Pipeline Efforts with a Freirean Twist: The Juntos Health Disparities Research Internship

Maria Alonso Luaces^1* Natalia Suarez² Octavio Estrella² Won Choi³ Megha Ramaswamy⁴ Ana-Paula Cupertino³

¹Office of Cultural Enhancement & Diversity, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, USA

²The National Center for Rural Health Professions, University of Illinois-Rockford 1601 Parkview Ave, Rockford, IL, USA

³Juntos Center for Advancing Latino Health, University of Kansas Medical Center, 4125 Rainbow Blvd, MS 1056, Kansas City, KS, USA

⁴Preventive Medicine and Public Health, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, USA

*Corresponding Author:

Maria Alonso Luaces
Director of Academic, Professional and Workforce Development
Office of Cultural Enhancement & Diversity
G028 Murphy, Mail Stop 4007
3901 Rainbow Boulevard, Kansas City, USA
Tel: (913) 588-1547
Fax: (913) 588-8890
E-mail: malonsoluaces@kumc.edu

Received date: August 20, 2013; Accepted date: September 10, 2013; Published date: September 13, 2013

Citation: Luaces MA, Suarez N, Estrella O, Ramaswamy M, Choi W, et al. (2013) Pipeline Efforts with a Freirean Twist: The Juntos Health Disparities Research Internship. J Community Med Health Educ 3:233. doi: 10.4172/2161-0711.1000233

Copyright: © 2013 Luaces MA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Increasing workforce diversity is essential to improving the health outcomes for minority populations, particularly Latinos. This paper describes an innovative 6-week health disparities internship program for underrepresented precollege and college students aimed at empowering students to become health science researchers focused on issues that continue to affect minority communities. Our program embraces the educational philosophy developed by Paulo Freire, which supports the development of critical awareness, critical thinking, and reflection. In this manner, this internship program shifts the paradigm away from traditional approaches focused solely on knowledge remediation. Program participants became conscious of their realities while they grew to envision themselves as agents of change capable of transforming their communities.

Keywords

Diversity; Health professions; Latinos; Critical pedagogy; Empowerment education; Community-based learning

Introduction

The Institute of Medicine’s report Unequal Treatment [1] indicates that pipeline programs aimed at diversifying the healthcare workforce are keys to improving health outcomes among minority populations and reducing health disparities. Although minorities make up 25% of U.S. population, they represent only 9% of nurses, 6% of physicians, and 5% of dentists. Even fewer minorities serve as public health researchers - less than 5% of the country’s public health faculty are African-American, and only 7% are Latino [2]. Increasing the number of health professionals and health researchers from underrepresented backgrounds has the potential to increase the production, transmission, and translation of scientific knowledge focused on the prevention and treatment of the medical conditions that disproportionately affect minority communities [3].

The lack of diversity in health professions and science results from factors that include limited educational opportunities, lack of role models encouraging minority youth to view the health professions and science as a viable career pathway, and inappropriate pedagogical models used to engage youth [2]. Among all minorities, Latinos are of particular concern. On one hand, Latinos are the fastest growing ethnic group in the nation: between 2000 and 2010, Latinos accounted for over half of the population growth, and the number of Latino children grew by 39% [4]. Recent data indicates that about 22% of all youth under the age of 18 living in the U.S. are of a Latino background, the majority of those being immigrants or the children of immigrants [5]. Even if immigration is kept at a constant, the Latino population is expected to more than double by 2050 [6]. On the other hand, however, educational trends among Latinoyouth are worrisome: Latinos represent one of the most educationally disadvantaged minorities frequently lacking school readiness, and performing on average worse than other school-aged groups [7-10]. Even though high school dropout rates have generally declined over the last three decades, they are still comparatively higher among Latinos; beyond that, the gap in the attainment of a bachelor’s degree has widened between Whites and Latinos [11,12]. Finally, Latinos are poorly represented in science and health fields [13].

