Vol XI: From Concern to Commitment: Learning to Center Equity in Occupational Therapy Admissions Processes

Authors: Layla Razek¹, Hiba Zafran PhD², Barbara Shankland¹, Caroline Storr¹

¹Department of Biology, McGill University, Canada

²School of Physical and Occupational Therapy, McGill University, Canada

Black students are systematically excluded from healthcare education, denying an increasing Black Canadian population access to diverse healthcare practitioners. This study explored admissions processes related to the inclusion of equity groups within McGill’s Occupational Therapy program and identified recommendations specific to Black applicants. Data was collected from a survey of current students and program graduates. Data analysis, applying a critical intersectional lens, was contextualized in dialogue with five key individuals at McGill and a review of the literature. Findings revealed  an application process that foregrounds the experiences of white upper-class ​applicants while leaving historically excluded students feeling dissatisfied and unable to authentically represent themselves. Barriers to admissions in occupational therapy include a website with no Black representation, a difficult-to-navigate admissions guide, and an admissions committee currently lacking Black or Indigenous representation. The valorization of Black applicants and students through visibly welcoming spaces and meaningful resources for inclusion and success are acknowledged, but not yet developed. The study findings support next steps by providing program-level recommendations such as the inclusion of Black faculty on the admissions committee and the option to submit an essay for Black applicants.  The implementation of an evidence-based Black Student Pathway is necessary.

Introduction

Diversity is necessary for equitable and high quality healthcare and education (1). An increasingly diverse population has a right to the type of care offered by healthcare practitioners of the same background (2). A United States report found that the mortality of Black newborn babies was nearly triple that of white newborns when taken care of by white physicians. Care by Black physicians reduced this mortality rate between 39 to 58% (3). When the quality of healthcare depends on diverse practitioners, the human right to “life, liberty, and security of person” are threatened by healthcare education which continues to exclude Black people (4). In recognition of this reality, inclusion should be understood as an integral component of academic excellence (5). However, even as the number of visible minorities is set to increase by around 30% by 2036 in Canada, the number of historically excluded  students accepted into healthcare programs continues to stagnate (6, 7).

The Occupational Therapy (OT) program at McGill moved to an entry-level masters program in 2008 with possible admission at the undergraduate level or by a qualifying year (QY) following completion of a relevant undergraduate degree (8). The OT Program admissions file review has traditionally considered a candidate’s academic performance as well as their non-cognitive attributes. The assessment methods of such attributes have evolved from semi-structured interviews, to Mini Multiple Interviews (MMIs), which were initiated in 2012 (9). Program evaluation results showed that MMIs were labor intensive, costly and often required candidates to travel long distances to Montreal. In 2019, the MMIs were replaced by a situational judgment test, the Computer-based Assessment for Sampling Personal Characteristics (CASPer). The CASPer test is used by university health science professional program admission committees throughout North America (10). At present, the admissions criteria for the professional program in OT at McGill include the grade point average (GPA), the CASPer test score, background courses and a personal statement submitted on video. In 2019, the OT Admissions Committee designated 2 seats for Indigenous applicants into the QY cohort and implemented a holistic file review process (11) alongside Indigenous partnerships for the admissions and support of Indigenous applicants (12).

This equity assurance project is led by the Occupational Therapy Program workgroup Reconfiguring for Equity, Praxis, Accountability, Inclusion and Reconciliation (7) and aimed to support tailoring the holistic admissions processes towards Black applicants, with the ultimate goal of making the McGill OT program more accessible and inclusive for Black applicants. This project took place over the summer of 2021 and inscribed itself within multiple other equity initiatives taking place at McGill University following a review of the 5-year diversity data profiles for OT students (2014-2019), and the release of McGill’s Action Plan to Address Anti-Black Racism (9). Data shows that on average, Black applicants made up 2.3% of the student population compared to 6.8% and 4% of the Montreal and Quebec population, respectively (6).  Other equity groups who are underrepresented include applicants with disabilities and those from a lower socioeconomic status. Visible minorities and those from the 2SLGBTQIA+ superficially appear represented but only when aggregated together as one category.  The goal of this project was to (1) identify how the McGill OT admissions process can be revised to be more equitable and inclusive for all equity groups, and (2) specifically consider factors relevant to Black applicants in making recommendations to the OTAC.

Methods

This qualitative study involved a survey that collected both demographic data with closed ended categories, and open ended questions about perspectives on the admissions process.

Survey Development: The demographic section of the survey aimed to capture diversity data and was developed based on current McGill and Canadian diversity questionnaires. The section on socioeconomic status was further developed based on the literature, and offered multiple questions to approximate both socioeconomic status and social class (13). The open-ended questions were developed based on the current qualitative literature outlining experiences of Black students in higher education related to outreach and admissions (13). These questions focused on identifying barriers during the application process, perspectives and opinions on the admissions process, what respondents wanted to show in the admissions process, what helped with the admissions process, and suggestions for the admissions process. The draft of the open-ended questions was reviewed by the third and fourth authors for comprehensibility and relevance.

