPPI director at one site did not take this approach. She had been a schoolteacher and principal in the local district, and entered negotiations with individual schools and teachers by laying out what the university could provide. Her presentations implied that she knew what was wrong with school programs and that she had materials and activities that could meet the needs of teachers and students. Telling teachers and schools what they should want and need was not well received; this director was replaced after the first year of the program. Her successor presented himself as interested in what the teachers and the schools themselves wanted from the partnership, and was willing to meet their needs rather than imposing a set of materials or services designed solely by the professional school. Every teacher and school administrator we met at that site uniformly praised the HPPI director for his ability to listen carefully to their needs and his respectful attitude toward their work with children.
As the above examples illustrate, the ability to listen to and be respectful of partners is clearly an important skill for individuals representing health professions schools. The culture, organizations, and needs of health professions schools are very different from those of public schools or other partners. This requires that representatives of health professions schools listen carefully to what partners are saying and be specific and careful in communication with them.
Simply listening may be the best way to begin a partnership project. The first Yale HPPI director spent her first six months at Hill Career High School listening to teachers' and administrators' concerns without suggesting any solutions. Careful listening is a component of building trusting relationships with partners. Another is for health professions school representatives to establish a physical presence with other partners, particularly in the public schools. At a number of HPPI sites, presence was developed by weekly visits to public schools by HPPI staff members, who spent time in the teachers' lounge or in the administrative suite talking with teachers and administrators.
Other types of partners also need to be heard and respected. After defining electronic educational resources as an area for joint work, staff of the Greater Kansas City HPPI asked its community church partners how they would like the program to support their computer ministries. The churches asked for additional equipment and support for Internet connectivity. The HPPI offered this support with the condition that no one from the community would be excluded from participation in the computer programs. The HPPI was able to identify sources to support both these requests as well as meet its own interests in supplying educational computer software for use by community children.
Equal relationships with other professional school and university partners are also important. We participated in meetings at the University of Louisville and the University of Massachusetts with representatives of schools of nursing and local four-year and community colleges. There was a sense at these meetings that each partner had a stake in the program and that their participation was welcomed and valued.
Asking what partners need, responding to these needs when possible, involving all partners in decisions, and developing a culture of respect lead to mutually successful programs. One of the most positive statements we heard was, “We did it, together!” The HPPI and the partners accomplished their goals by working together, rather than by one partner imposing its own goals on the other.
Characteristics of leaders and staff
At all sites we heard from a variety of partners that it was critical that HPPI leadership and staff could understand and work within a variety of institutional structures. The organizational structure of health professions schools—often described as a series of departmental fiefdoms—is very different from the more hierarchical organization of public schools. Being able to identify, understand, and maneuver within these organizational structures is an essential skill for a HPPI leader or staff member trying to open doors between two bureaucracies. Sometimes the task requires identifying not only the structure but also the individual within the structure who has the skills and informal influence needed to push a program forward.
It is particularly important for HPPI staff conducting the day-to-day activities of programs to understand the structure of public schools and the work of schoolteachers if they are to work effectively within the schools. Professional school personnel involved at greater distance from the public schools may not need prior experience in public schools, but they do need to listen to the needs and concerns of the teachers and schools.
Commitment and consistency of effort by HPPI leaders and staff are also important to successful programs. At several sites, turnover in staff meant that some promises for program activities were not met or were seriously delayed. Some projects almost needed to be restarted with the arrival of the new program coordinator. Delays in hiring appropriate staff also delayed program development.
Personal characteristics of leaders and staff members have made a difference in the partnerships we observed. Participants must have the skills and experience to deal with multiple bureaucracies and institutional cultures, as well as genuine interest and enthusiasm for their work. Sometimes happenstance, supported by personal relationships, can bring about a partnership: a health professions school dean's meeting a member of the school board at a party, or an HPPI coordinator's knowing a school district curriculum supervisor through prior employment at another school district. Without these relationships, opportunities for program development might have been missed. Yet without true interest in the work and concerns of others and enthusiasm for mutual interests, partnership leaders might never be able to build on these opportunities to foster a successful relationship.
