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Medical Education  |   December 2020
Motivating High School Students From Rural Areas to Attend College and Pursue Careers as Osteopathic Physicians
Author Notes
  • From the Burrell College of Osteopathic Medicine in Las Cruces, New Mexico (Drs Kadavakollu, Ontiveros and Student Drs Torres, Singh, and Pillai), California Health Sciences University College of Osteopathic Medicine in Clovis (Drs. Kadavakollu and Boyanovsky), and the Accounting and Information Systems Department at New Mexico State University in Las Cruces (Dr Shindi). 
  • Financial Disclosures: None reported. 
  • Support: This study was supported by a grant from U.S. Department of Education TRIO program New Mexico Catalog of Federal Domestic Assistance Number: 84.047. 
  •  *Address correspondence to Boris Boyanovsky, MD, PhD, Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, 2500 Alluvial Avenue, Clovis, California 93611. Email: bboyanovsky@chsu.edu
     
Article Information
Medical Education   |   December 2020
Motivating High School Students From Rural Areas to Attend College and Pursue Careers as Osteopathic Physicians
The Journal of the American Osteopathic Association, December 2020, Vol. 120, 877-887. doi:https://doi.org/10.7556/jaoa.2020.146
The Journal of the American Osteopathic Association, December 2020, Vol. 120, 877-887. doi:https://doi.org/10.7556/jaoa.2020.146
Abstract

Context: One potential way to address critical current and future projected health care workforce shortages is through comprehensive programs that could potentially inspire high school students to pursue osteopathic medical careers in underserved areas.

Objective: To determine whether a comprehensive, 5-week enrichment program could promote interest among rural high-school students in careers osteopathic medicine.

Methods: In May 2018, 116 high school students with a grade point average of 2.8 or higher from rural areas, including New Mexico and its surrounding rural areas in the US-Mexico border region, enrolled in а 5-week program offering American College Testing (ACT) preparation and biomedical sciences enrichment at Burrell College of Osteopathic Medicine (BCOM). During the program, students were offered more than 150 hours of interactive in-class lectures and hands-on activities with laboratories focusing on college preparedness, health sciences, and motivating students to pursue osteopathic medical career and practice medicine in rural areas. Clinically-oriented sessions covering osteopathic philosophy and osteopathic manipulative medicine were included. After completion, a voluntary and anonymous survey was sent to students who completed the program students through QualtricsXM©. Blinded ACT scores were collected from participants’ schools, along with college enrollment status information.

Results: Of 116 enrolled students, 106 (91.4%) completed the program successfully. In their postcompletion survey responses, students reported that they had gained a realistic perception of the field of medicine and were motivated to attend college (mean [standard error, SE] score on 5-point Likert scale over 2 questions, 4.8 [0.06]) and osteopathic medical school (mean [SE], 4.7 [0.1]). Participants also felt more informed about physician shortage in rural areas (mean [SE], 4.7 [0.07]) and appeared to be inspired to practice medicine in rural areas (mean [SE], 4.6 [0.09]). Students also reported feeling better prepared to take the ACT after finishing this program (mean [SE], 4.9 [0.04]). Finally, we were able to collect the ACT scores of 51 participants (48.1%) who completed the program; the mean ACT score was 24.3, compared with a reported national mean of 20.7 on a scoring scale of 1-36. We also performed a follow-up inquiry showing that 78 of the 81 participating students (96%) who had graduated from high school were enrolled in college or university and 59 (73%) had elected in science, technology, engineering, mathematics, or health majors.

Conclusion: Rural high school pipeline programs could be a tool to motivate high school students to attend college and ultimately to develop physicians who are interested to practice in medically underserved areas.

