Promoting Health Equity Through Holistic Admissions in Occupational Therapy Education

In the next 20 yr, the U.S. population is expected to shift from a White majority (Ewert, 2015). As of 2019, 60% of the country’s population identified as non-Hispanic White, 19% as Hispanic or Latinx/e, 13% as Black or African American, and 6% as Asian (U.S. Census Bureau, 2019). Population trends indicate an increasing need for health care practitioners who can provide the best care and outcomes for a changing demographic. However, the gap between the racial composition of health care professionals and the overall population continues to widen (Goode & Landefeld, 2018).

Health equity is achieved “when all members of society enjoy a fair and just opportunity to be as healthy as possible” (National Center for Immunization and Respiratory Diseases [U.S.], Division of Viral Diseases, 2020, p. 1). Achieving this equity requires deliberate efforts to eliminate disparities due to factors such as race and ethnicity so that all people can fully access health care services. Evidence shows that minoritized populations experience better interpersonal relationships and communication and are more likely to keep follow-up appointments with health care professionals who share their own ethnicity, race, or language. This concordance can be linked to improved public health through patients’ increased pursuit of and receipt of appropriate care (Goode & Landefeld, 2018).

According to Wilbur et al. (2020), “increasing the diversity of the healthcare workforce is essential for the provision of culturally responsive care, expanding healthcare access, and enriching the pool of leaders and policymakers to meet the needs of a diverse society” (p. 225). Expanding diversity among health care workers is a recognized strategy to increase equity of care among minoritized groups; however, implementing this strategy requires deliberate recruitment of diverse health care workers.

Students of color are underrepresented in academic programs across the health professions (Wilbur et al., 2020). From the perspective of ethnic and racial diversity, the occupational therapy profession is woefully ill equipped to meet the needs of a changing society. The racial demographics of occupational therapy practitioners in the United States—84% White, 6% Asian, 4% Hispanic, and 3% Black (American Occupational Therapy Association [AOTA], 2019b)—do not adequately reflect those of the population. This lack of diversity in our workforce is directly linked to the lack of diversity in our educational programs. Among occupational therapy master’s students, 77% are White, 8% are Hispanic, 7% are Asian, and 5% are Black. Among occupational therapy assistant students, 71% are White, 14% are Hispanic, 11% are Black, and 6% are Asian (AOTA, 2020).

Academic programs function as gatekeepers for diversity in the profession. Occupational therapy academic programs must make focused, intentional, and systematic efforts to successfully matriculate students who reflect the diversity of the broader population. Historically, college admissions practices in the United States have emphasized standardized test scores and academic metrics as the primary criteria for evaluating and admitting applicants; such practices have been shown to eliminate otherwise-qualified, primarily minoritized applicants who may score lower on quantitative metrics (Ballejos et al., 2015). The introduction of holistic admission practices in academia provides a formidable pathway toward growing a more representative workforce with the potential to address, and ideally eliminate, health care disparities and achieve health equity (Ballejos et al., 2015).

This holistic admissions process is widely considered the gold standard for increasing diversity in the student population (Michel et al., 2019). As part of this process, each applicant’s file is reviewed in its entirety, and no single factor excludes an applicant from admission. Holistic admission ensures that admitted students best represent an academic program’s mission and vision while maintaining academic rigor and excellence (Dewitty, 2018; Urban Universities for HEALTH, 2014). Reviewing applications holistically requires the careful consideration of both cognitive factors, such as the applicant’s academic history and standardized test scores, and noncognitive factors, such as desired experiences and attributes (Association of American Medical Colleges, 2013; Ballejos et al., 2015). Other best practices within a holistic admissions process include thoughtful selection of evaluation criteria, consideration of program outcomes, consideration of program cost, and establishment of review practices that mitigate bias.