Addressing the issue of diversity in health professions is, therefore, a complex endeavor; it requires comprehensive, multi-method approaches to achieve reforms- starting at the K-12 level and through higher education- in order to increase the number of opportunities available to minority youth for academic enrichment, career, and leadership training. Many of these challenges can be addressed through educational pipeline programs that focus on skill development, mentorship, and exposure to health professions, an approach which has shown great potential in increasing the number of underrepresented students in health related careers [14,15]. Programs that allow participants to experience a profession within the context of their own communities have proven particularly successful by illustrating how the students’ work can have an impact on their communities [16]. These contextualized experiences provide underrepresented students with a sense of ownership, and allow them to envision themselves as agents of change for their own people. Students develop a sense of purpose, “a stable and generalized intention to accomplish something that is at the same time meaningful to the self and the world beyond the self” [17]. The opportunity to synergistically fuse professional, academic, and personal goals has a positive impact on motivation and contributes to sustained engagement and a true commitment to a profession.

This paper describes the curriculum of a novel 6-week health disparities research internship for high school and college students from underrepresented backgrounds. The goal of the research internship is to empower underrepresented youth to address health disparities affecting their communities, and to in still in them a longterm commitment to careers in the health professions and science. We achieved this goal by providing students with the experiences, exposure, knowledge, and scientific skills needed to become members of the health science community and future voices focused on promoting change.

Theoretical Framework

Several programs have been implemented over the last decades in an attempt to counteract the major leaks in the U.S. educational pipeline and to increase diversity among health professionals, including academic achievement programs, summer enrichment camps, postbaccalaureate programs, and university partnerships [14]. However, many Science, Technology, Engineering, and Mathematics (STEM) pipeline programs aimed at serving underrepresented students are faced with a hard dilemma: these students are more likely to have deficits in essential knowledge and skills, to have attended schools that lacked a rigorous science and math curricula as well as key resources, and to have had ineffective teachers [13]. The evidence on the effectiveness of remedial education for minority college students remain ambiguous [18-20] Despite that, many of these STEM programs tend to focus on addressing educational gaps by “transferring” additional science knowledge to students [21-23]. Despite the modest achievements of these educational pipeline programs, researchers continue to report disproportionate attrition of minority students with devastating social and economic consequences for the nation [24,25].

The Juntos Health Disparities Research Internship (JHDRI) presented in this paper used Paulo Freire’s critical pedagogy to develop and deliver a novel curriculum that is transformative, context-laden, and student-centered. In his book Pedagogy of the Oppressed, Freire emphasizes the role of teachers as facilitators in charge of enabling continuous connections between the world (students’ realities) and the word [26]. By posing questions within the context of students’ realities, the critical educator engages students in a process of consciousness, whereby they become “critically conscious of the socio-historical world in which one intervenes or pretends to intervene politically” [27]. As Freire points out, education consists of “learning situations in which the cognizable object intermediates the cognizable actors - teacher on the one hand and students on the other” [26]. This view of teaching as fundamentally dialogical leads to adopting an anthropological approach that places students’ realities at the core of the curriculum. It is exactly the continuous problematization of students’ realities that leads to knowing and learning [28]. We believe that this approach contributes to minority youth’s long-term commitment to the health professions and science.

Rather than a static, top-down mandate, the JHDRI curriculum is student- centered, situated, and subject to change. Our program moves away from traditional remedial approaches and towards engaging disadvantaged Latino students, particularly in the areas of science, health, and technology. By adding a Freirean twist to pipeline efforts, we purposefully abandon “banking” education approaches- where knowledge is transferred from the teacher to the passive students- and embrace teaching as dialogic, knowing as experiential, and social change as the ultimate goal of the educational process. JHDRI is communityoriented and gives substantial weight to both students’ individual realities and the cultural process of marginalized groups coming together around a shared goal to develop understanding, find purpose, and effect change. This program provides Latino students with a unique opportunity to develop the knowledge and tools needed to investigate health disparities in their communities, to develop their “own understanding of consciousness,” and to problematize their realities. As students’ understanding of health science research increases, their participation in the scientific process shifts from peripheral to central; in this manner, they develop their identities as young health science researchers and as members of a scientific community of practice. More importantly, they come to see how creating knowledge through research is not something alien and alienating, but rather something purposeful and consequential. In Freirean terms, JHDRI creates a “counter-oppressive” space where Latinos can develop purpose and take charge to become the next generation of researchers that will bring change to the scientific community - a community with a long history of patriarchal discourses focused in advancing the health of those already in power [29].