The deficit of physicians throughout the nation, particularly in rural areas, is among the most persistent problems in the US health care system.1,2 The shortage of health care providers is projected to become worse in the future for both primary care providers and specialists.3-6 Therefore, the need to produce qualified medical school applicants who are willing to practice in underserved areas is more imperative than ever. 
Across the country, states are seeking various solutions to address these current and projected critical shortages in the health care workforce. It was previously believed that the geographic location of a medical school is a strong predictor of where graduating physicians would practice, but newer studies have concluded that it may no longer be an independent factor.36 The strongest factors currently associated with practice and retention in rural areas appear to be local upbringing and medical school curricula targeted to the importance of practicing medicine in rural areas.710 A potential method of addressing the provider shortage in medically-underserved areas is to implement pipeline programs motivating local students to pursue medical careers. 
Medical schools, both osteopathic and allopathic, have emphasized the importance of offering STEM outreach pipeline programs.11,12 For example, West Virginia School of Osteopathic Medicine has offered several high school pathway programs, including a 1-week “Just Say Know to Drugs!” course,13 a 2-hour anatomy lab tour program,14 and 1-day mini-medical school program.15 Additionally, a study conducted at the Edward Via College of Osteopathic Medicine demonstrated that a 1-week enrichment program offered in medically underserved areas increased high school students’ interest in careers in medicine.16 
Besides instilling interest to pursue medical education, these programs can also serve as a bridge between high school and medical school by providing students with mentoring about the importance of college education, college admission application preparation, and basic test preparation for American College Testing (ACT) or the Scholastic Aptitude Test (SAT). Scores from these standardized tests are basic criteria for admission into a 4-year college or combined Bachelor of Arts (BA)/Bachelor of Science (BS)-Doctor of Medicine (MD) or BA/BS-Doctor of Osteopathic Medicine (DO) programs.17 However, many students from rural areas who want to pursue ACT preparatory courses face difficulties with access or socioeconomic support. While there are supplemental programs providing general ACT preparation for high school students,18,19 we are unaware of any comprehensive programs that have jointly prepared students for college (or ACT) while also encouraging them to practice osteopathic medicine in rural areas. 
In a previous study,20 we offered a comprehensive medical college admission test (MCAT) preparatory program to premedical students and collected information about the students' inclination to pursue osteopathic medicine in rural areas. In that program, we emphasized the importance of osteopathic medicine as a crucial factor to foster primary care physicians who would be committed to practice in medically underserved areas. Based on the promising results from that study, which showed that our preparatory course was successful in encouraging premedical students to pursue osteopathic medical careers, we hypothesized that offering high school students from rural areas or those with low socioeconomic background a program addressing both standardized testing preparation and education about osteopathic medicine might increase their motivation to attend college and their interest in medical practice in rural settings. To assess that hypothesis, we designed a comprehensive, 5-week ACT and biomedical sciences enrichment program. 
The main goals of our study were to enhance motivation for college attendance and preparedness for standardized test-taking, to emphasize the importance of medical practice in underserved areas, and to introduce the osteopathic philosophy to high school students from rural areas. After the study, we assessed the students’ motivation to attend college and their awareness about osteopathic medicine, as well as their subsequent ACT scores and college enrollment status. 
Methods
Survey-based methodology was applied, using a nonexperimental design with a convenience sample of high-school students who completed a comprehensive 5-week ACT and biomedical sciences enrichment program, which was designed and performed at the Burrell College of Osteopathic Medicine (BCOM). The study was approved by BCOM's institutional review board (BCOM IRB_0050). 
Study Population
High school students were recruited to the program through BCOM's website, high school advisors or teachers, social media, newspaper advertisements, emails to local high school affiliates, and flyers. These prospective students lived in Las Cruces, New Mexico, the surrounding rural areas, and the US-Mexico border region. To apply for the program, interested students were required to be enrolled in the 9th to 12th grades with a minimum of 2.8 grade point average on a 4.0 scale. Participants applied to the program by submitting a 2-page enrollment form with personal data, including name, gender, ethnicity, current place of residence, name of the school, high school enrollment status, and parent/guardian emergency contact information. Our informed consent form also contained several questions designed to gauge participants’ motivation for taking the program, commitment to attendance, release of standardized test scores to BCOM, and interest in health-related careers. Parent/guardian informed consent for participants was collected on the first day of the program. 
Program Description
The ACT and biomedical sciences enrichment program ran from 8:00 am to 3:00 pm local time, Monday to Friday, for 5 weeks, at BCOM at New Mexico State University in Las Cruces, New Mexico, beginning in May 2018. This comprehensive program delivered 150 hours of interactive in-class lectures and hands-on activities with laboratories focusing on college preparedness, health sciences, and motivating students to pursue osteopathic medical careers and practice medicine in rural areas. 
Activities included presentations from osteopathic medical school faculty, first-aid and CPR certification, introduction to a medical school systems-based curriculum, demonstrations on medical simulation models, and basic career counseling with medical students and other medical professionals. To hopefully instill a desire to pursue careers in osteopathic medicine, the program included 6 hours of instruction on osteopathic philosophy and the tenets of osteopathic medicine, an introduction to osteopathic manipulative medicine, and a tour of a virtual anatomy lab and other osteopathic medical school facilities. Sessions related to the physician shortage, access to healthcare services, and the importance of practicing medicine in rural or underserved areas were also presented. Students also participated in team-building and cultural competency activities, as well as diversity enrichment sessions. 
Instructional sessions covering the 4 sections of ACT (English, reading, math, and science) included test-taking tips and strategies, following guidelines from the official ACT prep guide.21 The sessions were taught by BCOM faculty and other content experts. Four full-length ACT practice examinations were administered throughout the course to improve students’ test-taking skills. The program also included interactive instructional workshops for college application preparation, admissions, financial and federal aid, college major selection, college application essay writing, and resume preparation. College-level introductory short courses such as chemistry, biology, basic anatomy, and physiology were taught to improve students’ knowledge in biomedical sciences. The program provided hands-on experiences in basic computer application skills and college-level computer science as well as a mathematics course. Finally, 2 hours of indoor sports activities were also scheduled every week for physical and mental wellbeing. 
Survey
A voluntary and anonymous survey (Appendix) was sent through Qualtrics XM© to students who successfully completed the program by achieving 80% attendance. A title page containing a consent form and the parent or guardian signature was followed by a 20-item survey. 
The first 12 questions in the survey (Appendix) were graded on a Likert scale, where 1 indicated that the respondent “strongly disagree(d)” and 5 indicated the respondent “strongly agree(d).” The first 3 of those survey questions assessed students’ self-reported motivation to attend college and ACT preparedness. Questions 4 to 6 were intended to evaluate participants’ perceptions of and interest in medical careers. Questions 7 to 9 assessed participants’ attitudes toward a career in osteopathic medicine and whether they were inclined to practice osteopathic medicine. Questions 10 to 12 evaluated whether the program had any effect on the participants’ likelihood to practice medicine in the southwest region of the United States or to practice medicine in rural areas. The final 8 survey questions (Appendix) assessed respondents’ perceived additional benefits associated from the program on a binary (yes or no) scale. ACT scores were collected blindly from the students’ schools and we followed up to inquire about students’ college enrollment status. 
Data Collection and Analysis
Identifying information was kept confidential from most authors, who used participant identification numbers; only 1 author (S.K.) had access to full data. The primary investigators contacted the participants by email with a link for the online survey via QualtricsXM©. Data was stored on an encrypted flash drive in a locked cabinet. 
Descriptive statistics (number and percentages) were used to analyze demographic variables including ethnicity, gender, and size of the city where each participant lived. Statistical analysis of the 20-item survey was calculated with mean values, standard deviation (SD), and standard error22 (SE, SE = Image not available) where appropriate. The data acquired from QualtricsXM© was analyzed with tools available through QualtricsXM© software.23 Mean scores were calculated following the research methods reported in recent literature.20,24 
Results
A total of 116 students were enrolled in the program; 106 students (91.4%) completed it successfully, based on more than 80% attendance. Of those 106 students, 82 completed the postprogram survey. Students’ demographic information is included in Table 1. We were able to collect subsequent ACT scores for 51 out of 106 students (48.1%). 
Table 1.
Demographic Information of Participants in ACT and Biomedical Sciences Enrichment Program (N= 116)
Characteristic n (%)
Gender
 Male 60 (51.7%)
 Female 56 (48.3%)
High school year
 Freshmen 9 (7.8%)
 Sophomores 26 (22.4%)
 Juniors  58 (50.0%)
 Seniors 23 (19.8%)
Race/ethnicity
 Asian 5 (4.3%)
 Black 3 (2.6%)
 Hispanic/Latino 80 (68.9%)
 Mixed race or other 6 (5.2%)
 Native american/Alaskan native 3 (2.6%)
 White 19 (16.4%)
City size by population
 <2,500 14 (12.0%)
 2,500-50,000 18 (15.5%)
 50,000-100,000 82 (70.7%)
 >500,000  2 (1.7%)
Financial status
 Low-Income families* 65 (56.0%)
 First generation college students 78 (67.2%)

