Key Factors in Designing the Health System–Community Pathways Program for African American/Black Children and Young Adults

Background and Objectives

Many of the ethnic and racial workforce inequities in the United States are present in health care systems. Low representation of African American/Black individuals in the health care system can be traced to a history of exclusionary practices that leave such individuals less likely to pursue health careers. Low representation, in other words, is driven by inequities in health, education, and employment that are a result of structural racism (Boyd, 2019).

Pathways programs (previously referred to as pipeline programs) have been identified as one of the methods to increase recruitment, retention, and promotion in health-related fields for African American/Black individuals. For our research, with input from the study team's experts and community members, we used the term pathways—removing the stigmatizing language associated with the “school-to-prison pipeline” (Hill, 2019).

Pathways programs are defined as programs that recruit and support the graduation of students from underrepresented communities at all educational stages to increase their representation in specific fields (Katz, Barbosa-Leiker, and Benavides-Vaello, 2016). These programs use innovative models for recruiting and mentoring and nontraditional models for improving education opportunities and faculty development. Despite these efforts, African American/Black populations continue to be underrepresented in U.S. health care settings. For example, African American/Black physicians comprised only 5 percent of the national physician workforce in 2018 even though African American/Black individuals make up 13 percent of the U.S. population. This underrepresentation has implications for health equity, or “the opportunity to ‘attain [one's] full health potential’” regardless of “social position or other socially determined circumstances” (Centers for Disease Control and Prevention, 2022). Furthermore, this underrepresentation has been shown to adversely affect both patient health and provider outcomes, such as job satisfaction (Noguchi, 2020). For example, African American/Black patients have reported lower quality of patient-provider communication; less information-sharing, partnership-building, and joint decisionmaking; shorter office visits; physicians who were more verbally dominant; and worse outcomes on assessments of nonverbal communication, respect, and support.

This article describes efforts to develop a framework of key factors to increase the representation of African American/Black professionals in the health care workforce by (1) attracting children and young adults to careers in health care and (2) supporting that interest over time. We call this the Health System–Community Pathways Program (HCPP) framework of key factors. Developed within the context of an equity framework and drawing on both the research literature and community perspectives, the HCPP framework of key factors identifies how best to approach the following: (1) student recruitment, admission, and retention; (2) mentor recruitment and training; (3) programming; (4) program outcome measurement; and (5) long-term program sustainability strategies.

Methods

The development of the HCPP framework of key factors was informed by the following research activities:

• environmental scan of peer-reviewed and gray literature to evaluate understanding of best practices for pathways programs
• 12 interviews with pathways program administrators, former and current mentors, leaders and organizers of education and diversity programs, and diversity, equity, and inclusion (DEI) experts to fill in any gaps from the environmental scan around best practices for pathways programs
• two multistakeholder focus groups with community members, including young adults, parents or caregivers, representatives from community and grassroots organizations, and activists to understand community preferences around pathways programs at the interface of health care systems and communities
• a discussion panel with representation from African American/Black health care providers and DEI experts who focused on understanding the role of pathways programs in increasing DEI in health care systems
• inclusion of a four-member advisory group—consisting of African American/Black physicians and DEI experts—to provide input on the research design, execution, and analysis; the HCPP framework of key factors
• this study.

Many of the study participants were recruited in Michigan, where the project lead is based. However, some interviewees were located in other states.

We applied an equity lens at every step of the research design and execution (Valenzuela, 2017). This lens informed the research team's composition, composition of the project's advisory group, incorporation of analysis of gray literature in addition to peer-reviewed literature, and the sampling framework for the interviews, focus groups, and stakeholder discussion panel.

HCPP Framework of Key Factors

Our environmental scan and qualitative data analyses informed the development of the HCPP framework of key factors. Furthermore, we identified key framework factors weighted by the strength of evidence—how frequently the factor was supported by the environmental scan and qualitative analyses. As noted earlier, these factors fall into the following categories:

• student (e.g., kindergarten through 12th grade; undergraduate) recruitment, admission, and retention
• mentor recruitment and training
• programming (longitudinal programming and community engagement)
• program outcome measurement
• long-term program sustainability strategies.

The HCPP framework of key factors can be tailored to local needs in communities across the United States using input from the community and local data. Furthermore, in such states as Michigan, where public institutions are banned from using affirmative action programs that extend preferential treatment for public employment, education, or contracting purposes to groups or persons based on race, gender, color, ethnicity, or national origin (University of Michigan, Office of Diversity, Equity & Inclusion, undated), use of the HCPP framework of key factors would need to be evaluated (and extended, where indicated, to populations beyond African American/Black communities).