Inadequate access to health care and to higher educational opportunities are two salient issues facing underrepresented communities (African Americans, Latinos, and Native Americans). Twenty-one percent of African Americans and nearly one-third of Latinos did not have health insurance in 2010 compared with 12% of non-Hispanic whites.1 Even when controlling for insurance status, underrepresented groups face significant challenges accessing quality health care.
Chief among these are barriers related to language, geography (the scarcity of health care facilities in underrepresented communities), and cultural familiarity (the scarcity of minority health care providers).2 In this article, I examine the Urban Health Program (UHP) at the University of Illinois at Chicago (UIC) as an effective response to overcoming these barriers.
According to the Sullivan Commission on Diversity in the Healthcare Workforce report (2004),3 the dearth of minority health care professionals places the health of people of color at risk. Although underrepresented minorities made up approximately 25% of the population in 2004, they accounted for less than 9% of nurses, 6% of physicians, and 5% of dentists. Furthermore, less than 10% of baccalaureate nursing faculty members, 8.6% of dental school faculty members, and 4.2% of medical school faculty members were minorities in 2004.3 In some cases, these statistics have improved somewhat since 2004, but the disparities are still great. Joiner4 states:
The lack of minority doctors in minority communities is a major factor in health disparities. Too often, minority communities are faced with providers who do not look like them and do not understand their cultural environment or social situations.
In spite of significant improvements, “schools of medicine, dentistry, and nursing have been among the last to integrate their classrooms, and their professional organizations have been equally slow in recruiting minorities into their ranks.”3 As recently as 2011, the nation’s medical schools graduated a total of only 2,600 (15%) African American, Latino, and Native American students from more than 17,364 students.5 The graduation rates were similarly disparate for nursing and dentistry.
A Programmatic Response to the Problem
The Sullivan Commission’s report3 sets forth three principles for closing the health professions gap: changes in the culture of health professions schools, exploration of new and nontraditional paths to the health professions, and commitment at the highest levels.
For over 30 years, the UHP at UIC has combined these principles and one other critical principle: community activism and involvement in its quest to increase minority health care professionals and stem the tide on health disparities.
The mission of the UHP is to recruit, retain, and graduate minority students interested in health care careers, and to provide precollege educational and research experiences for underrepresented minority populations in elementary and secondary public schools. These key features speak to the uniqueness and comprehensiveness of the program. It is more than a recruitment, academic support, or pipeline program. The UHP is all of these combined—a holistic approach to increasing the number of minority health care professionals.
Since its inception in 1978 up to the 2010–2011 academic year, the UHP has graduated 5,327 underrepresented minorities into the health professions from the graduate college and the colleges of medicine, dentistry, pharmacy, nursing, applied health, and public health at UIC.6 The factors that have been essential to the program’s success include community action and demand for a clear and decisive legislative mandate to increase the number of minority health professionals, early outreach and academic pipeline initiatives designed to increase interest in health-related careers among underrepresented minority elementary and secondary students, changes in the culture and commitment of health professions colleges, and institutional commitment at the highest levels.
Essential role of community activism and involvement
The UHP grew out of the Illinois General Assembly’s response to community outcry and protest during the civil rights movement over the lack of adequate health care services in poor, predominantly minority communities on the South and West sides of Chicago. When Dr. Martin Luther King, Jr, moved to Chicago in 1966, he mobilized the African American community around the issues of fair housing, education, and health care. As Dr. King argued before the Medical Committee for Human Rights in Chicago in 1966, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”7 After Dr. King left Chicago, the community continued to press for these demands, leading to the creation of the Medical Opportunities Program (MOP) in 1969.
In 1978, the Illinois General Assembly mandated an expansion of the MOP, creating the UHP. The MOP program had, since 1969, assiduously worked to recruit minority students into the UIC College of Medicine. However, the creation of the UHP replaced and simultaneously expanded the MOP’s effort to include all of the health professions programs at the UIC: medicine, dentistry, pharmacy, nursing, applied health, public health, and the graduate college. The selection of the UIC to implement the UHP was well received by administrators, who felt that the university was better suited than other area universities to train underrepresented minority students, particularly considering its success with the MOP.