Prior experience in diversity programs
Problems with program development due to a lack of experience and infrastructure, as well a lack of focused goals for the whole institution, were identified at several sites. Nickens and Ready12 suggested that medical schools that have been successful in admitting and graduating significant proportions of underrepresented minority students are good candidates for partnerships with minority high schools. The work of Brazziel and Brazziel13 confirms the notion that prior experience and commitment to diversity programs can predict success in future programs. Having infrastructure in place in the form of offices, personnel, and connections with other diversity initiatives smoothes the path for developing new programs or initiatives in the area.
Changes in Health Professions Schools Resulting from Partnerships
Many of the successful sites we visited had a great deal of experience with and commitment to diversity programs before receiving HPPI grants, and those institutions had already undergone changes as a result. Other sites were so new to the diversity efforts that it would have been unreasonable to expect any substantive change in the attitudes of faculty and the structure of institutional programs at the time of our visits. HPPI grants were the first diversity-related awards received by the schools of public health at the University of Oklahoma and the University of South Carolina. The presence of HPPI programs at these institutions may increase the awareness of faculty about diversity issues, and form the basis upon which additional efforts will be built.
Characteristics of School Districts and Individual Schools Associated with Successful Partnerships
The schools and school districts involved in successful partnerships shared certain characteristics in four areas: vision and leadership in the district and individual schools, selection of strong schools, support of teachers' efforts rather than increases to their workload, and strategies to involve parents and families. Each of these is discussed in the following sections. Table 2 displays the numbers of sites at which these characteristics were identified.
Vision and leadership
The strongest public school factors that fostered successful partnerships were the vision and leadership of individuals within districts and schools. In some instances, this leadership clearly came from the highest levels in the district. The partnership with Worcester Schools began when the superintendent identified the need to support curricular reform and actively sought assistance from major employers in the community, including the school of medicine. The superintendent of the Birmingham City Schools led efforts to improve science and math education and quickly empowered his curriculum staff to work with CORD and the University of Alabama at Birmingham. These superintendents opened doors in district offices and individual schools that otherwise might have remained closed to partnership activities.
Sometimes interest in partnering came from external forces, such as major curricular reform enacted by the state in Massachusetts or standards and testing movements in Missouri, South Carolina, and Michigan. Educational reform within one district opened the possibility of partnering with professional schools to gain the resources needed to improve science education. In a few instances, moves toward partnerships were fostered by informal relationships between school district leaders and deans and faculty of the health professions schools. No matter what specific circumstances brought leaders together, a shared vision of change drew school districts and health professions schools into joint effort.
Vision and leadership at individual schools, from principals and individual teachers, is also important. The principals of the most successful and vibrant schools we visited were all enthusiastic supporters of partnering with health professions schools and felt that the schools, teachers, and students had clearly benefited from partnership activities. The principals supported the use of curricular materials and other resources from partners. They made sure that teachers could attend professional development activities sponsored by the partnerships, and found ways to involve students in partnership activities. At Alexander High School in Laredo, which is a member of the University of Texas Health Sciences Center at San Antonio HPPI, science research projects required of students for graduation are supported by partner-sponsored summer programs at the health sciences center in San Antonio and through relationships developed between students and professional school faculty. The partnership provides a clearly relevant and appreciated resource for students and teachers at Alexander. At North High, a partner in the University of Massachusetts HPPI, partnering activities have been welcomed for improvement of science curriculum and have become a core feature of the school's internship and work-related education programs. Principals and teachers have played important roles in furthering the work of partnerships.
Sometimes, principals and individual teachers can supply leadership and vision without the active support of the school district. The principal in one elementary school has championed the work of one HPPI while the district continues to experience strife between the school board and the district office and deals with the loss of state accreditation. The vision of the principal for a community-based school has kept the program alive and vibrant.
Lack of participation at all levels, from individual teachers in classrooms to district offices, may limit or slow efforts for educational activities of the partners. Governance structures can enhance or limit program effectiveness. The Comer governance council model14 employed at Hill Career High School, New Haven, Connecticut, and the cross-disciplinary approach to curriculum development at Alexander High School, Laredo, Texas, involve teachers and administrators equally in the management and decision-making process for educational issues at these schools. Management councils, responsible for making policy within the school, are made up of teachers across disciplines, administrators, and representatives of parent groups. Teachers are empowered to seek solutions to educational needs across disciplines and are supported in innovation by the administrators of the school.
