Addressing indigenous health workforce inequities: A literature review exploring 'best' practice for recruitment into tertiary health programmes

The aim of this literature review is to identify national and international evidence of best practice for recruitment of Māori or indigenous secondary school students into health related tertiary programmes.

A Kaupapa Māori Research (KMR) [28] methodological approach was utilised. KMR is based on a number of key principles [29]. In this instance it aims to provide: a critique of literature from a Māori paradigm that takes into account the structural and power imbalances within society that perpetuate inequities; an explicit challenge to or rejection of 'victim blame' and 'cultural deficit' analyses [30]; a commitment to ensuring that the research outputs will have positive benefits for Māori communities; a commitment to Māori, research leadership and workforce development. Such an approach involves questioning conclusions that require students to change their behaviour rather than the recruitment programme, inclusion of non-published but highly relevant Māori literature, acknowledging the relevance of other indigenous and under-represented minority population literature whilst maintaining a focus on Māori as indigenous peoples in the New Zealand context, rejection of findings that suggest the culture of Māori students is to blame for their educational failures and ensuring that any recommendations made from the review aim to facilitate Māori student success.

Literature were initially identified via searches within three sources: (1) Medline (Ovid) database, (2) ERIC database and (3) grey literature (unpublished documents or reports highly relevant to the aim).

Initial searches specific to Māori or other indigenous populations (i.e. Aboriginal, Torres Strait Islander, Native American, Inuit, Metis or First Nation peoples) produced very few results. The search was therefore widened to include Pacific (i.e. the heterogeneous composite of Pacific ethnic minority groups living in New Zealand e.g. Samoan, Tongan, Nuiean, Cook Island), however this also provided only a small number of articles. Given this context, the research team decided that the literature search would extend to under-represented minority groups or URM. ² Data on URM students have been included as their situations, statistics and challenges often mirror those of indigenous students. Furthermore, issues associated with power, privilege and agency within society are hypothesised to be similar for indigenous and URM groups and therefore exploring the literature for these groups collectively was thought to be appropriate given the small amount of data currently available. The term indigenous/URM is used when discussing the actual literature review findings with specific reference to Māori where appropriate.

Key search words included: 'Māori', 'Indigenous', 'Aboriginal', 'Minority', 'Ethnic', 'Race', Disadvantaged', 'Underrepresented', 'Recruit*', 'Secondary', 'Tertiary', 'Undergraduate', 'School', 'Student', 'Education', 'Programme', 'Health', 'Science', 'Careers', 'Selection', 'Transition', 'Retention', 'Admission', 'Best Practice', 'Intervention'. A total of 216 articles from Medline and 202 articles from ERIC were initially identified using various combinations of these key words. All abstracts were reviewed and articles were excluded using the following criteria: published before 1985; not specifically relevant to the stated aim; not in English language; could not be obtained in hard copy. Application of the above criteria resulted in 172 Medline and 195 ERIC articles being excluded. A total of 70 articles sourced from Medline (44), ERIC (7) and Grey Literature (19) remained for inclusion in this literature review [5, 6, 12, 14, 17, 18, 20‐22, 25, 26, 31‐90].

All data (hereon referred to as 'articles') were reviewed and article content was categorised via the following variables: country; population group; health profession focus; research methods; evidence of effectiveness; and discussion of barriers (Table 2). Recruitment activities were categorised into five broad contexts associated with the recruitment pipeline (Table 3). The potential overlap of activities between these broad contexts is acknowledged, however, the following definitions have guided this literature review: (1) early exposure (i.e. activities targeted towards secondary school students that aim to expose students to health careers and academic pathways), (2) transitioning (i.e. activities that assist secondary school students to enter tertiary study programmes), (3) retention/completion (i.e. activities that aim to support success in tertiary health professional programmes), (4) professional workforce development (i.e. activities that aim to develop the existing health workforce including continuous professional development, specialisation or career development) and (5) across the total pipeline (i.e. activities that occur in more than one aspect of the pipeline).

Table 4 provides a synopsis of the specific recruitment activities occurring within these five contexts. A summary of the content associated with each article based on the variables and contexts identified above is provided in Table 5.

The majority of articles are sourced from the United States of America (USA) (37/70), followed by Australia (15/70) and New Zealand (13/70) with only a small number of articles obtained from the United Kingdom (3/70) and Canada (2/70). Most articles referred to Under Represented Minority (37) population groups with 24 articles specific to Indigenous population groups. A smaller number of articles were identified if they specifically referred to Māori (12) and Pacific (11) population groups. Health profession areas of focus include medicine (40), followed by nursing/midwifery (31), dentistry (24), allied health professions (20) and pharmacy ( 11).

