Purposeful Recruitment Strategies to Increase Diversity in Physical Therapist Education

Abstract

Background and Purpose. 

A more diverse physical therapist (PT) workforce is needed to meet the rapidly changing demographic of the United States. To achieve this increased representation within the profession, PT education must recruit, admit, and retain a more diverse student body. A comprehensive definition of underrepresented minorities (URMs) in professional physical therapy education was recently expanded to include educational, economic, and geographic disadvantage in addition to race and ethnicity.

Position and Rationale. 

The PT profession has not examined the disadvantaged profile of its applicant pool or student demographic, but this expanded URM definition now supports this effort. This position paper reports on a survey conducted by the American Council of Academic Physical Therapy's Diversity Task Force designed to examine recruitment into PT education through the lens of the new URM definition, with a focus on how students from underrepresented and disadvantaged backgrounds decide to pursue a PT career. The position taken was that identifying potential differences in how URM students achieve this decision will support the development of purposeful recruitment strategies for students from URM groups.

Discussion and Conclusion. 

Students from URM backgrounds reported different critical decision ages, as well as different use of or preference for resources to learn about the PT career and to prepare for application to DPT programs. Although personal experience with physical therapy was the primary influence on white students' decision to pursue a PT career, values and interests were equally impactful on this decision for disadvantaged students. Both nonwhite and disadvantaged students were also more influenced by exposure to the patient–therapist relationship and by inclusion and diversity than white students. This paper uses these data to support the need for different strategies and tailored recruitment of URM students into physical therapy education programs.

BACKGROUND AND PURPOSE

The shortage of health care professionals from underrepresented groups significantly undermines the national effort to reduce health disparities and achieve a health care workforce that matches the US demographic.¹ To prepare more diverse graduates, professional physical therapist (PT) education in the United States must recruit, admit, and retain a student body that is congruent with the demographics of our rapidly changing population. To date, this has not been achieved, and the diversity gap in professional PT education is widening.

The distribution of enrolled students in PT education programs categorized by race and ethnicity has not changed significantly in at least a decade.² During the 2016–2017 academic year, only 9.7% of students were from underrepresented racial/ethnic groups (Asian students are not considered underrepresented minority [URM] in PT education); an additional 2.7% of students were designated by programs in the “two or more races” category for a combined total of 12.4% of admitted students.² Notably, the percentage of African-American students enrolled in PT education programs declined from 4.8% in 2004–2005 to 3.1% in 2014–2015 and held constant at 3.0% during 2016-2017.² Demographic data on applications and admissions to PT programs participating in the PT centralized application service (PTCAS) support that numbers of students from underrepresented racial/ethnic groups (19.4% of applicants in 2015–2016 and 11.8% of accepted applicants in 2016–2017) remain insufficient to meet the current and projected US demographic.^3,4

In response to the stagnant diversity in professional PT education, the American Council of Academic Physical Therapy (ACAPT) established the Diversity Task Force (DTF) in January 2013 and charged it with “defining URM in PT education and affirming a rationale for promoting a diverse PT student population and workforce in physical therapy.”^2(p.1) After reviewing similar academic organizations for other health-related professions, the DTF proposed a definition for URM, as follows: Underrepresented in physical therapy means those racial and ethnic populations that are underrepresented in the physical therapy profession relative to their numbers in the general population, as well as individuals from geographically underrepresented areas, lower economic strata, and educationally disadvantaged backgrounds. This definition was subsequently adopted by ACAPT in October 2013 and in June 2014 the American Physical Therapy Association (APTA) House of Delegates adopted an amended definition of URM that is specific only to physical therapy education, realizing that increased diversity in education will translate to an increase in diversity within the profession.^5,6

While race, ethnicity, and lower socioeconomic strata within this definition are commonly understood, educational, and geographic disadvantages may require explanation. Educational disadvantage includes being a student who is a first-generation college student and/or for whom English is a second language; it also includes coming from a school with a less than 50% graduation rate, no guidance counselor, no college preparation, or advanced placement courses available and/or being from a school district in which 50% or less of graduates attend college. Geographically underrepresented areas include specific regions (eg, Appalachia) and/or may be defined as a medically underserved area or a designated area with a shortage of health professionals.⁵ The PT profession has not examined the disadvantaged profile of its applicant pool or student demographic. We argue that this may be critical for efforts to increase recruitment and admission of URM students.