Materials, Methods and Program Description

The University of Kansas Medical Center (KUMC) has a longstanding commitment to promoting diversity and addressing problems that foster underrepresentation in medicine and the health sciences. The Office of Cultural Enhancement and Diversity (OCED), located within the School of Medicine, oversees KUMC’s K-20 educational pipeline programs. These programs aim to enhance diversity through the recruitment and retention of minority students, as well as enhance cultural competency [30]. During the past 20 years OCED’s programs have helped over 5,000 students from Kansas City, KS to successfully complete high school and enter undergraduate education; many of these have entered into the medical professions. Indeed, the success of OCED’s pipeline programs was a major factor in KUMC’s recent recognition as one of the top 5 “social mission” medical schools in the country.

Partially supported by OCED, Juntos Center for Advancing Latino Health at KUMC hosts a research internship for Kansas City youth focused on health disparities. Juntos was focused on building community-based participatory research (CBPR) programs that generate and translate research findings toward the elimination of health disparities in Kansas’ communities [31]. One of the center’s specific objectives is to promote educational programs geared toward existing and future health care providers in Kansas to allow them to master cultural competency and be able to provide high quality care to Latinos. Since its creation in 2009, the Juntos Health Disparities Research Internship (JHDRI) has served as a major educational outreach program for underserved youth in the Kansas City metro area [32].

JHDRI participants are current Latino high school students and recent graduates of public schools in Kansas City, KS, one of two urban cores in the state; the majority of participants have expressed an interest in pursuing a career in the health professions or science. Fifty-two percent of the population in Kansas City, KS, identifies as belonging to racial or ethnic minorities, which is three times the proportion of minorities in the state of Kansas [33]. Participants in JHDRI come from five public high schools where more than 70% of students belong to racial or ethnic minorities, more than 80% depend on free and reduced lunch, and 10 to 30% rely on English proficiency services.

Over the past four years a total of 73 high school, undergraduate, and graduate students, selected through a competitive process, have completed the summer internship program (Table 1). Interested students submit application materials including demographic information, professional interests, a personal essay, a resume, academic transcripts, and a letter of recommendation. Applications are reviewed by a Community Advisory Board composed of KUMC/ Juntos staff, educational professionals from several local colleges (such as Donnelly College and Kansas City Kansas Community College), and public health professionals working in the area. Applicants are rated based on merit, and the top ones are accepted into the program. Though every effort is made to accommodate as many students as possible, the actual number of students accepted each year varies depending on funding. Qualified students who could not enter JHDRI are referred to other KUMC/OCED’s pipeline programs.

Table 1: Number of students completing JHDRI, 2009-2013.

Offering compensation has been listed as a best practice in experiential learning [34]. Therefore, participation in the health disparities research internship is compensated with a financial incentive to ensure equal opportunity to participate. In addition, due to the challenges of accessing public transportation in many of the neighbourhoods in which participants reside, transportation to and from the internship is arranged through a contracted bus service. Each participant is assigned a workstation equipped with a computer, a telephone, and internet connection for the duration of the internship. The goal is to create “a learning environment that promotes engagement, deep learning, and meaning” in a space that emphasizes the process of learning, personalizes learning, and contributes to whole the development of the individual as a whole [35]. In order to achieve our goal, participants are accommodated throughout our office space, which allows them to develop their professional and social skills alongside peers as well as Juntos’ staff and faculty. Students participate in group research and extracurricular activities that provide them with the opportunity to interact with one another. When possible, participants are encouraged to accompany their mentors to meetings and other research-related activities on and off campus.