Abbreviation: ACT, American College Testing

*According to Federal TRIO Program Low-Income Guidelines, the term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount.30

Table 1.
Demographic Information of Participants in ACT and Biomedical Sciences Enrichment Program (N= 116)
Characteristic n (%)
Gender
 Male 60 (51.7%)
 Female 56 (48.3%)
High school year
 Freshmen 9 (7.8%)
 Sophomores 26 (22.4%)
 Juniors  58 (50.0%)
 Seniors 23 (19.8%)
Race/ethnicity
 Asian 5 (4.3%)
 Black 3 (2.6%)
 Hispanic/Latino 80 (68.9%)
 Mixed race or other 6 (5.2%)
 Native american/Alaskan native 3 (2.6%)
 White 19 (16.4%)
City size by population
 <2,500 14 (12.0%)
 2,500-50,000 18 (15.5%)
 50,000-100,000 82 (70.7%)
 >500,000  2 (1.7%)
Financial status
 Low-Income families* 65 (56.0%)
 First generation college students 78 (67.2%)

Abbreviation: ACT, American College Testing

*According to Federal TRIO Program Low-Income Guidelines, the term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount.30

×
To the question inquiring about students’ confidence in their ability to perform well on the ACT after attending the program, 90.2% (n=74) answered “strongly agree” and 8.5% (n=7) answered “agree”; there were no “disagree” or “strongly disagree” answers (mean [SE], 4.9 [0.04] on the Likert scale of 1-5; Table 2). We observed virtually the same trend regarding the following 2 questions inquiring about students’ test-taking skills and motivation to attend college: “I feel more confident about the ACT test-taking tips, techniques, and strategies” and “I feel more confident in attending college after graduating from high school.” These results were also supported by questions in Table 3 about whether the program advanced their knowledge in STEM and health fields (Yes: 78 [95.1%]; No: 4 [4.9%]), helped them obtain information about college or university admissions (Yes: 81 [98.8%]; No: 1 [1.2%]), and enhanced their reading, problem-solving, and critical analysis skills (Yes: 82 [100%]). 
Table 2.
Survey Results of High School Students Enrolled in the ACT and Biomedical Sciences Enrichment Program at the Burrell College of Osteopathic Medicine (N=82)a
Category Survey item Strongly agree n (%) Agree n (%) Neutral n (%) Disagree n (%) Strongly disagree n (%) Mean score (SE)
ACT and pursuing college-level education Compared to how I felt before the program:
1. I feel more confident in my ability to perform well on the ACT exam. 74 (90.2%) 7 (8.5%) 1 (1.2%) 0 (0%) 0 (0%) 4.9 (0.04)
2. I feel more confident about the ACT test-taking tips, techniques, and strategies. 72 (87.8%) 10 (12.2%) 0 (0%) 0 (0%) 0 (0%) 4.9 (0.04)
3. I feel more confident in attending college after graduating from high school. 73 (89.0%) 8 (9.8%) 1(1.2%) 0 (0%) 0 (0%) 4.9 (0.04)
Pursuing medicine Compared to how I felt before the program:
4. I am more attracted towards careers in medicine. 68 (82.9%) 9 (11.0%) 1 (1.2%) 4 (4.9%) 0 (0%) 4.7 (0.08)
5. I feel more knowledgeable about what medical school is truly like. 63 (76.8%) 14 (17.1%) 3 (3.7%) 1 (1.2%) 1 (1.2%) 4.7 (0.08)
6. I feel more knowledgeable about what life of a medical student is really like. 56 (68.3%) 19 (23.2%) 4 (4.9%) 2 (2.4%) 1(1.2%) 4.6 (0.07)
Pursuing osteopathic medicine Compared to how I felt before the program:
7. I am more interested in pursuing my career in osteopathic medicine. 48 (58.5%) 27 (32.9%) 5 (6.1%) 2 (2.4%) 0 (0%) 4.7 (0.1)
8. I feel more knowledgeable about osteopathic medicine. 43 (52.4%) 25 (30.5%) 10 (12.2%) 2 (2.4%) 2 (2.4%) 4.6 (0.1)
9. I feel more knowledgeable about osteopathic manipulation techniques. 56 (68.3%) 18 (22.0%) 4 (4.9%) 2 (2.4%) 2 (2.4%) 4.3 (0.11)
Serving in rural or underserved areas Compared to how I felt before the program:
10. I am more educated about physician shortage in the rural parts of the nation. 66 (80.5%) 12 (14.6%) 3 (3.7%) 0 (0%) 1 (1.2%) 4.7 (0.07)
11. I am more likely to practice rural medicine if I become a physician. 58 (70.7%) 17 (20.7%) 5 (6.1%) 1 (1.2%) 1 (1.2%) 4.6 (0.09)
12. I am more likely to practice in the southwest US if I become a physician. 74 (90.2%) 7 (8.6%) 1 (1.2%) 0 (0%) 0 (0%) 4.6 (0.08)