Following the adoption of the URM definition, the DTF undertook the second part of its charge: to affirm a rationale for promoting a diverse PT student population. Although studies have examined factors predictive of graduation and licensure success of PT students including URMs, these studies have not specifically explored the extent to which diversity factors impact student recruitment.^7-14

Three common initiatives to support the successful recruitment of URM students across medicine, dentistry, nursing, and pharmacy include student mentorship, pipelines, and enhancement programs. Each theme addresses “opportunity gaps” that occur based on inequities and disparities in the educational system and the deeply entrenched history of educational and economic disadvantages for many underrepresented groups.^15-17 The PT educational community has not systematically developed these initiatives, although academic programs recognized for minority initiatives and achievement often have one or more of these initiatives very intentionally developed.¹⁸

In determining the most significant challenges facing professional PT education relative to URM student recruitment and retention, the DTF conducted and reported on a survey of program directors of professional PT education programs.⁵ Forty-five programs responded to the online survey representing 21.02% of the professional PT education community at the time. Although the response rate was likely not sufficient to reflect the entire scope of URM recruitment and retention strategies in PT education, the data obtained suggested that recruitment of qualified URM students to professional physical therapy educational programs posed a greater challenge than retention.⁵ Thus, the DTF adopted a secondary focus on recruitment.

The purpose of this position paper is to examine recruitment into PT education through the lens of the new URM definition by examining how students from underrepresented and disadvantaged backgrounds make a decision to pursue a PT career. We propose that identifying potential differences in how URM students achieve this decision will support the development of recruitment strategies to specifically target URM groups. By reviewing PTCAS data (2015–16) after its adoption of questions that probe underrepresentation and disadvantage and by reporting on a survey of enrolled PT students, a preliminary picture will be described including 1) factors students consider in selecting a PT career and 2) differences in the composite of factors across nonwhite and disadvantaged groups. These data will then be applied in proposing recruitment strategies that respond to influential factors in career decision-making for URM students.

POSITION AND RATIONALE

The ACAPT DTF identified a need to determine what factors most significantly contribute to a student's decision to pursue a PT career and, within this, to understand the similarities or differences in the process by which URM students make this decision. To achieve this objective, qualifiers based on the URM definition were used in a survey to identify similarities and differences in factors influencing student decisions for and pathways to a career as a PT.

Student Data

Survey of Enrolled DPT Students

A survey of enrolled DPT students was developed by members of the DTF and APTA and was approved as exempt by the Alabama State University Institutional Review Board. The survey was then administered by APTA through the Formsite.com website. Solicitation efforts targeted the more than 25,000 students currently enrolled in DPT programs and included four communications to program directors asking them to encourage student participation and five total communications to enrolled DPT students using Facebook, Twitter, and the Student Pulse. Each communication included the link to the survey. The survey was opened on March 1, 2015 and it was closed on May 1, 2015.

This 11-question survey (Appendix, Supplemental Digital Content 1, https://links.lww.com/JOPTE/A14) was designed to examine students' self-reported background and factors affecting their decision to pursue a career as a PT. Specifically, nine survey questions were closed-choice, asking students to select one or more responses from a predetermined list of options, and two questions were open-ended. Within the nine closed-choice questions: two questions inquired about race/ethnicity; 1 question probed the extent of underrepresentation and disadvantaged background of each student; five questions targeted support systems and exposure from middle school through college, including advising, health care focused programs and clubs, and STEM programs that might have influenced decisions to pursue application to DPT programs; and 1 question asked what communication and social media tools are used by students. Additionally, two open-ended questions were designed to further our understanding of influences on students' decision to pursue PT education. One question asked students to indicate the age at which they decided to become a PT. The second open-ended question asked students to describe factors affecting their decision to pursue PT as a career.

Survey Response and Data Analysis

A total of 2,513 students completed this survey, yielding a response rate of approximately 10%. Given that demographic data informed by the recently expanded URM definition (including self-report of disadvantaged background) were available at the time this manuscript was prepared, parallel data from PTCAS, and in some instances from Commission on Accreditation in Physical Therapy Education (CAPTE), were used to support the representation of the student sample who responded to this survey.

