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Chapter 1 |
Key words: dental education, community-based clinical education, minority student recruitment, curricular change, dental care access
This report describes the evaluation of the Pipeline, Profession, and Practice: Community-Based Dental Education program, sponsored by the Robert Wood Johnson Foundation (RWJF) and The California Endowment (TCE). The Pipeline program was developed to address the critical shortage of oral health care for underserved and disadvantaged populations in the United States. The report is published to document the successes, challenges, and lessons learned in the program and explore implications for the dental and other health professions.
RWJF funded programs in eleven of the fifty-six accredited dental schools in 2002. In 2003, TCE funded four additional programs in dental schools in California. The National Evaluation Team (NET) based in the Department of Health Services at the University of California, Los Angeles, School of Public Health was chosen by the foundations to be the national evaluator of the Pipeline program. The NET employed a multidisciplinary team using qualitative and quantitative methods and multiple data sources to conduct a comprehensive five-year evaluation of the program. In addition, the NET in collaboration with the American Dental Education Association (ADEA) received a grant from the RWJF to publish this report.
In total, the two foundations invested more than $25 million in the Pipeline program and its evaluation. Additionally, the W.K. Kellogg Foundation and TCE contributed $1.6 million for financial aid to underrepresented minority and low-income students recruited by the Pipeline schools.
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Significance of the Pipeline Program |
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The Pipeline program is part of RWJF’s major program area, the Human Capital Portfolio. This portfolio "seeks to assure that the nation has a diverse, well-trained leadership and workforce in health and health care to meet the needs of all Americans."3 It aims to build diversity in the health professions and increase the number of health and health care professionals trained in quality improvement methods.
The Pipeline program is also an implementation of TCE’s mission, which includes expanding "access to affordable, quality health care for underserved individuals and communities."4 A goal to achieve this mission is to make a health care system that is "culturally competent to respond to the diversity and demographic changes in the state of California." Under this goal, TCE funds proposals that "focus on increasing racial and ethnic diversity of the health care workforce and improving the geographic distribution of health providers, particularly in rural and underserved areas."
Both foundations are especially interested, from a human capital perspective, in investing in underrepresented and low-income populations. These needy populations have great potential for human capital development through increased investment in their education, training, and medical treatment.
The need for the Pipeline program and the importance of the concerns it addresses have been documented by significant national reports. First, the Institute of Medicine’s report on diversity in health care emphasized that human capital development of diverse populations through health care requires a strong, capable, and diverse health care workforce.5 Such a workforce is nurtured through leadership development, training, and research funding. Second, the U.S. surgeon general’s report on oral health referred specifically to the oral health professions’ workforce diversity and development.6 The nation’s oral health has improved, but critical access problems remain and disparities exist, according to the report, especially for underrepresented minority populations. Arguably, the disparities are greater for oral health than for general health. Yet the dental safety net of providers for the underserved is limited, and access problems seem likely to accelerate unless a new tack is taken.
One such tack is to make the dental workforce more diverse by increasing minority representation in the dental profession. In general, minorities appear more willing to seek care from someone with whom they more easily identify.7 For example, they may prefer language-concordant providers.8 Also, minority providers are more likely to provide care to underserved minority populations, and minority dental students and dental students prepared to treat diverse populations are more likely to plan to care for diverse patients.9–14 Entry into the health professions by underrepresented minorities at least in proportion to their number in society (if not in proportion to the needs of minority groups) might be argued to be a requirement in an equitable society.
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Goals of the Pipeline Program |
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Specifically, the primary goal of the Pipeline program is to reduce disparities in access to dental care. To achieve this goal, the objectives established by RWJF were the following:
TCE made some adjustments to the three RWJF program objectives. In addition to senior students, TCE accepted general and pediatric dentistry residents to meet the average of sixty days in community-based facilities treating underserved patients, but specified that 25 percent of the community sites had to be located in rural communities. Also, TCE required the California schools to cooperate in the development of a regional recruitment program for underrepresented and low-income students and a coordinated state and federal health policy agenda. The purpose of the policy effort was to sustain the community-based education and disadvantaged student recruitment programs after the Pipeline program ended and, more broadly, to reduce disparities in oral health.
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Contents of This Report |
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Chapter 2 describes the Pipeline program.15 It is written by Howard Bailit and Allan Formicola, co-directors of the National Program Office (NPO), and their associates who developed the Pipeline program, selected and monitored the participating schools, and provided them with technical assistance throughout the project. It is written from the perspective of these involved stakeholders who, indeed, were part of the intervention and includes their perceptions of what did and did not work.