Results

The Juntos Health Disparities Research Internship (JHDRI) offered a fluid, heterogeneous curriculum, free of constraining educational agendas. The curriculum reflected the purpose of the internship, that is, to empower Latino students to become researchers focused on health-related issues that affect minority communities. In alignment with recognized best practices for experiential learning, the curriculum is constantly improved through student feedback [34]. Since 2009, the program and curriculum have evolved with the ongoing goal of giving voice to each cohort of students. New components were added each year, and those that were carried over were refined. In this manner, JHDRI created a space that honors the students’ world and helps them expand their spheres of understanding and possibility.

Table 2 describes the current structure of the program and curriculum design. The curriculum was structured around six central training themes: Community Building and Diversity, Health Disparities and the Social Determinants of Health, Community-Based Participatory Research Design, Collecting and Making Sense of Data, Data Analysis and Interpretation, and Community Engagement. Table 2 also illustrates the organization of program activities and how they aligned to both curriculum themes and the competencies we want students to develop.

Table 2: 6-Week Health Disparities Research Internship Curriculum.

Our research internship moved away from traditional lecture formats to embrace “culture circles.” Culture circles are not knowledge distribution centers where students memorize what the teacher “serves” them [36]. Rather, they “are spaces to seize conflicts as opportunities for learning” [37]. In culture circles, teachers become coordinators; lectures turn into dialogue; pupils are group participants and prescribed syllabi are codified into learning units [38].

To build the atmosphere of trust and respect that is conductive to a “culture circle,” Week 1 focused on building rapport and sense of community. Popular team building activities, such as “The story of your name” or “What does cake represent in your community?” provided an opportunity for students to get to know each other and to realize that their stories and their realities are central to the program. Sessions were student-centered and mostly student-led, allowing participants to become acquainted with a participatory structure that challenges the status quo of the educational system that most participants have experienced throughout their school years. In addition, a preassessment of students’ knowledge of health disparities was done to help facilitators better prepare and tailor individual plans that account for students’ realities.

During Week 2, participants started to problematize, contextualize, and deconstruct the concept of “health disparities” as experienced by their own communities. Rather than being designed beforehand, the JHDRI curriculum emerged in a dialogical interplay with participants’ realities; this way, it honored Freire’s theory of knowledge as something that “emerges only through intervention and re-invention, through the restless, impatient, continuing, hopeful inquiry men pursue in the world, with the world, and with each other” [26]. This dialogical approach challenged to reconsider the power relationships that derive from presenting themselves as knowledge holders to the students and to the communities they work with.

Week 2 started with a “Community Health Assessment” of the participants’ community, Wyandotte County. This assessment took the form of a bus tour, and as students drove around their county, they were given an opportunity to discuss the state of their community versus the city as a whole. Facilitators situated themselves within the group as ethnographers, studying the practices of students’ communities and bringing up additional information and opportunities for students to name community health concerns [37]. Participants were encouraged to observe their community with a critical eye, paying close attention to sidewalks, parks, houses, and access to groceries stores, as an example. The assessment was used to develop themes, or cultural and political topics around health disparities, access to health care, and minority health. After acknowledging the problem, or “naming the problem” in Freirian terms, facilitators proceeded to problem posing. Within this framework, “people develop the power to perceive critically the way they exist in the world with which and in which they find themselves” [26]. Rather than transferring knowledge, facilitators challenged students to think critically about their reality and to consider the social, historical, and political factors that have shaped the current status of their communities. A few examples of questions include “Why do health disparities exist between dominant and underprivileged groups?” “What environmental, social, and economic factors do you think have an impact in the health of your community?” “How does health care access in your community affect health outcomes?” Yolanda, one of the 2011 interns from a local community college, commented: “You learn about things that you know are there, but you don’t acknowledge them until someone tells you.” The ultimate goal was for students to become conscious and take ownership of their realities to affect changes within their communities.