Survey responses were downloaded and, where possible, quantitatively summarized. The responses to the open-ended question about factors affecting students' decisions to pursue PT as a career were qualitatively analyzed/coded to iteratively identify and then group themes. Two of the authors (V.M. and B.W.Y.) met to extract themes from the responses and develop the coding scheme for the data. This approach involved reviewing each response thoroughly for open coding of the responses. Open codes were then compared and consolidated into categories or axial codes through four iterations. The axial codes were then grouped into core concepts or selective codes to broadly capture the factors that influence students' decisions to pursue a career in physical therapy. Inter-rater reliability was achieved (kappa, 0.922) for axial coding using a random 25% of the sample before each reviewer engaged in coding the full data set. Additionally, a third reviewer (J.D.), who was not involved in the development of the codes, cross-checked the coding scheme by using it to code 30 randomly assigned survey responses. The coding of the third reviewer was then compared to the coding of the two primary reviewers, and a weighted kappa of 0.919 was calculated. Each axial code could only be counted once per each response although each response could be captured with more than one axial code. Finally, the frequencies of codes per respondent were summed and percentages determined for analyses.

Survey Outcomes

Race/Ethnicity

Students who identified as white (alone or in combination with other categories) responded to the survey more than any other group; compared to white respondents, only 11.91% of respondents represented all other racial categories, alone or in combination. Respondents indicating Hispanic ethnicity represented 5.7% of the respondents, and this ethnicity was spread among all racial categories. Racial/ethnic composition of survey respondents was similar to 2016–2017 CAPTE³ reported data for Black/African-American, Native Hawaiian or Other Pacific Islander but was higher for American Indian or Alaska Native and white respondents. Racial/ethnic composition of survey respondents compared to the PTCAS Applicants 2015–16 Application Cycle⁴ was lower for all categories except American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and white respondents (Table 1).

Table 1.: Diversity Among Survey Respondents Compared to 2016–2017 CAPTE^a Reported Student Demographics, 2015–2016 PTCAS^a Applicants, and the United States Population⁴ as of July 1, 2015

Disadvantaged Backgrounds

Educational, socioeconomic, and/or geographic disadvantages were indicated by students from all racial categories. However, students of color (alone and in combination with Hispanic or other races) represented the greatest percentage of disadvantaged backgrounds (Table 2). Educationally disadvantaged background was reported by 34% of the total sample. Within this subgroup, over 20% of students identifying as American Indian or Alaska Native, Asian, or Black, and 40% of students identifying as Hawaiian or Pacific Islander, were the first in their families to attend college. Students reporting as Hawaiian or Pacific Islander, American Indian or Alaska Native, or as being from two or more races were more likely to indicate having graduated from High Schools and school districts with low graduation rates and low advancement to college. Economically disadvantaged background was reported by 9.6% of the total sample. Within this subgroup, students who identified as racial minorities were 3–4 times more likely than white students to report having received meals at school during primary education and/or being from a family who received some form of public assistance. Finally, geographic disadvantaged background was reported by 4.5% of the sample, and Hawaiian or other Pacific Islanders were more than 10 times as likely to report coming from a geographically medically underserved area than whites.

Table 2.: Survey Respondents Report of Disadvantaged Background by Race^a

Age of Career Choice

Collapsed across all respondents, the mean age at which students reported deciding to become a PT was 19.6 years (mode 18 years, with a range of 5–56). When examined by ethnicity, race, and disadvantage (Table 3), slight differences were noted for Hispanic, nonwhite, and disadvantaged students. These URM students indicated fewer career decisions under age 20 and more between 21 and 25 years compared to the non-URM students. Additionally, nonwhite and disadvantaged students did not report career path decisions after age 30.