Ongoing role of the Community Advisory Council
In recognition of the key role of the community, the UHP Community Advisory Council (CAC) has institutionalized the community activism that led to the creation of the UHP, and has served as a defining force in the maintenance of the program. The CAC’s membership consists of leading business and community leaders, educators, health professionals, representatives of interested organizations, and alumni. Several former CAC members serve in the U.S. Congress, the state legislature, and other pivotal health- and education-related positions within the state. Through their combined efforts, CAC members, both past and present, have been leading advocates for the goals and mission of the UHP and have provided invaluable resources to the program and its students. Perhaps the most essential source of support comes from the CAC’s ability to hold the university and the legislature accountable through informal and formal relationships.
The mission of the CAC is to monitor, evaluate, and support the programmatic efforts of the UHP and to provide periodic advice to the chancellor regarding policies and practices that may enhance the university’s ability to attract and maintain a culturally diverse health sciences graduate and professional student body and that help maintain the image that the institution projects to the community in carrying out the mission of the UHP.
The CAC is a 26-member body. Although CAC members serve at the pleasure of the chancellor, because of their community standing there is reluctance to remove them. As a result, most members have served for lengthy periods, with several serving 15 or more years.
There have been two areas of tension historically between the CAC and the university administration: (1) on matters of budget, and (2) on matters of organizational structure. Over the years, these matters have been addressed by ensuring greater transparency in the budgeting process (particularly how the state appropriation is divided between colleges) and in making alterations to the organizational structure that ensure clearer lines of reporting and accountability.
Organizational structure of the UHP
The leading role of the CAC is illustrated in the organizational structure of the UHP (see Figure 1). The CAC has a direct role, advising the chancellor, the provost, and the executive director of the UHP. As indicated in the figure, the UHP uses both a centralized and decentralized organizational structure to reduce the silo effect, which is a tendency to work in an insular and individualistic manner without regard for larger university or program goals and objectives. UHP offices are located in the university’s six health professions colleges—applied health sciences, dentistry, medicine, nursing, pharmacy, and public health—as well as in the graduate college at the university. Each college has either an assistant or associate dean acting in the capacity of UHP director, who reports to the college’s deans and has a fiduciary responsibility to report to the executive director of the central UHP administrative office. The Early Outreach Program (EOP), which is a central component of the UHP, has a director who reports directly to the UHP executive director.
Each college is disbursed a portion of the Illinois State Legislature’s appropriation to the UHP according to the size and specific needs of its program. The faculty and staff of each college are responsible for supporting their UHP students as they progress through the curriculum. Support services for UHP students include academic and personal counseling, peer and nonpeer tutoring, and a broad variety of retention activities designed to enhance study skills and student success.
Recruitment efforts in the UHP are shared between the EOP, the central administration, and the college offices. The EOP is a central component of the UHP and shoulders the major responsibility of preparing K–12 students to enter the health sciences. College student recruitment, or talent search, is the responsibility of each college and is carried out by their designated personnel.
The central UHP administrative office provides support and coordinates activities between the individual UHP college offices, encourages cross-curricular collaboration, organizes comprehensive health-care-related programming and activities, and serves as the liaison to community organizations interested in issues of health disparities and educational access. The executive director is responsible for overseeing the enrollment management plan, which tracks and monitors recruitment, retention and graduation goals in each college, and the manner in which program dollars are spent.
Changes in the Culture and Commitment of the University’s Health Professions Colleges
The sustainability and effectiveness of the UHP over the past 34 years has resulted in changes in the culture, practices, and commitment of individual health professions colleges at the university. These changes have proven fundamental to ensuring that minority students in the health care professions receive the support needed to excel.
The initial state appropriation to the UHP was $58,000 in 1978. In 2010, this disbursement had increased to $2,013,213. When the UHP began, the financial commitment from the colleges to the UHP was nominal, with most contributing no financial resources to the program. In 2010, however, the college commitment exceeded the state commitment, at $2,289,992, for a total of $4,303,205 for UHP programs and activities.
In addition to changes in financial commitment, changes in the collaborative efforts of the colleges and their accountability to the central UHP administrative office and the provost have been fundamental to the maintenance of the program. In the past, there has been a tendency for colleges to go it alone, creating varying levels of student support and access across colleges. Collaboration and accountability are key principles in ensuring effectiveness. The UHP management team, which consists of UHP directors in the colleges, and the executive director, who serves as chair, works diligently to maintain a global focus. As a collective, the program partners with university-wide academic support programs, professional student associations related to the health professions, and university diversity offices and units. Through the efforts of the EOP, the UHP works directly with public elementary and secondary schools, Upward Bound, and other talent search programs, as well as with community organizations. These recruitment efforts create partnerships that enable the UHP to promote information on health professions to underrepresented students.