Chapter 3 presents the comprehensive evaluation framework developed by the NET and the literature review relevant to each component of the framework.16 The components include the context or environment in which the Pipeline program operates, as well as the structure and processes of the program itself that influenced program outcomes for the Pipeline schools. These outcomes include changes in recruitment, curriculum, external clinical rotations, practice plans of graduating students, health policy initiatives, and oral health care outcomes for underserved populations, as well as the likelihood of whether observed changes can be sustained.
Chapter 4 describes the ingredients for conducting a large-scale longitudinal evaluation.17 The evaluation process was initiated when the NET successfully competed for the grant to evaluate the Pipeline program. The major purpose of this chapter is to describe the process used to conduct the longitudinal evaluation and to summarize the methods used in the data collection and analysis. We show how the larger policy questions related to workforce diversity and oral health care access were translated into concrete and measurable evaluation questions. In turn, these questions led to the design of the evaluation framework or logic model. The framework was used as a guide for specifying and operationalizing variables to assess the effects of context, structure, and process on the intermediate and longer-term program outcomes. We identified relevant stakeholders and used existing data sources or created new data sources if none existed. Various evaluation designs were used in the study, depending on the evaluation questions and data sources used to address the question. The chapter culminates with a description of opportunities and challenges related to data triangulation.
After an introduction in Chapter 5.0, Chapters 5.1 through 5.14 are case studies for fourteen Pipeline schools participating in Phase I of the program.18–32 These case studies are written by co-investigators on the NET team who chaired multiple site visits to each of the schools over the course of the project (three visits to the RWJF-funded schools and two visits to the TCE-funded schools). The coauthors for each case study are other NET team members who participated in the site visits. The UCLA site visits were chaired by Dr. Helen Gift, Ruth Stafford Co-nabeer Distinguished Service Professor of Sociology and Organizational Systems at Brevard College, who has extensive oral health care research and evaluation experience but no UCLA affiliation in order to ensure the objectivity of the UCLA evaluation. (All of the NET co-investigators have affiliations with the UCLA Schools of Public Health and/or Dentistry.) The case studies utilize all of the data sources collected by the NET and include discussions of all of the major outcomes as assessed for that particular school. These include recruitment, curriculum, clinical services, and practice plans of the fourth-year dental students, as well as consideration of the sustainability of Pipeline achievements and the involvement of the California schools and some others in collaborative health policy initiatives. Each case study also includes an invited response of the principal investigator of the Pipeline initiative at that school to critique the case study and provide general commentary on the program.
Chapters 6.0 through 6.6 present findings from the evaluation but shift from case studies of the Pipeline schools to comparisons across the schools and between Pipeline schools and other dental schools not part of the Pipeline program.33–39 These chapters report on the results of multivariable analyses using variables from all components of the conceptual framework to determine the influence of the Pipeline program on key outcomes expected. These outcomes include URM recruitment, community-based dental education curriculum development, extramural clinical rotations, practice plans of graduating students, health policy involvement of the Pipeline schools, and the likelihood that Pipeline achievements can be sustained after completion of the project.
Chapter 7 brings the work of the NET evaluation together.40 It summarizes the findings, draws conclusions, and reports on the policy implications of the results and lessons learned for program implementation and evaluation.
For this study, the NET obtained the assistance of two respected external reviewers: Dr. Raymond Kuthy, University of Iowa, and Dr. Marilyn Woolfolk, University of Michigan. These reviewers critiqued and provided comments on drafts of Chapters 1 through 7 of this report. In Chapter 8, they provide their own assessments of the Pipeline program and its evaluation.41 The chapter also includes assessments and lessons learned from the perspective of Howard Bailit, Allan Formicola, and Kim C. D’Abreu from the National Program Office.
An afterword by George Zamora and Ignatius Bau from The California Endowment follows Chapter 8.42 This afterword describes Phase II of the California Pipeline program that seeks to further increase minority enrollment, integrate cultural competence into the curriculum, and expand community-based dental education in the California dental schools.
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Utilization of the Report and the Evaluation Findings |
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REFERENCES |
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This article has been cited by other articles:
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  H. L. Bailit, A. J. Formicola, K. C. D'Abreu, I. Bau, G. Zamora, and J. S. Stavisky The Dental Pipeline Program: The National Program Office Perspective J Dent Educ., February 1, 2009; 73(2_suppl): S15 - 22. [Full Text] [PDF]
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J. J. Gutierrez, T. T. Nakazono, D. C. Carreon, and R. M. Andersen Introduction to the Cross-Site Comparisons and Multivariable Analyses of the Dental Pipeline Program J Dent Educ., February 1, 2009; 73(2_suppl): S236 - 237. [Full Text] [PDF]
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