Background

URM students often face significant challenges when progressing through the educational system due to system-level inequities, implicit biases, and a lack of access to resources. In some cases, access to high-level pre-collegiate schools, tutors, course preparation programs, and even participation in extracurricular activities favored during the admission process may be limited. Additionally, URM students may have fewer role models in academic medicine who represent their backgrounds. AAMC data suggests that only 5.5% of academic faculty are Hispanic or Latino, and only 3.6% are Black or African American.¹

Unfortunately, the underrepresentation of Latino and African American physicians is also evident in the field of urology. Despite an increase in their relative proportion in U.S. society, data from the 2021 American Urologic Association Census reveals that only 4.4% and 2.4% of practicing urologists are Hispanic and African American, respectively.²

In response to these disparities, the MA-AUA launched its PEP program with the goal of empowering historically underrepresented minorities who are first-generation students considering medicine. Howard University, the oldest and highest-ranking HBCU medical school in the U.S., has a long-standing interest in training URM students, and one of our institutional mission statements is to “advocate for excellence in education and healthcare for underrepresented population(s)”.³ We were fortunate to be among the grant awardees for the inaugural class of the PEP program.

There has been a long history with educational “pipeline” programs to facilitate URM students into the medical field. These have included both undergraduate and post-baccalaureate academic enrichment programs for URM students. In 1989, a Minority Medical Educational Program (MMEP) was established by the Robert Wood Johnson Foundation and by 1991 nearly half of all medical schools sponsored similar preprofessional programs.⁴ These mainly focused on preparing students to effectively study, take tests, present and interview. Subsequently, summer college academic enrichment programs (SCAEPs) have been initiated and have been shown to increase diversity, likelihood of application and matriculation into medical school and to produce physicians with an increased intention to practice in underserved areas.⁵ To our knowledge, the PEP is unique to the MA-AUA and is the first SCAEP to target diversity in urologic training.

During the candidate selection process, we encountered questions and concerns from applicants that surprised us, indicating that we did not fully understand the mindset of these students. To gain a better understanding, we developed a survey to help us appreciate their interest and perception of barriers to participation. We conducted this survey of both HBCU and PWI students, comparing their responses to explore the interest and perceptions among URM students versus their counterparts across the undergraduate spectrum.

We recognize that to resolve disparities, we must first examine their root causes. To maximize the potential impact of our curriculum and our ongoing participation in the PEP program, we sought to identify what makes the program attractive and what perceived barriers to participation exist. This project was designed to help us understand and better accommodate students in an enrichment program, and to support the “Academic Study” of our PEP student, one of the four core pillars of the PEP program.

Methods

A voluntary response survey was developed and distributed electronically to students at HBCUs and PWIs. The survey included information about the undergraduates designed to allow us to determine basic demographic information such as age, sex and college attended. Questions were also asked to determine their interest in an elective program that mentors and supports their progression into a professional career. The survey aimed to determine perceived barriers to participation, which were ranked in order of importance. Socioeconomic status, prior participation and mentorship have been used in other studies on SCAEPs. Other possible responses such as location, citizenship status and finances were added to give additional options to the respondents for commonly perceived barriers we hear from students at our HBCU. A link to this survey was then placed on various social media platforms (Instagram/Snapchat) and in email and large undergraduate group chat apps (Patio/GroupMe). This link was left active for approximately 14 days and then the data was collected and analyzed.

Results

School, Age and Race

We had a total of 90 student respondents. Howard University and three other HBCUs accounted for 53 respondents (58.9%). 22 PWIs were represented in the responses. 73 of the total respondents identified as Female (81.11%) with 58.9% of HBCU respondents identifying as Female. All respondents were between 19 and 23 years of age. 59 (65.56%) respondents identified as African American or Afro-Caribbean with 84.75% attending an HBCU and only 15.25% from a PWI. Only 3.33% of the total identified as Hispanic.

Socioeconomic Background

To gather information on the socioeconomic backgrounds of U.S.-born students, we asked for their zip codes of residence while growing up. Using an internet search to find the median income of these locations, we found that the average family income of HBCU students was $72,455, compared to $101,954 for PWI students. This represents a difference of almost 30% in average family income between the two groups.

Interest and Type of Program

Out of the 90 students surveyed, 89 expressed interest in a program of this nature and believed it would be valuable to them. While 62.2% preferred a program that could be completed during the school year or summer, only 34.45% were interested in a summer-only program. Notably, the majority of HBCU students were interested in participating in both summer and in-semester programs, whereas the majority of PWI students expressed interest in summer-only programs. The ideal program length for most students was 1-3 months (38.92%), with 61.11% of HBCU students and 38.89% of PWI students preferring this duration.