Table 3.: Age at Which DPT Students During 2015 Decided to Pursue PT as a Career Option

Resources for Recruitment

All groups of students identified PTs and the PTCAS website as the resources most frequently used for questions about the career field, educational program application, and admission process (Table 4). However, URM students reported more frequent use of Google or another search engine than a college advisor and were less likely to consult with a faculty member, compared to non-URM students. Interestingly, nonwhite students identified greater use of a DPT Program for their questions than all other groups, despite all respondents indicating low referral to a DPT education program for guidance with pre-PT academic planning (Table 5). Hispanic and disadvantaged students reported accessing a health professions or career advisor with higher frequency than other groups, and Hispanic and nonwhite students were less likely to utilize a pre-PT club for career information than other students. When surveyed about the role of minority faculty in decision-making for applying to or attending a DPT program, all students disagreed more than agreed that minority faculty impacted their decisions (Table 6); however, both Hispanic and nonwhite students compared to non-Hispanic and white students reported that the presence of minority faculty was impactful. This outcome is arguably confounded by the extreme lack of minority faculty in DPT programs.

Table 4.: Sources of Support Used While Exploring Physical Therapy as a Career Option, Presented in Relative Order of Most Used to Least Used Based on the Data Collapsed Across All Respondents^a

Table 5.: Referral to DPT Program for Academic Planning by Race

Table 6.: Role of Minority Faculty in Decision to Apply to and/or Attend a DPT Program

Qualitative Analysis: Factors that Influence Pursuit of a Career as a Physical Therapist

A total of 886 students (35.2% of the survey sample) responded to the open-ended question regarding identifying and selecting PT as a career choice. The focus of the survey was to inform our understanding of how students from URM groups decide to pursue a career as a PT and what factors lead to their application for admission to DPT programs. Given this focus and the limitations of the small number of open-ended responses, we broke the data into three nonmutually exclusive groups for qualitative analysis: white (N = 729), nonwhite (N = 142), and disadvantaged (N = 232). Before we coded, we used a random numbers generator to randomly select 142 responses from both the white and disadvantaged groups, so as to assess 142 open-ended responses for all three groups (ie, 142 was the maximum number in the nonwhite group). Code development based on review of all responses resulted in 40 open codes that were condensed into 12 axial codes which were ultimately captured by two selective codes: Experience and Influence and Values and Fit (Table 7).

Table 7.: Coding Schema that Emerged From Examining the Open-Ended Responses to the Question “Please Describe Any Other Factors Affecting Your Decision to Pursue a Physical Therapist Career”

Examination of the open-ended responses (Figure 1) revealed that white students identified factors related to Experience and Influence as more strongly influencing their career decision for PT. This was less true for nonwhite students, and disadvantaged students identified factors related to Values and Fit as more influential in their career decision. We further examined this relationship using the relative frequencies of the axial codes per selective code across the three groups (Figure 2). Personal experience was a strong influence for all groups, but is the primary influence for white students (Figure 2A). Career assets were also influential for all groups, but URM students, and disadvantaged students in particular, differentially reported a strong influence of values + interests (Figure 2B). Additionally, URM students also identified patient–PT relationships and inclusion + diversity as important in their decision-making.

Figure 1.: Selective Codes by Groups

Figure 2.: Frequency of Axial Codes by Groups Within Selective Code Categories: (A) Experience and Influence, (B) Values and Fit

Survey Summary

The response rate to the survey was low. The data nonetheless allowed for a preliminary exploration of similarities and differences in students' pathways to selection of a PT career when race, ethnicity, and disadvantage were considered. In summary:

• 1) With data collapsed across race and ethnicity, 34% of the sample reported educational disadvantage, 9.6% reported economic disadvantage, and 4.5% reported geographic disadvantage.
• 2) Enrolled PT students who identified disadvantaged markers spanned all races and ethnicities, yet disadvantaged backgrounds were more common among students of color.
• 3) More URM students reported making their career decisions in the 21–26 year age range than non-URM students.
• 4) Nonwhite and disadvantaged students did not report career path decisions after age 30 years.
• 5) URM students reported using online resources more than advisors and faculty to obtain information about preparing for and applying to DPT programs.
• 6) URM students were less likely to be involved with pre-PT clubs.
• 7) Summative themes of Experience and Influence and Values and Fit captured factors that influenced the career decision-making of all students, regardless of URM or non-URM status.
• 8) All students were impacted by personal experience with physical therapy. Whereas this was the primary influence reported by white students, values and interests were equally impactful for disadvantaged students.
• 9) Both nonwhite and disadvantaged students were influenced by values and interests, the patient–therapist relationship, and by inclusion and diversity; inclusion and diversity, in contrast, was barely identified by white students.
• 10) All students were influenced by career assets and career exploration.