In contrast, we observed a number of high schools with a strong departmental structure that prevented cross-disciplinary innovation and helped to isolate teachers from change. In one instance, the vocational departments of a health-careers magnet high school had become very involved with internship and worked-based educational opportunities offered through the partnership. When we asked students in these programs if anything that they had learned or seen in their internship settings had been touched upon in biology, chemistry, or any other science course, the consistent answer was no. Science teachers at this school were very unwilling to become involved with any work of the partnership and had refused to discuss the possibility of curriculum change in the school. The strong departmental organization of teaching in the school, which placed authority for curriculum within the department, the unwillingness of teachers to either discuss issues outside their discipline or entertain change in instruction, and the inability of the principal to foster reform across departmental barriers resulted in an incomplete set of curriculum changes that missed opportunities for students to integrate information from their experiences in a meaningful way into classroom learning.
In elementary and middle schools, where there is less compartmentalization of teaching into disciplines, support of the principal can be very influential. The presence of an interested principal at one magnet middle school opened classroom doors to partnership involvement. That principal's successor was not interested in continued participation, and the relationship with the partnership withered.
At a minimum, the governing organization of a school, as vested in a principal or a governing council, needs to be supportive of partnership activities. Teachers must also be willing to participate in programs. Participation is supported by a vision of improving the learning experiences for all children in the school, shared by the principals, the governing boards, and the teachers. Additional features of partnership activities can be realized when district leadership is also supportive, allowing access to other schools and the possibility of coordinated programs from elementary to middle and high schools. Curriculum improvement across a district, as seen in Birmingham, can also be realized when the district leadership is supportive.
Willingness to sustain a partnership beyond the period of outside funding can also be related to the vision of a district's leadership. The partnership in Worcester is important enough to the district that funds were found to support its continuation after the end of HPPI grant, in addition to funds committed by partner professional schools and colleges. The importance of the partnership in carrying out the vision of the school resulted in continuation despite the loss of the original district superintendent under whom the program began. In other instances, where the partnership had not developed strong support within the district or within individual schools, there was no willingness to fund continued partnership activities with monies from the school district. The inability to sustain programs appears to stem, in part, from lack of support from district leadership and the inability to overcome governance structures in individual schools.
Selection of strong schools
The selection of a school partner also appears to be a critical factor in success of partnerships. The most unfortunate example of this tenet was found in a partnership assigned to a high school by the district leadership because the school was the most in need of help. Although the school had been named a health sciences magnet, the quality of the teachers and the facilities did not support the title. Within the first 18 months of the partnership, the principal and all teachers were replaced. It was impossible to mount any type of a partnership program in an environment of organizational confusion and mistrust. Although the district sought to place the resources of the partnership where they were needed the most, the school, its teachers, and principals were unable to utilize any outside resources when basic organizational issues had to be resolved. In this example, turnover was a major problem. In other instances, loss of a small number of key personnel disrupted program development and required that new teachers be brought into the program and oriented to its goals and activities.
Schools able to utilize resources from a partnership have principals who have the time, interests, and ability to consider ways to use outside resources. Successful teachers are those willing to attempt changes in teaching methods and integrate new content into course work. Facilities too must be adequate to support teaching innovations. Successful schools may not have the most resources or the best buildings, but they are in position by virtue of staff, leadership, and resources to begin the process of innovation and improvement.
Competing priorities and programs in a school may limit the success of a partnership. In an earlier example, change in leadership brought with it a change in priorities for educational activities, and the partnership was no longer relevant to the school program. Other issues, such as increased stress on standards-based testing attached to funding, may get in the way of reasonable program development. In one school district, teacher interest was focused so closely on standards-based testing that the only service welcomed was helping students become better test takers, rather than helping them to master curricular content. Creativity in science education was lost to anxiety about test performance. In another state, the students were tested in science only in specific, noncontiguous grades instead of at all grade levels. This led to emphasis on science education in specific grades, frustrating efforts to build programs across grades and resulting in students' loss of science knowledge and ability from year to year.