The majority of articles are descriptive in nature (55). Thirty-four articles provide some evidence and/or analysis of tertiary student data. Twenty-four articles involved surveys of students, families, programme and/or university staff with a smaller number of sources presenting findings from interviews (14), focus groups (11) and workshop/seminars (10).

Nearly three quarters of the articles present their findings within the context of a pipeline that integrates recruitment across both the secondary and tertiary education sectors (51/70) compared to articles that have a specific focus on either secondary education (7/70) or tertiary education (12/70). Overall, there is a similar amount of evidence that refers to recruitment activities within early exposure (59/70), transitioning (47/70), retention/completion (60/70) and those activities that occur across the total pipeline (66/70). A small number of articles discuss the importance of professional workforce development (12/70) within the recruitment pipeline; however, these articles are not the key focus of this literature review, and therefore a more extensive literature review focused on professional workforce development is required to examine this aspect of the pipeline further.

The literature identifies a number of barriers for indigenous/URM secondary school students wishing to pursue health careers. These barriers reflect education, information, aspiration and access issues requiring the development of appropriate interventions within the early exposure context.

For example, within the New Zealand context, inequities in academic achievement rates between Māori and non-Māori secondary school students, particularly within science subjects, are a major barrier underlying the need for early exposure. In 2007 nearly two out of five Māori aged ≥ 15 years had no formal qualification and participation in a Year 13³ science subject was only 23% for Māori secondary school students compared to 41% for non-Māori [91]. In 2009, only 29% Māori versus 54% non-Māori students received university entrance at the completion of their final year of secondary school study [92, 93]. Similar academic achievement inequities exist internationally and therefore interventions that encourage indigenous students to choose the appropriate prerequisite subjects at secondary school such as sciences (i.e. Chemistry, Biology, and Physics) and other relevant subjects are needed (e.g. English and Mathematics) [19, 71, 83, 84]. Once students have chosen the right subjects, appropriate support should be provided to ensure indigenous students attain the necessary credits for entry into health programmes [27, 83]. Early exposure must therefore ensure that secondary school students have access to the necessary academic building blocks for movement into health professional programmes.

The literature also discusses the importance of actively including parents, families and indigenous/URM communities in early exposure activities due to their influence on student career choices [13, 19, 37, 60, 78, 83, 90]. This is particularly important as indigenous/URM students are often diverted away from health careers via careers advisors and teachers [18, 19]. For example, Chesters et al. [35] found that only 18% (26/144) of secondary school advisors or guidance counsellors were able to demonstrate the knowledge required to effectively advise or support indigenous students into health careers. Similar findings are described elsewhere [18, 19, 27, 44, 60, 64, 74, 78, 83] with Hollow et al. [44] noting "when counsellors or teachers "track" minority [or indigenous] students into less rigorous academic courses - intentionally or not - they limit student's academic achievement and inhibit their career aspirations"(p. 4).

Addressing the deficit or failure discourse of career advisors via professional development [35] and, more importantly, supporting the use of indigenous/URM staff, role models or mentors to provide careers advice is recommended [21, 44, 83, 94].

Other enrichment activities such as visits to tertiary institutions that expose indigenous/URM students to campus environments early [17, 70, 71, 95] are recommended. These enrichment activities are important as they introduce students to indigenous/URM role models they may not have had access to previously [47, 56, 67, 82], they foster trust between tertiary providers and families/communities [47, 56] and enhance student confidence and motivation to apply for health programmes [42].

Indigenous/URM students face significant barriers when transitioning into tertiary programmes. While many students entering university have to leave their families, communities and support networks; indigenous/URM students have the additional pressure of entering into what is generally a non-indigenous/URM, foreign and unfriendly tertiary environment [18, 51, 96]. Madjar et al. [96] discuss the large size of first year degree lectures as contributing to student's feelings of isolation [96], with indigenous/URM students often feeling 'culturally alienated' (p. 1049) within the tertiary environment [97]. Indigenous/URM specific orientations may therefore create a more welcoming and indigenous/URM appropriate introduction to tertiary settings [17, 41, 71].

Indigenous/URM students experiencing academic barriers to programme entry (often complicated with additional pastoral and socio-economic issues) [13, 95] may be best supported by a bridging/foundation programme. To achieve this comprehensive support, bridging/foundation programmes differ according to their duration (from 4-6 weeks to an academic year), content focus (individualised to a specific student versus generic programme provision) and cohort size (from 6 students to over 100 students) [95, 98] and are often designed for their local contexts. Many utilise indigenous/URM curriculum content (e.g. Aboriginal health topics) [13, 61, 74, 96], specifically support the acquisition of study skills required for tertiary study [71, 86], whilst also ensuring that students are given access to indigenous/URM role models for motivation to continue along the pathway towards health careers [13, 48]. Bridging/foundation programmes therefore have the potential to provide comprehensive transitioning support to address gaps in educational achievement whilst also ensuring that students are set up for success from a pastoral perspective.