Exploration of New and Nontraditional Paths to the Health Professions
The most essential component of the UHP consists of the students who are served. To ensure that there are underrepresented minority students in the health professions pipeline, the program starts serving them early, by accessing them at all points of the preschool through graduate school (P–20) pipeline through the EOP. Figure 2 depicts the UHP’s efforts in the health professions pipeline. States across the nation have encouraged the creation of kindergarten through 12th grade (K–12) and P–20 programs to streamline educational governance so that elementary and secondary and postsecondary educational systems work more closely together. During its 2005 National Education Summit, the National Governors Association endorsed An Action Agenda for Improving America’s High Schools,8 which calls for states to develop comprehensive plans to “restore value to the high school diploma by revising academic standards, upgrading curricula and coursework, and developing assessments that align with the expectations of college and the workplace.” These programs are particularly important in the educational preparation of underrepresented minority students, who typically attend underresourced schools.
The EOP is staffed by a director, assistant director, parent liaison, and seven project coordinators. Approximately 30 high school students graduate from the program annually. During the 2010–2011 school year, 97% of EOP students attended college (24% at UIC) and had an average college grade point average of 3.06.
The EOP works with students as early as kindergarten, providing summer and after-school enrichment programs that teach young students about the scientific method, assisting them in enhancing their academic skills, particularly in math and science, and exposing them to the health professions to promote interest in health-care-related professions.
The EOP’s enrichment programming is enhanced by in-school programs sponsored by individual UHP college offices. For example, the college of dentistry’s UHP office conducts a “Healthy Smiles” program, which teaches students the importance of proper dental hygiene, and the college of pharmacy has a “Pathways to Pharmacy” initiative in UHP-supported elementary and secondary schools, that encourages students to careers in pharmacy. The UHP college offices also work closely with the UIC College Preparatory High School (UIC Prep), which has proven an invaluable source of minority students interested in health care professions. UIC Prep is a charter school established in partnership with UIC. Several faculty and staff in the health professions colleges contribute to the UIC Prep math and science curriculum, and many UIC Prep students participate in EOP programs for high school students, which include Saturday College, an intensive math and science program, and the High School Senior to College Transition Program. Additionally, each year the UHP sponsors a daylong information fair and conference for 6th- to 12th-grade students to expose them to the health professions. The conference draws over 500 students annually.
Partnership with community colleges
The UHP has a long-standing partnership with community colleges in Illinois, particularly the Chicago city colleges, which primarily serve underrepresented minority students. The university hosts community college articulation conferences every year and is aggressively pursuing two-plus-two programs with the city colleges, which provide students seamless admission and transition from community colleges to the university.
The health professions colleges recruit extensively in the city colleges’ health-professions- affiliated programs (nursing and applied science) and, in 2010, initiated an annual student motivational conference in which African American and Latino health care leaders shared stories about their own career and educational paths.
As Table 1 illustrates, during the 2010–2011 academic year, the proportion of African American and Latino students enrolled in the health professions colleges was approximately equal, at 578 and 575, respectively. When the program began, African Americans represented a much larger proportion of UHP students; however, with the growth of the Latino population and increased efforts to recruit eligible students, the numbers of Latino students have increased significantly. The growth in the number of Latino students has seen an attendant increase in academic support programs that directly target these students.
Importance of Commitment at the Highest Levels
The commitment of the UIC and the Illinois State Legislature forms a feedback loop that is directly associated with community activism and involvement. As noted earlier, community outcry and protest led to the creation of the UHP, and the CAC has maintained this commitment through a direct and indirect system of accountability.
The commitment of the university is manifested in the interaction and accountability of the chancellor and provost to the CAC and in the increasing commitment of resources to the UHP on the part of the health profession colleges. The Illinois State Legislature’s commitment is evident in continued appropriation to the UHP in spite of dwindling state resources and the need for austere measures in other areas of the state budget. While other state appropriations have dwindled, UHP appropriations have remained constant.