Health science magnet schools or science magnet schools may be good choices as partners, but the appellation of magnet does not necessarily indicate a better candidate partner or always refer to the same type of education program. At Laredo and New Haven, the magnet designation included a selective admission policy, an emphasis on health science content, and enriched science content within courses. Hill Career High School has a series of emphases, and every program available includes enriched or advanced courses. The health sciences magnet at Alexander High School is a small school within a larger general high school. Other designated magnet schools were not selective in admissions and varied in the numbers of enriched or advanced science courses they offered. At one school, the enrichment was limited to more offerings in vocational and work-based experiences. Titles alone do not indicate appropriateness of a school for partnership.
A strong school is one that has the characteristics of vision, leadership, and governance structure described earlier and whose faculty and leadership are interested in improving instruction relating to sciences and health sciences careers. Its staff has the instructional and administrative skills necessary for a reasonably successful educational program. Strength includes the ability of the school staff to focus on issues of educational improvement without being distracted by problems outside the school, and the will to turn challenges such as mandated testing into opportunities to improve the general education in the school. Schools that experience high rates of staff turnover, or the loss of single key staff members, may also lose their strength as program participants.
Professional development activities, curriculum materials, curriculum development, and any other activity undertaken by the partnership must be designed to help teachers to function better with their current responsibilities within the classroom. Activities imposed from the outside and designed without adequate consultation of teachers and schools may fail to be implemented because they were designed to meet needs not important to the teachers and failed to take into account teacher priorities. Failure to develop a consensus on the need or relevance of materials and to develop a sense of “buy-in” for the program will probably lead to failure. The best strategy is to find ways to support teachers' needs rather than burdening them with new demands that distract their attention from curriculum priorities.
A second aspect of this concern is demonstrating respect for the teachers as professionals through compensation for their time and effort. Asking teachers to participate in professional development or programs outside regular classroom hours without compensation, either financial or in release time, is perceived as a message that the teachers' time is not valuable. Teachers' involvement in program activities should include ways to recognize the professional value of their participation, particularly if the activities require time outside school hours. Difficulties involving teachers in tutoring activities at the University of Michigan HPPI were quickly overcome when one teacher at each school was designated as tutoring coordinator and given a small stipend. In this instance, the financial support of only one teacher acted, perhaps symbolically, to raise the importance of the project and recognize the contribution of teachers.
Parental and family involvement
Some schools have been successful in involving parents in school programs. In these instances, it was the enthusiasm and persistence of the principal that stimulated active parent programs. At one elementary school, the principal established the school as a community of families where parents were welcome at any time. It was also expected that teachers would contact each child's parents within the first few days of each academic term and then every other week during the school year. Parents at another elementary school were actively involved in designing and conducting after-school programs for students and their own families.
At other sites, teachers and administrators were struggling with involving parents. Sites that were successful at involving parents in partnership programs worked with schools that already had success in this effort. Strong parental involvement with school programs and effective outreach to parents were based in the efforts of the school, not the partnership itself. Organizations such as the Urban League in Birmingham and individual churches in Kansas City conducted successful programs that required parental participation. Partnerships can work through such organizations to reach parents. It is much more difficult, although not impossible, for partnerships to draw the attention and loyalty of parents beyond the schools and community organizations with which they are already involved.
Changes in Public Schools Resulting from Partnerships
Successful partnerships have resulted in total redesign of a sciences curriculum at one school, development of new advanced courses for use in high schools in several districts, and improvements in science and math offerings in elementary, middle, and high schools. Some schools have received significant amounts of materials and supplies, such as an electron microscope, for use in their programs. Access to other resources, such as science laboratories in professional schools or at science museums, has been made available to partner schools. In a number of partnerships, teachers received advanced training in science topics and research skills and have translated this training into changes in content and teaching methods. In the words of one middle school principal, science is now taught as a “hands-on” activity in her school because of the professional development offered by HPPI. Research requirements for graduation from one magnet school are being met, in part, by research training provided to students on a professional school campus. Other schools have enjoyed increased access to career education through internships and other educational offerings made available at health sciences centers. Many of these changes have remained and will remain in place after the ending of HPPI funding to the partnership.
Partnering with Community-based Organizations
Demonstrating participation of community-based organizations was required of HPPI applicants in the second- and third-round awards. The call for proposals stated that these organizations were to be “predominantly minority” and “with roots in the community of students to be served by the grant.” These organizations were, at a minimum, to play a supportive, advisory role to the partnership. Table 3 displays the numbers of sites at which these characteristics were discovered.