Historically, as was the case with many programs across the United States, the University of Southern California’s Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy (hereinafter USC Chan) program relied heavily on cognitive metrics for admission. Common admission practices included setting minimum scores on standardized tests, such as the Graduate Record Examination^® General Test (GRE), as well as minimum grade point averages (GPAs). These practices facilitated the admission of students who performed well with traditional academic markers, but they did not ensure a student body that would be representative of the population they would serve as practitioners. Furthermore, overreliance on cognitive metrics posed barriers to admission of students with other meritorious attributes and life experiences that are arguably critical to culturally responsive care in occupational therapy practice. Recognizing these major impediments to equitable health care, and acknowledging our profession’s responsibility to ameliorate these disparities through workforce diversification, we at USC Chan committed to a comprehensive restructuring of the admission process in alignment with our long-range vision and core values.

To initiate the process, USC Chan used the Experiences, Attributes, and Metrics model (Association of American Medical Colleges, 2013), in conjunction with desired outcomes established for program graduates, to identify applicant attributes and experiences aligned with those outcomes. Examples of these included compassion, cultural humility, and teamwork skills. Next, the program modified application components to capture these attributes and experiences. A diverse team of faculty revised the existing personal statement, short-answer questions, and video prompts. In addition, metrics such as grade trends were aligned with letters of recommendation and GPA. The goal of mapping these experiences, attributes, and metrics throughout the application was to ensure that selected applicants would best reflect the desired outcomes for program graduates.

After revising the components of the application, the program critically examined how disparities and bias might influence every level of review, from the structure of the admissions process to how each component is evaluated. Examples of how disparities and bias might affect an application include personal statement essay structure, grade inflation, availability of suitable recommenders, and recommenders’ perceptions of student performance (Michel et al., 2019). Standardized tests, such as the GRE, which are commonly used in higher education, were especially scrutinized during our reflective process. Michel et al. (2019) demonstrated that considerable differences in GRE scores were present among test takers according to gender, race, and socioeconomic status, likely as a result of the testing structure and costs associated with test preparation and administration. Thus, graduate programs’ emphasis on GRE scores negatively affects diversity among admitted students and undermines holistic admission processes (Millar, 2020).

To lessen bias, the first step implemented by USC Chan was the selection of a diverse committee of faculty to review applications. The admissions committee represented the program’s core values, and members were varied in their experiences, practice areas, and demographics. This diversity provided a range of perspectives on applicant merit, preparedness, and aptitude for success. To reduce the introduction of personal bias, the committee received orientations from admissions faculty on holistic admission practices, implicit bias, and the file review processes in alignment with best practice (Association of American Medical Colleges, 2013; Michel et al., 2019).

The next step toward reducing bias in application review was the careful crafting of rubrics to capture the desired applicant qualities from the mapping process, as per recommended best practices (Association of American Medical Colleges, 2013). The admissions team consulted with university instructional designers on the development of these rubrics. Once rubrics were prepared, the admissions committee completed calibration training to ensure accurate and consistent evaluation of application components across reviewers.

A critical consideration was the overall weighting of cognitive and noncognitive application components. Research shows that the overweighting of cognitive criteria reduces the admission of minoritized applicants and consequently compromises the holistic review process (Ballejos et al., 2015). In alignment with the vision of the program and profession, the weighting of cognitive criteria (cumulative GPA) was limited to 33% of the total holistic score.

Once processes were in place to mitigate bias in the holistic review process, USC Chan implemented communication and outreach efforts. Prospective applicants were presented with clear and consistent messaging, including details of the application and evaluation processes, via the USC Chan website as well as during in-person and online information sessions. Targeted efforts implemented to bring in applicants from diverse populations included outreach to university cultural centers and attendance at events for minoritized students by diverse faculty and students. In addition, pathways into the profession were created through summer programming in collaboration with undergraduate colleges that serve minoritized students. Figure 1 illustrates the holistic admissions implementation process.