aResults are based on a Likert Scale, where 1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree

Abbreviations: ACT, American College Testing; SE, standard error.

Table 2.
Survey Results of High School Students Enrolled in the ACT and Biomedical Sciences Enrichment Program at the Burrell College of Osteopathic Medicine (N=82)a
Category Survey item Strongly agree n (%) Agree n (%) Neutral n (%) Disagree n (%) Strongly disagree n (%) Mean score (SE)
ACT and pursuing college-level education Compared to how I felt before the program:
1. I feel more confident in my ability to perform well on the ACT exam. 74 (90.2%) 7 (8.5%) 1 (1.2%) 0 (0%) 0 (0%) 4.9 (0.04)
2. I feel more confident about the ACT test-taking tips, techniques, and strategies. 72 (87.8%) 10 (12.2%) 0 (0%) 0 (0%) 0 (0%) 4.9 (0.04)
3. I feel more confident in attending college after graduating from high school. 73 (89.0%) 8 (9.8%) 1(1.2%) 0 (0%) 0 (0%) 4.9 (0.04)
Pursuing medicine Compared to how I felt before the program:
4. I am more attracted towards careers in medicine. 68 (82.9%) 9 (11.0%) 1 (1.2%) 4 (4.9%) 0 (0%) 4.7 (0.08)
5. I feel more knowledgeable about what medical school is truly like. 63 (76.8%) 14 (17.1%) 3 (3.7%) 1 (1.2%) 1 (1.2%) 4.7 (0.08)
6. I feel more knowledgeable about what life of a medical student is really like. 56 (68.3%) 19 (23.2%) 4 (4.9%) 2 (2.4%) 1(1.2%) 4.6 (0.07)
Pursuing osteopathic medicine Compared to how I felt before the program:
7. I am more interested in pursuing my career in osteopathic medicine. 48 (58.5%) 27 (32.9%) 5 (6.1%) 2 (2.4%) 0 (0%) 4.7 (0.1)
8. I feel more knowledgeable about osteopathic medicine. 43 (52.4%) 25 (30.5%) 10 (12.2%) 2 (2.4%) 2 (2.4%) 4.6 (0.1)
9. I feel more knowledgeable about osteopathic manipulation techniques. 56 (68.3%) 18 (22.0%) 4 (4.9%) 2 (2.4%) 2 (2.4%) 4.3 (0.11)
Serving in rural or underserved areas Compared to how I felt before the program:
10. I am more educated about physician shortage in the rural parts of the nation. 66 (80.5%) 12 (14.6%) 3 (3.7%) 0 (0%) 1 (1.2%) 4.7 (0.07)
11. I am more likely to practice rural medicine if I become a physician. 58 (70.7%) 17 (20.7%) 5 (6.1%) 1 (1.2%) 1 (1.2%) 4.6 (0.09)
12. I am more likely to practice in the southwest US if I become a physician. 74 (90.2%) 7 (8.6%) 1 (1.2%) 0 (0%) 0 (0%) 4.6 (0.08)

aResults are based on a Likert Scale, where 1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree

Abbreviations: ACT, American College Testing; SE, standard error.

×
Table 3.
ACT and Biomedical Sciences Enrichment Program Learners’ Postprogram Responses (N=82)
This program helped me to: Yes, n (%) No, n (%)
Receive first aid, CPR, and course completion certification 82 (100%) 0 (0%)
Advance my knowledge in stem and health fields 78 (95.1%) 4 (4.9%)
Obtain information about college or university admissions 81 (98.8%) 1 (1.2%)
Prepare my statement of purpose and resume or curriculum vitae 78 (95.1%) 4 (4.9%)
Enhance my reading, problem-solving, and critical analysis skills 82 (100%) 0 (0%)
Get basic knowledge about college chemistry and biology 82 (100%) 0 (0%)
Develop my knowledge towards cultural competency to overcome healthcare disparities 77 (93.9%) 5 (6.1%)
Learn basic spanish terminology 79 (96.3%) 3 (3.7%)

Abbreviations: ACT, American College Testing; CPR, cardiopulmonary resuscitation.