There was a wide range of understandings about what constituted a community-based organization. As one HPPI staff person asked, “What is meant by ‘community’?” HPPI sites designated churches, the National Association for the Advancement of Colored People (NAACP), the Urban League, a housing project association, educational science centers, AHECs, minority professional organizations, and even the public schools themselves as their community-based organization partners; only the first four of these met the criteria of being predominantly minority and based in the community of the students served. Instructions to round-three applicants further specified that although AHECs and professional societies were permissible additional partners, they were distinct from community-based organizations and could not be counted in fulfillment of this grant requirement.
Four of the ten sites we visited had significant involvement of organizations that were truly community-based in the spirit of the call for proposals. Two were not working with any community-oriented organizations. Four worked with AHECs, minority professional societies, and science centers—organizations that did not meet the requirements of the call for proposals. At two sites, we were told that initial efforts to include the community-based organizations had not resulted in any significant contributions to HPPI activities. The comments reviewed here are from organizations that meet the characteristics of a community-based organization defined in the call for third-round proposals.
It was not for lack of effort that only a minority of the projects had solid relationships with community-based organizations. Several sites had attempted to work with churches or ministerial alliances but met with only limited success. For this reason, we met with fewer community-based or other local organization representatives than other types of partners during our site visits. Nevertheless, the comments of both HPPI project staff and local organization representatives point to several key factors that made the difference between a true partnership and less successful collaborations.
Organizations that became active HPPI partners had several common features: They shared the vision of improving minority academic and career achievement, they had resources to contribute to the partnership, and they had stable leadership.
In addition, they often had pre-existing youth programs in academics and community service that made their activities compatible with the HPPI mission, or they had independently identified these kinds of programs as a desired goal before their involvement with HPPI. For example, the Urban League of Birmingham had a youth coordinator on staff and sponsored a series of leadership activities for middle and high school students in the area before it partnered with UAB. The Urban League had significant resources committed to leadership and career development activities that could be shared. The HPPI provided content in health careers and access to resources of the academic health care center. In another instance, a public housing facility management organization had supported a series of after-school and weekend activities in tutoring and academic enrichment before it partnered with the University of Massachusetts HPPI. The HPPI gained access to a group of students to work with, and public housing group gained access to HPPI-sponsored programs.
Community organization representatives at three sites specifically mentioned complementarity of needs and resources with other HPPI partners as an important motivation for their participation. Furthermore, organizations had to be willing to share resources: four sites experienced territoriality, especially among churches, as a significant barrier to collaboration. HPPI staff felt they had no alternative than to discontinue working with organizations that wanted to “own” and control their programs independently or otherwise were not interested in cooperating with the partnership.
A successful example of partnering with community churches is found in the Kansas City HPPI. A number of churches were identified that had begun to develop a computer “ministry” program for their members. These churches had committed money, space, and staff time to develop a computer facility in their own buildings that could be used by parishioners to learn computer skills and utilize computer-based educational resources. As a partner, HPPI provided additional computers, Internet connections, and access to educational software to these ministries with the only proviso that anyone in the community, not just church members, could have access to these resources. In this successful arrangement, a HPPI program was able to identify a need and provide a service in several churches without competing directly with the churches or increasing competition between churches.
In contrast, another site failed to establish a working partnership with a ministerial alliance whose members provided after-school tutoring services in their own buildings. A number of these churches seemed to compete with each other for student attendance and established barriers to prevent nonmembers from using their services. A major activity of the HPPI in this relatively small community was to develop additional tutoring services for middle and high school students that took place in the local schools. It was reported to us that churches were reluctant to participate in the HPPI because of suspicion of the intent of the large medical center conducting the program and because the program would end in only five years. It also seems possible that the HPPI was perceived as competing with, rather than complementing, the churches' own activities.
Organizations that had a vital community presence were able to act as equals in four partnerships. In contrast, HPPI staffs at four other sites found it impossible to partner with weak or resource-poor community organizations. In two instances, HPPIs attempted to partner with ministerial alliances that were primarily organizations for meetings and discussions of issues without formal programs or resources, and which also experienced changes in leadership within the first year of the program. Although these alliances included pastors from important and large congregations, the alliance leaders could not provide any substantial resources for program use and could not provide access to child members within individual churches. As organizations, they had little or no resources to offer to a partnership.