Weeks 3, 4, and 5 focused on research methodology and the research process. To be effective, experiential learning must offer meaningful professional experiences to students [34]. Therefore, JHDRI participants were responsible for framing and designing a community research project; in this way, they used their acquired knowledge to promote change in the community. Through guided examination of a variety of research studies, students were pushed to challenge traditional scientific discourses of normalcy and objectivity, as well as reductive ontological, epistemological, and methodological research perspectives. Examples of Community-Based Participatory Research (CBPR) and qualitative studies were presented to the students as alternative methodologies that go beyond the clinical to explore social, environmental, and economic factors that may explain existing health disparities. Facilitators posed questions to the students around problematic themes such as the objectivity of the scientific methods, ethical considerations around mainstream researchers investigating minority communities, or the lack of sociocultural connections between researchers and the groups they study. Such questions led to a complex dialogue about the connections between research methods, the persistence of health disparities amongst minority groups, and the need for minority researchers to bridge the cultural gap by providing voice to silenced communities.

At this point, students developed their own research questions; their interests led the process and helped maximize engagement. Despite the fact that the composition of the student cohort was mainly Latino, projects in past years have focused on a range of topics that reflect the realities of Wyandotte County as a whole. Examples include projects that ranged from the impact of built environment on physical activity, comparisons between culturally tailored smoking cessation programs, health awareness among Latinos, barriers that prevent colorectal cancer screenings in African American Faith-Based Communities, barriers to diagnosis and treatment of mental health among Bhutanese/Nepalese Refugees, or access to healthy foods in tiendas (corner stores) among the Latino community in Wyandotte County. Writing workshops were used to assist students in drafting research questions.

There is evidence that college research mentorship has a positive effect on the retention of underrepresented students and academic success in scientific fields [14,34,39]. At JHDRI, each participant was assigned a mentor, who acted as a partner and co-investigator rather than an all-knowledgeable individual. Mentors were carefully selected and invited to participate on a volunteer basis; though not all mentors were Latino, most were KUMC faculty with a long history of working with underserved communities and clear interest in issues of workforce diversity and health disparities. Mentors played a critical role in providing assistance and guidance to students as they developed their research project. Before working with students, mentors participated in training sessions around the methodology of the program as well as expectations regarding their participation. At a minimum, mentors were expected to: familiarize themselves with their mentees’ career goals; provide guidance on health career pathways; assist students in drafting, developing and executing a research plan for the summer; and provide students with ongoing support as they write and present their research finding to the KUMC community at the end of the program. In the same manner, students participated in a short training and received a research contract outlining basic expectation for their relationship with their mentor. Topics such as setting clear timelines, co-authorship, and communication method were brought up with students as important factors to discuss with their mentors.

One-on-one interactions with mentors were crucial to our framework because they ensured individualized plans and the possibility to explore in-depth research methodologies that were aligned with students’ goals. They also provided students with an opportunity to develop connections and to build cultural capital that will assist them in their career endeavors. Students’ comments about the flexibility in topics and their relationship with their mentors were always very positive. A 2010 high school intern said on his post-program survey that “the research topics are great; you have variety and get to choose. The mentors are very involved, and caring.”

During Weeks 4 and 5 students went out into the field to try to understand the reason(s) behind some of the most prominent issues in their communities, with the ultimate goal of problem-solving to develop recommendations that improve minority health. Their understanding of health disparities as a complex endeavor that is context-dependent and multifaceted became more apparent at this point. In other words, they were “capable of perceiving hunger as more than just not eating; as the manifestation of a political, economic, and social reality of deep injustice” [29]. One of our 2011 community college interns, Yazmin, exemplified this understanding by stating that “when we succeed in educating our young Latinos, we will have a healthier community. Having a healthier community means endless opportunities… It is time to stand up and save our community.” Yazmin’s comment clearly demonstrates a complex understanding of the ramifications of the problem at hand.