Table 3.
ACT and Biomedical Sciences Enrichment Program Learners’ Postprogram Responses (N=82)
This program helped me to: Yes, n (%) No, n (%)
Receive first aid, CPR, and course completion certification 82 (100%) 0 (0%)
Advance my knowledge in stem and health fields 78 (95.1%) 4 (4.9%)
Obtain information about college or university admissions 81 (98.8%) 1 (1.2%)
Prepare my statement of purpose and resume or curriculum vitae 78 (95.1%) 4 (4.9%)
Enhance my reading, problem-solving, and critical analysis skills 82 (100%) 0 (0%)
Get basic knowledge about college chemistry and biology 82 (100%) 0 (0%)
Develop my knowledge towards cultural competency to overcome healthcare disparities 77 (93.9%) 5 (6.1%)
Learn basic spanish terminology 79 (96.3%) 3 (3.7%)

Abbreviations: ACT, American College Testing; CPR, cardiopulmonary resuscitation.

×
The majority (68; 82.9%) of students answered “strongly agree” and 11% (9) answered “agree” to our question about their interest in pursuing a career in medicine (mean [SE], 4.7 [0.08]; Table 2). Similarly, most of the participants felt more aware about life in a medical school: 56 (68.3%) of the students strongly agreed with the statement, “I feel more knowledgeable about what medical school is truly like after finishing this program” (mean [SE], 4.7 [0.08]). A small percentage of the students disagreed with (4; 4.9%) or were neutral (1; 1.2%) about the statement, “I am more attracted towards careers in medicine [after this program].” 
The largest percentages of students answered “strongly agree” (48; 58.5%) or “agree” (27; 32.9%) to the statement “I am more interested in pursuing my career in osteopathic medicine”; 5 (6%) of the students were “neutral” and 2 (2.4) “disagreed” with that statement. These results specifically show that interest in osteopathic medicine increased after finishing this program. Similarly, students felt more informed about osteopathic medicine (“strongly agree”: 43 [52.4%]; “agree”: 24 [30.5%]; mean [SE], 4.6 [0.1]; Table 2) and osteopathic manipulation techniques (“strongly agree”: 56 [68.3%]; “agree”: 18 [22.0%]; mean [SE], 4.6 [0.1]). However, in this section, there was also a higher number of mid-value and low-value responses on the Likert scale to the following questions: “I feel more knowledgeable about osteopathic medicine” (10 [12.2%] answered “neutral,” 2 [2.4%] answered “disagree,” and 2 [2.4%] answered “strongly disagree”) and “I feel more knowledgeable about osteopathic manipulation techniques” (4 [4.9%] answered “neutral,” 2 [2.4%] answered “disagree,” and 2 [2.4%] answered “strongly disagree”). 
The majority of participants in the program were aware of the physician shortage in the rural parts of the nation, as evidenced by their responses to the question, “I am more educated about physician shortage in the rural parts of the nation”: 80.5% (66) responded “strongly agree” and 14.6% (n=12) responded “agree” (Table 2). Our finding that virtually all the students found it more likely they would practice in the Southwest US (74 [90.2%] responded “strongly agree” and 8 [8.6%] responded “agree”) is consistent with the fact that geographic upbringing is a strong predicting factor for the geographic area of practice. 
For the 51 students (48.1%) for whom we were able to obtain an ACT score, the ranges were as follows: 15 students (28.8%) scored 16 to 19 (below 50th percentile), 23 (44.2%) scored 20 to 28 (50th-90th percentile), and 13 (21.6%) scored 29 to 36 (above the 90th percentile), including 4 students who scored 36 (100th percentile) on a scale of 1 to 36. The mean ACT score of our study population was 24.3, higher than the national mean of 20.7,25 which represents approximately the 74th percentile according to the official ACT reporting category interpretation guide.26 
Our follow-up inquiry showed that 96.3% (78) of the juniors and seniors who completed the survey were currently enrolled in college and/or university and 72.8% (59) of them were in science, technology, engineering, mathematics, or health (STEM-H) majors. 
Discussion
According to the US Census Bureau, New Mexico—where our program was offered—is one of the most medically underserved states and has the lowest state (50th) ranking for kindergarten through 12th grade education nationwide.27,28 Further, the majority (68%) of our participants in this program were Hispanic compared with only 6.3% of applicants to the US medical schools,29 making programs of this kind potentially useful in increasing representation in health care from practitioners of all ethnicities. In addition, 56% (65) of the high-school participants in our program were from low-income families meeting specific U.S. Department of Education income guidelines30 and 67.2% (78) were first-generation college students (meaning neither parent has a college degree). In general, first-generation students lack career advising and mentoring opportunities and face many academic obstacles, including financial challenges, during their college-level education.31,32 
The need for quality medical providers is especially critical for patients who reside in geographic locations that have limited access to health care. We believe that our results support our hypothesis that rural high school pipeline programs might be a valuable tool to develop future osteopathic physicians willing to practice in medically underserved areas of the nation. Our results also indicate that our summer program was useful for enhancing high school students’ confidence and motivation to take the ACT examination and to attend college. Lastly, this program also appeared to have strengthened the participants’ awareness of osteopathic medicine. 
Unfortunately, many high school graduates lack the foundational knowledge required for college-level course work.33 Enhancing students’ test-taking abilities beginning in high school is also crucial, since standardized tests like the ACT are a gateway to most colleges and universities. (In New Mexico, most colleges require ACT scores for admission.) For these reasons, we covered a spectrum of ACT and STEM related content and provided students with the opportunity to practice with 4 full-length examinations to enhance their confidence in taking the ACT examination. After completing this program, all students stated that they felt they had enhanced the skills required for attending college, including problem-solving and critical analysis. Program graduates reported enhanced skills after completion; this confidence was supported by the data we collected on subsequent ACT scores. Notably, the mean program graduate ACT score of 24.3 was above the national mean of 20.7 and especially the mean for the state of New Mexico, which was 19.3.25 Ninety-six percent of the junior and senior-high-school students enrolled in a college or university after finishing this program. 