Volatility of leadership in community-based organizations also proved problematic in some partnerships. A partnership with a local chapter of the NAACP provided significant access to community organizations and other resources for a HPPI for the first year of the project. When a new leader was installed during the project's second year, support of HPPI activities nearly stopped, as did access to community resources and groups. Staff at one HPPI observed that the HPPI acted as a stabilizing and strengthening influence on otherwise weak community-based organizations, rather than the other way around.
Are the relatively low levels of involvement of community-based organizations in HPPI projects cause for concern? Though it is difficult to generalize from the relatively small sample in this study, it is reasonable to conclude from our findings that community-based organizations can be helpful but are not always necessary for the establishment of successful partnerships between professional schools and K–12 schools and districts. Although several HPPIs had excellent relationships with community-based organizations that included the sharing of significant resources and contact with a larger number of students, these relationships were not a component of all programs that successfully partnered with schools and districts.
General Issues in Partnering
There were three characteristics associated with any good partnership regardless of the type of organization: the right person at the right time, strategic responsiveness, and communication and coordination between members. Table 4 displays the numbers of sites at which these issues were discussed.
Right person at the right time
The personalities and interests of partner leaders did have an important influence on the success of partnerships. Leaders needed to be enthusiastic and concerned about the goals of the program, to be able to work well with many types of people, and to have solid leadership skills. “The right person” for the job was an important factor in beginning and sustaining partnership activities. Sometimes, the success of a program stemmed from pre-existing relationships between individual leaders in the public and professions school partners. The right person could also be one with a history of contacts in the schools that gave access to other resources and leaders.
At the successful sites we visited, many of the founding leaders remained. It is not clear whether, or at what point in its history, a partnership can endure the departure of a successful leader. Change in leadership may not necessarily result in damage to the partnership; the founding school superintendent in Worcester left but was succeeded by the person who had been an assistant superintendent in the system when the partnership was founded. The new superintendent's prior experience aided the transition to new leadership, as did stability in leadership at the school of medicine. It is also possible that the partnership had developed sufficient organizational maturity by the point of the leadership change to survive.
How much change in leadership and personnel is deleterious? Earlier we reported that turnover in partnership staff and member organizations affected the success of individual programs. Will simultaneous changes in staff and leaders of an established partnership result in a nonfunctional organization? Birmingham City Schools lost its superintendent at the same time that the founder of CORD left her position at the UAB. Will the loss of leaders from two major institutions result in damage to the partnership, or will the historical success of CORD's work with public schools keep the program moving forward? These questions cannot be easily answered, and the HPPI has inadequate case histories upon which to base solid assertions. It can be concluded, however, that a leader's personality and the situation in which opportunities for partnering are found do play a major role in the success of a program, particularly in the initial stages. Partnerships with more experience and histories of working relationships between members may be better able to continue despite changes in leadership.
A corollary of good leadership is the ability to respond in a strategic, or careful and well-planned, manner. Successful programs have expressed clear goals to guide their efforts but have not attempted to achieve all goals and objectives from the beginning of the partnership. They began with a series of small activities that led to early successes and gradually added new programs, building toward much larger goals. Sites that attempted to mount too many programs initially quickly realized the need to refocus efforts on smaller numbers of projects to achieve success.
Another important feature of successful sites was the ability to respond to opportunities for new partnerships with organizations working toward similar goals. The University of Massachusetts and University of Oklahoma experienced difficulty in working with original partners and were able to add new, more interested, and better-suited partners later on. Organizations that are unable to act upon new possibilities may lose opportunities for success in their communities.
Communication and coordination
Although governance issues did not occupy a large portion of discussions during site visits, there were a number of comments regarding the nature and pattern of communication between members. There was concern about inclusion of all members in the making of important decisions and about support of this by adequate patterns of communication.
Teachers and administrators in several elementary schools at one site were very concerned that they had not been consulted, or informed, about changes in the middle and high schools in the partnership and that significant decisions had been made without any discussion. The issue was lack of communication and shared decision making, even if the decisions themselves were reasonable and probably would have resulted from broader consultation. Adequate communication about decisions and activities was seen as an important component of partnering and equality between members.