In the 2 yr since implementing holistic admissions, USC Chan has matriculated two of the most diverse entry-level master’s cohorts in our program’s history. This outcome is in alignment with the program’s strategic goals and priorities as well as those of the profession at large. The racial composition of the most recently admitted entry-level master’s cohort was 45% White, 27% Asian, 32% Latinx/e, 15% Black, and 2% Native American. The class admitted before holistic review was implemented was 52% White, 38% Asian, 19% Latinx/e, 4% Black, and 0% Native American. For comparison, the demographics of USC Chan’s applicant pool averaged 47% White, 37% Asian, 25% Latinx/e, 5% Black, and 1% Native American over the last three cycles. Table 1 further depicts the demographics of the admitted class 2 yr before the implementation of holistic admissions and shows the demographics of two admitted cycles since that implementation. Although the initial outcome focus has been on diversifying racial demographics, we noted that intersectionalities with disability, sexual orientation, age, and gender identity also significantly expanded. The success of our holistic admission practices also contributed to related diversity efforts in the areas of recruitment, retention, and financial support. For example, USC Chan has more than doubled scholarship funding to support the entry-level class since the implementation of holistic admissions. Not only was the budget doubled, but also scholarship distribution was changed from solely being based on cognitive scores for merit to being distributed according to candidates’ holistic scores. This change tremendously affected individuals who had been excluded from receiving funding—often applicants from minoritized backgrounds—who were now given opportunity to receive a competitive funding package.

Increasing diverse representation in occupational therapy and occupational therapy assistant educational programs will, in turn, diversify the profession, leading to more personalized, culturally responsive, and client-centered care, thereby facilitating improved outcomes and contributing to reductions in health disparities (Goode & Landefeld, 2018). Increased diverse representation in the classroom expands perspectives, thoughts, and ideas; fosters creativity; and supports academic success (Taff & Blash, 2017). In addition, as students are exposed to more diverse representation, the curriculum should also support increased dialogue about cultural humility and implicit/unconscious bias and address the systemic barriers contributing to health care disparities. These intentional discussions are ways to prepare our students to be advocates for diversity and should provide them with the tools to deliver culturally responsive and equitable care. The growing body of diverse practitioners will ultimately better equip our profession to meet the occupational needs of an ever-changing population.

This outcome directly aligns with a pillar of AOTA’s Vision 2025: Equity, Inclusion, and Diversity, which states that the profession will be “intentionally inclusive and equitable and embrace diversity in all its forms” (AOTA, 2019a). To achieve this vision, it is imperative that all occupational therapy and occupational therapy assistant educational programs consider implementing admission practices that will increase representation for minoritized groups and contribute to bridging the health disparity gap.

As we transitioned to an entry-level doctoral program the fall of 2022, USC Chan is well poised to build on its gold-standard holistic admissions process, which was intentionally created with broad faculty input and a growing evidence base generated from two diverse master’s cohorts. We will continue to systematically collect and analyze diversity demographics and successful program outcomes to demonstrate the effect of our holistic admissions practices. Data collection includes faculty feedback; National Board for Certification in Occupational Therapy pass rates; USC comprehensive exam scores and pass rates; fieldwork performance; academic, scholarly, and professional engagement; and job placement. This information can be used as a model for diversity-driven data across the profession, with educational outcomes serving as a clear way to demonstrate how AOTA’s Vision 2025 is being accomplished.

Occupational therapy and occupational therapy assistant educational programs have a responsibility to continuously assess the alignment of admission practices with their mission, core values, and program goals, as well as with AOTA’s (2019a) Vision 2025. If current practices are not successfully contributing to equity, inclusion, and diversity, then it is critical to evaluate which criteria and processes can be changed to enable “all people, populations, and communities” (AOTA, 2019a, p. 1) to have representation within this profession. As gatekeepers to the profession, academic programs have a responsibility to grow diversity in the health care workforce and positively influence health equity in our society. As more programs adopt holistic admissions processes, AOTA’s Vision 2025 is one step closer to becoming a reality.