During Week 6, students presented their finding(s) to the faculty at the School of Medicine, community leaders, and family. Students became expert panelists presenting not only the results of their research, but also their recommendations for improvement. Given the long history of abuse and mistrust between research institutions and minority populations, this opportunity empowered participants - and their communities - to become knowers and producers of knowledge rather than receivers, as well as to act as cultural brokers between academia and their worlds, reaching the ultimate goal of teaching [40]. At this point, it became clear that students reached a deeper level of consciousness. Alex, a 2011 participant, noted that “in order to have a healthy county, all residents need to put effort to make it possible. Everything is possible when we really want to get it done.” A similar sentiment was echoed by several 2010 participants; Megha commented on her intentions “to contribute to change that all individuals can benefit, and allow me to give back to my community.” Raul’s passion is obvious when he stated that “it is time to stand up and save our community.” In Freire’s words, they have a “different understanding of history and of their role on it; they refuse to become stagnant, but will move and mobilize to change the world; they know that it is possible to change the world, but impossible without the mobilization of the dominated” [29].

Conclusion

The accountability movement in general, and No Child Left Behind in particular, have had serious unintended consequences on K-12 public education, especially in underserved communities [41,42]. The fear of being labelled as inadequate or “at-risk” has led many districts to focus on basic “testable” knowledge in detriment of skills such as critical thinking, leadership, and personal responsibility - skills proven to be excellent predictors of enrollment in and graduation from postsecondary education institutions [43]. In line with the current K-12 landscape, pipeline programs aimed at increasing diversity in the health professions have frequently focused on science and math knowledge remediation, providing students with one more de-contextualized opportunity to “receive” knowledge [10,19,20,23]. The JHDRI, on the other hand, embraced Paulo Freire’s philosophy of education and represents a paradigm shift from traditional approaches, making it a viable effort toward increasing diversity among science researchers.

The Juntos Health Disparities Research Internship provided Latino students - who frequently lack access to resources in research - with the opportunity to experience the work of a researcher within the context of their communities. Besides gaining exposure and content support, students were provided with an empowering space to develop a sense of purpose and possibility. Far from looking at Latinos as “at-risk” or in need of knowledge remediation, we welcomed students into our research community as experts, as voices from the community needed to improve our practice, and as colleagues. Within this environment, scientific knowledge became consequential and meaningful for students and their communities. Participants became conscious of their realities and envisioned themselves as agents of change capable of transforming communities. It is the opportunity to bring personal meaning and professional goals together that can develop sustained engagement and a true commitment to pursuing a career in the health professions and science. Moreover, within public research institutions, programs such as JHDRI emerge as true efforts to bring in community voices, to collaborate with and empower the community rather than to teach to it. These partnerships develop community trust and open the door to a new generation of committed researchers, prepared to question health disparities and improve their own communities.

Future work should follow JHDRI participants longitudinally to improve our understanding of the long-term impact of this approach on academic development, career choice, and community engagement. Additionally, we should expand our program, using its content and theoretical framework in the regular classroom experience and during the whole academic year - not just over the course of a 6-week summer internship. This program has the potential to empower both teachers and students to consider a career in health and science by providing them with the needed infrastructure to learn, implement, and test new pedagogical and curricular approaches that link science and health to their personal experiences.

Acknowledgements

This project was supported in part by the National Center for Research Resources and the Division of Program Coordination, Planning, and Strategic Initiatives of the National Institutes of Health through Grant Number R25OD011166-05 Science Education Partnership Award. We also acknowledge the support of Clarice Amorim, Public Health PhD student at Oregon State University, and Todd Funke, Director of Microbiology Laboratories at the University of Kansas, in the final editing and formatting of the paper.

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