A longer-term goal of our program was to strengthen the high school students’ motivation to pursue careers in medicine and to specifically educate them about osteopathic medicine. We believe that we achieved this goal in broader terms, based on the overall positive responses to our questions inquiring about knowledge and motivation to pursue careers in medicine. The relatively moderate answers to our specific questions about knowledge about osteopathic medicine and osteopathic manipulative techniques indicate that more efforts are warranted on this matter. Further study could include more longitudinal follow-up of our students, where we hope that we will be able to identify the real percentage of students who will go on to enroll in medical schools, especially osteopathic medical schools, and the percentage of students who will commit to practice in rural areas. This ambitious plan will help us to identify students with potential to become osteopathic physicians. 
Overall, offering similar programs at other osteopathic medical schools may provide a platform for increasing students’ exposure to college and medical school life, introducing the osteopathic profession and osteopathic manipulative medicine, furthering the college preparedness, and ultimately to motivating participants to serve in rural and underserved communities as osteopathic physicians. However, many other factors, such as access to resources in urban locations and practice possibilities in large hospitals, which are limited for those in rural areas, should also be considered and potentially addressed. 
One limitation of our study is that we did not perform a preliminary survey to directly compare students’ answers before and after the program. To address the need for comparison, we phrased all postprogram survey questions in a specific way, beginning with “Compared to how I felt before the program…” Additionally, response rate was a limitation; we were only able to collect answers to our questionnaire from 77.4% of the participants (attrition rate, 22.6%). Ideally, we would have been able to collect all responses and ACT scores. However, it can be difficult to motivate school-aged participants to commit actively in questionnaires. We limited our efforts to pursue students to report their ACT scores, due to the sensitive nature of this information. Finally, social desirability bias should also be considered as a potential limitation. To prevent it, our survey was voluntary and strictly anonymous with questions designed to encourage sincere and unbiased answers. Based on this study, we have developed a new program emphasizing newest teaching technologies used in medical schools, such as virtual anatomy and high fidelity simulation models, and most importantly, we plan to expose prospective candidates to osteopathic manipulative medicine and philosophy to further increase interest and understanding about osteopathic medicine. 
Conclusion
Programs like our comprehensive ACT and biomedical sciences enrichment program appear to be a promising tool for motivating high school students to attend college and potentially pursue a career in medicine, specifically osteopathic medicine. Ongoing monitoring will be required to fully understand the impact of this educational program, but we believe that offering and expanding similar college preparedness programs to high-school students by osteopathic medical schools across the country may have a positive impact on reducing physician shortage problems in medically underserved areas. 
Acknowledgments
The authors thank the Doña Ana Community College at New Mexico State University (NMSU) for use of their facilities, TRIO upward bound at NMSU, South West Foundation of Osteopathic Education and Research, Las Cruces Public Schools, New Mexico Summer Food Service Program, University of New Mexico Health Sciences Center College of Pharmacy, and Integrated Planning and Advising for Student Success at NMSU. The authors thank the American Heart Association for providing presentations, first-aid, and CPR training sessions and certifications. They also thank the Burrell College of Osteopathic Medicine (BCOM) Department of Biomedical Sciences, Department of Anatomy and Cell Biology, Simulation Labs, Department of Medical Education, Department of Information Technology, Facilities, Compliance, and Institutional Review Board for providing the space, tour to the facilities, instruction and additional support. The authors extend special thanks to BCOM scientific, clinical, and OMM faculty, as well as BCOM OMS I and II medical students for providing instruction and advice to high school participants. 
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Appendix.
ACT and Biomedical Sciences Enrichment Program 
High School Student Survey Questionnaire 
Likert Scale Response Items (Item Number 1 to 12) 
Please use the following scale to answer the questions in this survey 
1: strongly disagree 2: disagree 3: neutral 4: agree 5: strongly agree 
Compared to how I felt before the program: 
 1. I feel more confident in my ability to perform well on the ACT exam 
  1 2 3 4 5 
 2. I feel more confident about the ACT test-taking tips, techniques and strategies 
  1 2 3 4 5 
 3. I feel more confident in attending college after graduating from high school 
  1 2 3 4 5 
 4. I am more attracted towards careers in medicine 
  1 2 3 4 5 
 5. I feel more knowledgeable about medical school is truly like 
  1 2 3 4 5 
 6. I feel more knowledgeable about what life of a medical student is really like 
  1 2 3 4 5 
 7. I am more interested in pursuing my career in osteopathic medicine 
  1 2 3 4 5 
 8. I feel more knowledgeable about osteopathic medicine 
  1 2 3 4 5 
 9. I feel more knowledgeable about osteopathic manipulation techniques 
  1 2 3 4 5 
 10. I am more educated about physician shortage problem in the rural parts of the nation 
  1 2 3 4 5 
 11. I am more likely to practice rural medicine if I become a physician 
  1 2 3 4 5 
 12. I am more likely to practice in the southwest United States if I become a physician 
  1 2 3 4 5 
Yes/No Response Items (Item Number 12 to 20) 
This program helped me to: 
 13. Receive First Aid, CPR and course completion certification (Yes or No) 
 14. Advance my knowledge in STEM and Health fields (Yes or No) 
 15. Obtain information about college or university admissions (Yes or No) 
 16. Prepare my statement of purpose and resume or curriculum vitae (Yes or No) 
 17. Enhance my reading, problem-solving, and critical analysis skills (Yes or No) 
 18. Get basic knowledge about college chemistry and biology (Yes or No) 
 19. Develop my knowledge towards cultural competency to overcome health care disparities (Yes or No) 
 20. Learn basic Spanish terminology (Yes or No) 
Table 1.
Demographic Information of Participants in ACT and Biomedical Sciences Enrichment Program (N= 116)
Characteristic n (%)
Gender
 Male 60 (51.7%)
 Female 56 (48.3%)
High school year
 Freshmen 9 (7.8%)
 Sophomores 26 (22.4%)
 Juniors  58 (50.0%)
 Seniors 23 (19.8%)
Race/ethnicity
 Asian 5 (4.3%)
 Black 3 (2.6%)
 Hispanic/Latino 80 (68.9%)
 Mixed race or other 6 (5.2%)
 Native american/Alaskan native 3 (2.6%)
 White 19 (16.4%)
City size by population
 <2,500 14 (12.0%)
 2,500-50,000 18 (15.5%)
 50,000-100,000 82 (70.7%)
 >500,000  2 (1.7%)
Financial status
 Low-Income families* 65 (56.0%)
 First generation college students 78 (67.2%)