On the other hand, reliance on large and bureaucratically designed councils for communication and participation in decision making was portrayed as potentially hindering progress. Meetings of senior leaders from all organizations, such as deans, superintendents, and presidents, are difficult to schedule and conduct. Such leaders frequently did not have sufficient day-to-day experience of partnership activities upon which to base their guidance. Frequent communication, both formal and informal, was needed between individuals who were actively involved in daily program activities.
The frequency and type of communication should fit the partnership tasks involved and the types of representatives participating. While weekly informal communication might be needed between staff conducting programs, formal meetings of partnership councils might take place only every six months to review general policy or renew institutional commitment. On the other hand, it was noted that relying solely on informal and unscheduled communication could lead to inequality in the types of information available to each member and problems in representation in major decision making. The specific tasks involved and the types of decisions to be made should dictate the frequency and types of communication patterns required.
Partnerships between health professions schools, public schools and districts, and community-based organizations are complex and challenging endeavors that require leadership, vision, and the ability to mold a common set of programs that span the unique interests and cultures of all institutions involved. Efforts to increase the number of underrepresented minority students in health careers education must focus on the problems in our schools that result in underperformance and inadequate preparation for advanced education, as well as introducing children and parents to the potential careers available to them in health fields.2
The most effective methods for increasing the number of students academically capable of entering health careers appear to be based in general and systematic reform of education, from the earliest levels of primary school through high school. A single intervention in one grade or school level or a series of unconnected interventions will not result in a sustainable increase in academic performance. As students progress through their education, they also need guidance by career education, counseling, and mentoring into the activities that will support their choices of careers. But motivational and career education alone will not provide the academic skills needed for education in the health professions.
The qualitative analysis of our interviews and site visits has provided insights and examples of how health professions schools can work successfully with public schools. To summarize: The most successful partnerships were located in health professions schools that had interest in and commitment to service in their communities. Individuals who could work in both cultures of the health professions and public schools led the partnerships. Attitudes of respect and a stance of listening to the needs of partnership members were essential. Governance of the public schools supported innovation and problem solving. Happenstance and convergence of interests played a significant role in the development of the partnerships: e.g., the president of the professional school attended a party with the school superintendent, or a state-initiated school reform was written into law just as the professional school became interested in partnering for school improvement. Perhaps the most telling statement from successful programs was “We did it, together.”
A number of public schools and districts have received major benefits from partnering: the professional development of their teachers, assistance in curriculum development in the sciences, materials and supplies needed to support science education, and assistance in career education through the provision of internships, mentoring, materials, and enrichment activities. In some instances, these benefits resulted in permanent changes to the skills of teachers and curriculum offerings of the schools. Exactly how these changes affected children or parents is not known.
By design we did not attempt to document outcomes in terms of numbers of children influenced by programs or individuals entering health careers; this type of data had not been collected by the partnerships or by the national program office. We were also unable to identify specific instances in which the programs had resulted in lasting changes in health professions schools. The health professions schools with the most successful partnerships had developed the vision, leadership, and infrastructure for partnering before the advent of the HPPI award. Although other health professions schools that had not been involved with prior diversity efforts were changed by the presence of new HPPI personnel and programs being sponsored, it is not clear whether lasting changes in the faculty or schools' programs will result from the advent of HPPI, or even whether HPPI's efforts will be institutionalized.
While the results of this study can point out characteristics of schools and organizations that are associated with smoothly working partnerships, identify barriers to successful partnering, and suggest the types of strategies and programs that appear reasonable to support the increase of underrepresented minorities in health careers, it cannot provide evidence that these partnerships will achieve their workforce goals, or even identify the best specific educational practices appropriate to their goals. As with all other programs sharing the goal of increasing underrepresented minority health care practitioners, evaluation of outcomes is inherently difficult and has received inadequate attention.15,16 Development of competently functioning partnerships between professional schools, public school districts, and community-based organizations can be the basis on which successful educational interventions are built. The results of this investigation can inform educational institutions how to approach the establishment of their partnerships. Additional work is needed to establish the educational practices that will bring about the changes in the schools and in children that will support the ability of underrepresented minorities to enter and successfully navigate the pipeline to a health professions career.