90% of students were willing to live away from home and 89 out of 90 students wished to have a program that paid or reimbursed them for their participation. Additionally, 83 students wanted to publish or present their work as part of the program. No significant differences were observed between HBCU and PWI students in these categories. While 82% of students agreed to follow-up obligations after the program, 17% of HBCU students and 27% of PWI students were not interested.

Despite their interest in these programs, 74.44% of students expressed personal barriers to participation, with a higher percentage of HBCU students (67.16%) responding affirmatively. This was reflected in their responses to the question, “Do you think opportunities to participate are equal opportunity?” where 88.89% responded “No,” with 61.36% of these responses coming from HBCUs.

Causes of Perceived Inequity

The respondents were presented with a list of nine variables that could be potential causes of barriers and inequities and were asked to choose as many as they felt applicable. The variables included Age, Location, Financial status, Economic class, Race, Gender, Citizenship, Mentorship and Lack of educational resources. Lack of educational resources was the most selected response, chosen by 12.45% of all students, and was also the most frequently chosen answer in the HBCU group. Economic class was the second most common response overall, selected by 12.05% of all students, and was the most selected response in the PWI group. Gender and age were the least commonly chosen answers, with 8.23% and 8.43% of students selecting them, respectively, and there was no significant difference in the distribution of responses between the HBCU and PWI groups for these variables.

 

Perception of Personal Barriers

The participants were asked to rank nine factors on how they believe these factors act as personal barriers and affect access to a professional development and exposure program such as PEP. The factors were: Age, Location, Gender, Socioeconomic Status, Mentorship, Finances, Race, Citizenship and Lack of educational resources. Overall, finances followed by location were the most chosen answers. HBCU respondents chose finances most commonly while PWI respondents were tied between these two answers. Citizenship was the least chosen answer overall, with HBCU respondents ranking gender lowest and PWI respondents giving race the lowest total responses.

 

Severity of Problem

The final set of questions asked the participants to rank seven factors on how they believe these factors affect access to a professional development and exposure program such as PEP. The factors were: Location, Insurance status, Economic class, Race, Gender, Citizenship and Mentorship. Overall, citizenship was the factor most believed to affect access while insurance status came in last. This was mirrored in the responses from HBCUs. At PWIs, citizenship and location tied for the highest effect while insurance was ranked least likely overall.

 

Discussion

The results of this study provide encouraging insights into the potential success of the PEP program. Most of the participants expressed a keen interest in enrichment programs to help in pursuing professional training and showed enthusiasm toward presenting, publishing, and engaging in follow-up activities. However, it was observed that students expected financial compensation or remuneration and did not view participation in these programs as a “sweat equity” opportunity.

Moreover, the study highlights the possibility that URM students may come from relatively lower income families as compared to their PWI counterparts. While these students may not be living in poverty, participating in such programs may mean foregoing summer employment and other economic necessities. This may explain the desire for programs overlapping with the school semester, which was found to be the most popular option amongst HBCU responses, but not from PWI respondents. These findings will help in designing future programs that are more accessible and better suited to the needs of URM students.

Notably, most participants recognized the existence of inequality in access to these programs. Surprisingly, the factors that ranked highest in impacting access were citizenship and economic standing, rather than gender or race. This highlights the need to identify at-risk undergraduate populations who may be hesitant to apply for these programs.

This study is limited by its small sample size and short duration of data collection. The survey was distributed in a fashion that would be accessible to thousands of students and a total of 90 respondents likely reflects a low response rate overall. Additionally, most responses were from Howard University students and the responses from HBCUs were received from fewer total schools than the PWI cohort. This may skew the data towards perceptions at Howard that are different than other HBCUs and that may not represent all URM students. Open-ended questions were avoided to make data collection more manageable, which may have unintentionally restricted response choices. Future studies should aim to have larger participant numbers and more participating schools to allow powered statistical analysis. Furthermore, a feedback program after the application and participation phases of the PEP experience will be developed to further improve the program.

Conclusion

Our study demonstrates that there is an ongoing undergraduate interest in professional enrichment programs such as PEP. It helps to determine the desired design of such programs as it pertains to length of involvement, expectations, and financial remuneration. This will help to tailor such programs and increase student interest. Other “pipeline” programs have shown to increase URM presence in medical training and our hope is that the PEP program will increase URM presence in urology.

HBCUs historically graduate a high number of URM students that programs such as this are designed to target, and this study demonstrates a high level of perceived barriers or inequities. Interestingly, even PWI respondents share these notions, although at different levels and with varying perceived barriers. By further studying these barriers, we can start to break them down. Studies such as this help to elucidate barriers and allow us to target students who may otherwise feel they should not apply or will not get an opportunity to participate.