The UHP Student Experience
The UHP’s efforts at the undergraduate, graduate, and professional levels are extensive. The UHP supports the Pre-Health Undergraduate Student Organization, which encourages the pursuit of health care careers among minority students enrolled in the sciences at UIC. The organization is a source of information, academic and career counseling, opportunities to network with current minority health professions students, links to support programs and faculty and staff in the health professions colleges, and access to UHP forums and events.
The UHP also hosts a summer research opportunities program for undergraduate students that promotes mentoring relationships with UIC faculty and UHP alumni. With assistance from the university, the UHP has also created a “living and learning community”—a dorm floor dedicated specifically for undergraduate UHP students interested in the health sciences to enhance networking and cohort support among those students.
UHP students enrolled in the health professions colleges receive academic support services, such as peer and faculty tutoring as well as test preparation for various tests, such as the Graduate Record Examination, the Medical College Admission Test, the Dental Admission Test, the Pharmacy College Admission Test, and licensure exams. The students are encouraged to participate in national student and professional organizations and conferences, linked with alumni and faculty/staff mentors, and are provided opportunities to work in underrepresented communities. The UHP’s location in the medical district provides students convenient access to clinical experiences at the university of Illinois Hospital, John H. Stroger, Jr Hospital of Cook County (formerly Cook County Hospital), and community health clinics. The goal of these practical experiences is to promote service within underrepresented communities in order to address health care disparities. According to Shenice Williams, a former college of dentistry student, “The Urban Health Program has been one of the most important factors contributing to my success in the health care profession.”9
As is the case for all academic programs, the measures of success for the UHP have been recruitment, retention, and graduation rates. The Illinois State Legislature’s financial commitment has been dependent on the UHP’s carrying out its mission to increase the number of underrepresented minority students graduating in the health professions. The UHP has exceeded state legislative expectations and has become a national leader in the graduation of underrepresented minority health care professionals across the health professions, second only to historically black colleges and universities and Latino-serving institutions with health professional programs.
Since its inception, the UHP has ranked high in the enrollment and graduation of minority students in the health professions. For example, in 2010 the UIC College of Medicine ranked number 1 in the graduation of Latinos, number 2 in the graduation of all minorities (including Asians), and number 5 in the graduation of African Americans nationwide.10 The UIC’s record enrolling Latino students is part of this success:
According to data from the Association of American Medical Colleges, in 2010 UIC had 212 enrolled Latino medical students, the highest number in the continental US; more than schools in California, Florida, New York, and Texas, states with much larger Latino populations.11
Between 1978 and the 2010–2011 academic year, 5,327 degrees were awarded to UHP students in the health sciences at UIC. This is an average of 148 degrees per year. Of the total degrees awarded during this period, the college of medicine awarded 40%, applied health sciences, 17%; nursing, 14%; pharmacy, 7%; graduate college, 6%; and dentistry, 5%. Between 1997 and 2010, UHP students have composed 10,618 (16.3%) of the nearly 65,000 students enrolled in the health sciences programs at the UIC and have received approximately 13% of total degrees earned.
Another significant milestone has been the ability to retain UHP students in Illinois. Currently (2011), 70% of UHP graduates remain in the state of Illinois. This has significant short- and long-term economic and nonmonetary benefits to the state economy and to meeting health care needs of underrepresented communities. Many of the state of Illinois’ top health care professionals and leaders have been alumni of the UHP, including the commissioner of the Chicago Department of Health, the director of the Cook County Department of Health, and the director of the Illinois Department of Public Health, attesting to the influence of the program.
Suggestions for Academic Institutions Seeking to Adopt the UHP Model
The UHP has been a pioneer in the efforts to increase the number of minority health care professionals and the provision of vital health care services to underrepresented communities. Four key preconditions (listed earlier as key factors) are needed to implement the UHP model in other university settings:
* Community action and demand for a clear and decisive legislative mandate to increase the number of minority health professionals
* Early outreach and academic pipeline initiatives designed to increase interest in health-related careers among underrepresented minority elementary and secondary students
* Changes in the culture and commitment of health professions colleges
* Institutional commitment at the highest levels
The long and winding road is made less arduous when the community, legislature, university, and health care professionals travel it together with the will and commitment needed to exert change.
Other disclosures: None.
Ethical approval: Not applicable.