Abbreviation: ACT, American College Testing

*According to Federal TRIO Program Low-Income Guidelines, the term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount.30

Table 1.
Demographic Information of Participants in ACT and Biomedical Sciences Enrichment Program (N= 116)
Characteristic n (%)
Gender
 Male 60 (51.7%)
 Female 56 (48.3%)
High school year
 Freshmen 9 (7.8%)
 Sophomores 26 (22.4%)
 Juniors  58 (50.0%)
 Seniors 23 (19.8%)
Race/ethnicity
 Asian 5 (4.3%)
 Black 3 (2.6%)
 Hispanic/Latino 80 (68.9%)
 Mixed race or other 6 (5.2%)
 Native american/Alaskan native 3 (2.6%)
 White 19 (16.4%)
City size by population
 <2,500 14 (12.0%)
 2,500-50,000 18 (15.5%)
 50,000-100,000 82 (70.7%)
 >500,000  2 (1.7%)
Financial status
 Low-Income families* 65 (56.0%)
 First generation college students 78 (67.2%)

Abbreviation: ACT, American College Testing

*According to Federal TRIO Program Low-Income Guidelines, the term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount.30

×
Table 2.
Survey Results of High School Students Enrolled in the ACT and Biomedical Sciences Enrichment Program at the Burrell College of Osteopathic Medicine (N=82)a
Category Survey item Strongly agree n (%) Agree n (%) Neutral n (%) Disagree n (%) Strongly disagree n (%) Mean score (SE)
ACT and pursuing college-level education Compared to how I felt before the program:
1. I feel more confident in my ability to perform well on the ACT exam. 74 (90.2%) 7 (8.5%) 1 (1.2%) 0 (0%) 0 (0%) 4.9 (0.04)
2. I feel more confident about the ACT test-taking tips, techniques, and strategies. 72 (87.8%) 10 (12.2%) 0 (0%) 0 (0%) 0 (0%) 4.9 (0.04)
3. I feel more confident in attending college after graduating from high school. 73 (89.0%) 8 (9.8%) 1(1.2%) 0 (0%) 0 (0%) 4.9 (0.04)
Pursuing medicine Compared to how I felt before the program:
4. I am more attracted towards careers in medicine. 68 (82.9%) 9 (11.0%) 1 (1.2%) 4 (4.9%) 0 (0%) 4.7 (0.08)
5. I feel more knowledgeable about what medical school is truly like. 63 (76.8%) 14 (17.1%) 3 (3.7%) 1 (1.2%) 1 (1.2%) 4.7 (0.08)
6. I feel more knowledgeable about what life of a medical student is really like. 56 (68.3%) 19 (23.2%) 4 (4.9%) 2 (2.4%) 1(1.2%) 4.6 (0.07)
Pursuing osteopathic medicine Compared to how I felt before the program:
7. I am more interested in pursuing my career in osteopathic medicine. 48 (58.5%) 27 (32.9%) 5 (6.1%) 2 (2.4%) 0 (0%) 4.7 (0.1)
8. I feel more knowledgeable about osteopathic medicine. 43 (52.4%) 25 (30.5%) 10 (12.2%) 2 (2.4%) 2 (2.4%) 4.6 (0.1)
9. I feel more knowledgeable about osteopathic manipulation techniques. 56 (68.3%) 18 (22.0%) 4 (4.9%) 2 (2.4%) 2 (2.4%) 4.3 (0.11)
Serving in rural or underserved areas Compared to how I felt before the program:
10. I am more educated about physician shortage in the rural parts of the nation. 66 (80.5%) 12 (14.6%) 3 (3.7%) 0 (0%) 1 (1.2%) 4.7 (0.07)
11. I am more likely to practice rural medicine if I become a physician. 58 (70.7%) 17 (20.7%) 5 (6.1%) 1 (1.2%) 1 (1.2%) 4.6 (0.09)
12. I am more likely to practice in the southwest US if I become a physician. 74 (90.2%) 7 (8.6%) 1 (1.2%) 0 (0%) 0 (0%) 4.6 (0.08)

aResults are based on a Likert Scale, where 1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree

Abbreviations: ACT, American College Testing; SE, standard error.