DISCUSSION

Data on disadvantaged backgrounds have not been routinely collected by PT education programs or by the PT profession. As a result, student diversity and the profession's diversity have been measured, tracked, and understood solely on the basis of racial/ethnic origin, which may not adequately capture true diversity as defined by a broader set of metrics. The adoption of the new URM definition and its application to data collection through PTCAS begins to change the way we approach diversity in education, which should ultimately change the way the profession measures its progress toward meeting the diversity needs of the health care workforce.

The purpose of this position paper was to examine recruitment into PT education through the lens of the new URM definition by examining how students from underrepresented and disadvantaged backgrounds make the decision to pursue a PT career. The open-ended questions of the survey allowed us to probe the utility of the data collected through PTCAS, and indeed the outcomes are meaningful toward informing recruitment strategies.

Recruitment Efforts Across the Lifespan

The ages at which students from URM backgrounds make their decisions to pursue PT as a career tend to be shifted a bit later relative to non-URM students, which may reflect that URM students take longer to complete their undergraduate degrees and/or are less aware of careers or engaged with career mentoring at earlier academic stages. These data do not point to new insights, but instead confirm that recruitment is a comprehensive and long-term commitment.²⁰ Additionally, fewer students from nonwhite and disadvantaged backgrounds identified making late career decisions to pursue PT. While this may have been a function of the small sample captured with the survey, this finding warrants further investigation and lends itself to the question of whether second career or returning adults from URM backgrounds may be an untapped population in the effort to increase the diversity of the work force.

Fostering and Sustaining Relationships With Professional Education Programs

Underrepresented minority students reported high use of online resources and lower use of advisors and faculty in obtaining information about the profession and about preparing to apply to professional graduate education programs. This suggests lack of relationships with academic and professional mentors. Although all students reported low referrals to DPT programs for advising, nonwhite students identified a slightly higher influence of DPT programs on their decision-making process. The educational pipeline model has been leveraged by many undergraduate institutions for successful recruitment, matriculation, and retention of URM students, yet very few PT education programs seem to invest in its proven success.^7,15 Dialog within the PT profession about pipeline initiatives should be considered.

Supporting Early and Meaningful Socialization Into Health Care Professions

Underrepresented minority students did not report involvement with pre-PT clubs. This warrants further investigation. If this observation holds true for other preprofessional students, guidance toward or development of undergraduate clubs for URM health care students might address this gap. This would provide an avenue for informal interprofessional education and a place for URM students to belong and learn about health care professions, early and broadly. Given that disadvantaged backgrounds were more common among students of color, such clubs or student organizations would potentially reach this less visible demographic. Majority and minority faculty support of such an organization should shape the career information students access, profession-specific mentoring, and opportunities for inclusive interaction with profession-specific clubs. This may also provide the opportunity for alumni and practitioners of color to engage as “mentors into the profession,” in a manner that academic programs with limited or no minority faculty are unable to provide. Closing this opportunity gap of a career club that draws and supports URM undergraduate students would benefit the diversity of the health care workforce, broadly.

Tailored Recruitment

Students who identified as having disadvantaged backgrounds were nearly equally impacted by factors related to values + interests as they were by personal experience in making their decisions to pursue a PT career. Recruitment strategies should target the areas captured by the open codes related to values + interests that emerged from the survey data (Table 7). Relatedly, students from disadvantaged backgrounds were more influenced by factors related to Values and Fit than by Experience and Influence. They specifically valued the patient–therapist relationship and inclusion + diversity. These themes should be visibly incorporated into recruitment strategies and evident on educational program and/or professional websites.

CONCLUSIONS

This position paper continues important conversations about supporting URM students into the PT profession. The PTCAS addition of questions for self-report of disadvantaged background positions the profession to better collect and track URM data in PT education. Recruiting students from underrepresented and disadvantaged backgrounds, especially students of color, should remain a priority to reflect the growing diversity of the United States population. This paper supports that utilizing information collected directly from students may help us identify promising practices for recruitment of URM students. Recruitment strategies should then be tailored specifically to these practices to attract URM applicants for PT education.