Tertiary institutions should demonstrate a tangible commitment to equity initiatives via the provision of well defined, accessible and targeted admission policies or quotas for indigenous students. Support to navigate the often complex university application processes should also be provided [81]. These activities not only create direct pathways for indigenous/URM student entry, they also promote the institution as valuing cultural diversity which has been identified as being attractive for indigenous/URM students considering health as a career [17, 31].

It is acknowledged that transitioning in a broader context occurs at multiple sites along the pipeline whenever students move between environments within the education sector (e.g. secondary to tertiary, undergraduate students into graduate health study). Therefore institutions may need to provide multiple forms of transitioning support beyond the definition outlined within this literature review [27, 96].

Inequities in academic achievement for indigenous/URM students persist into the tertiary context. New Zealand statistics for example, show that national participation rates for Māori aged 18-19 in degree level study is less than half the rate for all students, Māori first year attrition rates in bachelor degree level programmes are 28.8% versus 18.2% for non-Māori [99, 100] and Māori rates of participation in health professional degree level programmes remain low [101]. This data supports the need for successful recruitment programmes to extend beyond getting students into programmes and provide indigenous students with comprehensive retention and completion support within the tertiary context [17, 18, 73].

Similar to other educational settings [102], support for indigenous/URM students within health professional programmes should include academic interventions such as additional tutorials [69, 84], study support [84] and formation of study groups [21, 64]. Pastoral interventions should also be provided to facilitate student access to financial assistance (a pivotal support requirement) [54, 69, 86, 90], referral to counseling as required [51, 80, 84] and provision of ongoing career advice [51, 69]. Tertiary institutions need to provide the resources to support retention activities including the provision of culturally safe spaces for indigenous students [51, 69]. Having access to an indigenous/URM specific space encourages peer support, provides a safe haven from any racism experienced from their non-indigenous/URM peers or institution and allows students to operate within culturally appropriate contexts (e.g. physical study spaces that include shared eating opportunities) [13, 18, 51, 83].

However, encouraging indigenous/URM students to become more resilient to unsafe environments and negative experiences within their health professional training is an inadequate response [18]. Tertiary institutions can address these issues and target student development via curriculum reform that includes both indigenous/URM and cultural safety content [17, 83]. The provision of professional development for staff to understand and address these issues is also required [17, 51, 54, 71] alongside the development of indigenous/URM academic and general staff positions [17, 18, 56] and the promotion of indigenous/URM academics to positions of tertiary leadership [56]. Whilst many of these interventions are not new to those delivering tertiary support, the framing of these interventions within a secondary school recruitment framework reflects the broader pipeline approach.

Debate exists around the definition and scope of 'receruitment' with some commentators suggesting that recruitment activities cease once students enter a tertiary institution [103]. However, the literature clearly frames recruitment activity as occurring across a pipeline that extends from secondary through to tertiary education contexts and in some instances vocational (post-graduate) training [13, 21, 25, 27, 74, 82, 85, 104].

Recruitment should be framed from a comprehensive and integrated pipeline perspective that has the ability to include secondary, tertiary, community and workforce stakeholders. Active inclusion of indigenous/URM communities throughout the recruitment pipeline is encouraged [19, 32, 68], with some articles highlighting the need to better incorporate indigenous spiritual and cultural practices within secondary and tertiary contexts [19, 61]. Using a specific mission statement or vision to demonstrate a commitment to equity initiatives may assist institutions to maintain support for an integrated, indigenous/URM-appropriate, recruitment approach [13, 51, 71, 85, 90].

A number of common recruitment activities operating across the pipeline are described in the literature. For example, both secondary and tertiary students are noted to benefit from exposure to indigenous/URM role models, mentors and work experience in health settings [17, 27, 35, 69]. Unfortunately, clear and detailed descriptions of these specific activities are rarely provided and therefore assume a common understanding. 'Mentoring' for example, can be delivered both formally and informally, and may involve student peers, staff or health professionals [105]. Understanding exactly what programmes mean by mentoring is important as different models will have different protocol and resourcing implications.

Given the limited evidence of effectiveness obtained from this literature review, recruitment programmes and tertiary institutions need to improve data tracking and research potential to better inform recruitment initiatives [69]. New Zealand in particular needs to increase its contribution to the published literature in order to better present and examine the numerous recruitment strategies targeted at Māori students.