Table 2.
Survey Results of High School Students Enrolled in the ACT and Biomedical Sciences Enrichment Program at the Burrell College of Osteopathic Medicine (N=82)a
Category Survey item Strongly agree n (%) Agree n (%) Neutral n (%) Disagree n (%) Strongly disagree n (%) Mean score (SE)
ACT and pursuing college-level education Compared to how I felt before the program:
1. I feel more confident in my ability to perform well on the ACT exam. 74 (90.2%) 7 (8.5%) 1 (1.2%) 0 (0%) 0 (0%) 4.9 (0.04)
2. I feel more confident about the ACT test-taking tips, techniques, and strategies. 72 (87.8%) 10 (12.2%) 0 (0%) 0 (0%) 0 (0%) 4.9 (0.04)
3. I feel more confident in attending college after graduating from high school. 73 (89.0%) 8 (9.8%) 1(1.2%) 0 (0%) 0 (0%) 4.9 (0.04)
Pursuing medicine Compared to how I felt before the program:
4. I am more attracted towards careers in medicine. 68 (82.9%) 9 (11.0%) 1 (1.2%) 4 (4.9%) 0 (0%) 4.7 (0.08)
5. I feel more knowledgeable about what medical school is truly like. 63 (76.8%) 14 (17.1%) 3 (3.7%) 1 (1.2%) 1 (1.2%) 4.7 (0.08)
6. I feel more knowledgeable about what life of a medical student is really like. 56 (68.3%) 19 (23.2%) 4 (4.9%) 2 (2.4%) 1(1.2%) 4.6 (0.07)
Pursuing osteopathic medicine Compared to how I felt before the program:
7. I am more interested in pursuing my career in osteopathic medicine. 48 (58.5%) 27 (32.9%) 5 (6.1%) 2 (2.4%) 0 (0%) 4.7 (0.1)
8. I feel more knowledgeable about osteopathic medicine. 43 (52.4%) 25 (30.5%) 10 (12.2%) 2 (2.4%) 2 (2.4%) 4.6 (0.1)
9. I feel more knowledgeable about osteopathic manipulation techniques. 56 (68.3%) 18 (22.0%) 4 (4.9%) 2 (2.4%) 2 (2.4%) 4.3 (0.11)
Serving in rural or underserved areas Compared to how I felt before the program:
10. I am more educated about physician shortage in the rural parts of the nation. 66 (80.5%) 12 (14.6%) 3 (3.7%) 0 (0%) 1 (1.2%) 4.7 (0.07)
11. I am more likely to practice rural medicine if I become a physician. 58 (70.7%) 17 (20.7%) 5 (6.1%) 1 (1.2%) 1 (1.2%) 4.6 (0.09)
12. I am more likely to practice in the southwest US if I become a physician. 74 (90.2%) 7 (8.6%) 1 (1.2%) 0 (0%) 0 (0%) 4.6 (0.08)

aResults are based on a Likert Scale, where 1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree

Abbreviations: ACT, American College Testing; SE, standard error.

×
Table 3.
ACT and Biomedical Sciences Enrichment Program Learners’ Postprogram Responses (N=82)
This program helped me to: Yes, n (%) No, n (%)
Receive first aid, CPR, and course completion certification 82 (100%) 0 (0%)
Advance my knowledge in stem and health fields 78 (95.1%) 4 (4.9%)
Obtain information about college or university admissions 81 (98.8%) 1 (1.2%)
Prepare my statement of purpose and resume or curriculum vitae 78 (95.1%) 4 (4.9%)
Enhance my reading, problem-solving, and critical analysis skills 82 (100%) 0 (0%)
Get basic knowledge about college chemistry and biology 82 (100%) 0 (0%)
Develop my knowledge towards cultural competency to overcome healthcare disparities 77 (93.9%) 5 (6.1%)
Learn basic spanish terminology 79 (96.3%) 3 (3.7%)

Abbreviations: ACT, American College Testing; CPR, cardiopulmonary resuscitation.

Table 3.
ACT and Biomedical Sciences Enrichment Program Learners’ Postprogram Responses (N=82)
This program helped me to: Yes, n (%) No, n (%)
Receive first aid, CPR, and course completion certification 82 (100%) 0 (0%)
Advance my knowledge in stem and health fields 78 (95.1%) 4 (4.9%)
Obtain information about college or university admissions 81 (98.8%) 1 (1.2%)
Prepare my statement of purpose and resume or curriculum vitae 78 (95.1%) 4 (4.9%)
Enhance my reading, problem-solving, and critical analysis skills 82 (100%) 0 (0%)
Get basic knowledge about college chemistry and biology 82 (100%) 0 (0%)
Develop my knowledge towards cultural competency to overcome healthcare disparities 77 (93.9%) 5 (6.1%)
Learn basic spanish terminology 79 (96.3%) 3 (3.7%)

Abbreviations: ACT, American College Testing; CPR, cardiopulmonary resuscitation.

×