Sampling: All current and graduated occupational therapy students from the McGill program since the inception of the masters-level entry-to-practice program in 2008 were eligible to participate.

Recruitment: All current OT students and graduates were invited to participate in the anonymous survey through the email listservs of current and alumni students, and the social media channels (Twitter, Instagram, and Facebook) of the McGill School of Physical and Occupational Therapy. The invitation was sent out three times between May and August 2021.

Data analysis: Descriptive statistics of the diversity demographics were performed. The open-ended responses from the survey underwent multiple rounds of analysis to discern themes and patterns. The first author conducted the primary analyses, with weekly meetings with the second author for critical interpretation. A thematic analysis of qualitative survey responses led to the creation of several categories within themes.  A further intersectional analysis (14) of survey responses linked the diversity demographic data to the themes to foster attention to the equity groups’ differential perspectives on admissions to OT. Reflexivity and rigor were fostered through dialogue with 5 key individuals at McGill: the chair of the OT admissions (3rd author), and OT faculty member who sits on the Widening Participation Committee(4th author), an OT faculty member responsible for outreach initiatives, a Black healthcare student spearheading admissions initiatives in the Faculty of Medicine and Health Sciences, and a new Black employee hired for enrollment and outreach on main campus. The draft of the report was then shared with these individuals for their validation and feedback was integrated.

Ethics: This project was an equity appraisal initiative inscribed within the OT program and was explicitly described as such – and not a research project – to prospective participants. All survey respondents provided electronic consent to enter the survey and remained anonymous.

Results

Survey respondents

The majority of survey respondents (N=73) were aged 21-24 (30.14%) and identified as either white or east/south-east Asian (32.88% and 21.92%), women (50.68%), and Canadian citizens (64.38%). Linguistic minorities accounted for 13.7% of responses, visible minorities for 28.77%, and LGBTQ+ for 35.62%. Those who had a disability, were disabled, or had a chronic/episodic condition made up 31.51% of respondents. Two Black students entered the survey, and one completed it. Those who did not complete or finish the survey accounted for 27.4% of the total.

The following pie chart represents survey respondents who completed the survey, of which the majority were white or east/south-east Asian (46% or 27%).

Figure 1. Self-identified racial identity of survey participants

Intersectional Thematic Findings

Survey responses have indicated that there are several barriers to healthcare admissions and education to OT at McGill which are not limited to the experiences of Black people, but also affect those who identify with other equity-deserving groups, including LGBTQ+, neurodiverse, visible minorities, and people from lower socio-economic backgrounds.

Figure 2. Reported satisfaction with the admissions process grouped by racial identity.
Economic Capital

“Since I had this stability [of living with their parents], I had the opportunity to go out and gain experience necessary to improve the quality of my application (e.g., take up different jobs, volunteer) because I didn’t have to commit to a 40hr work week at one job for financial stability.”

Several survey respondents were worried about going into debt because they decided to pursue OT at McGill. The cost of application was the most common barrier, and 75% of those who noted this barrier were not from financially stable households and were worried about going into debt.

“My family’s financial situation made me really think twice before accepting my offer of admission”

Many suggestions for the admissions process were related to financial aid, with some suggesting scholarships for specific marginalized populations and others requesting a clear financial breakdown of costs involved

“scholarships for incoming students in extenuating circumstances as sometimes we are cut off from of families and their financial and / or emotional support due to homophobia about our sexual orientation”

Respondents noted that current information about finances in the application package was not clear nor accurate.

Social Capital

Social capital allows certain people to hear about OT and have the proper tools to apply successfully (32). Of the survey respondents who had friends and family in OT and were able to shadow them in their jobs and support them in the application process, 75% were white, and 63% had both parents attend post-secondary institutions. Those who found the application process easy to complete were all from financially stable households.

“Prior to applying I consulted a bunch of friends of friends who had a sister and or cousin in OT, and shadowed one or two OTs”

Familiarity with McGill, volunteering experience, reliable internet and a good R score were other factors which helped with the admissions process. However,  others found the application process stressful and overwhelming, for example mature applicants.

“It was very stressful for me, it seemed very overwhelming I did not know where to start. The orientation package was helpful, but very daunting. I did not want to give myself much hope throughout this vigorous process as I had already applied to the bachelor’s program 3 years prior, but was not accepted.”

“Forms and applications felt a bit byzantine at times. There were a lot of systems to access and documentation to get from elsewhere. I remember joking that completing a university application was an informal aptitude test for attending one.”

Respondents who identified a lack of community support majoritarily identified as visible minorities (71.4%).

Cultural Capital

Most white students felt adequately represented and satisfied by the application process. Challenges related to cultural capital included language barriers as well as lower grades in their previous undergraduate degree.  Applicants would have liked someone to contact during the admissions process to answer any questions. Of those survey respondents who did not feel adequately represented by the admissions process, they believed that other qualities should have been showcased. Many mentioned interpersonal skills, personality, being well-rounded, advocacy work, and important life challenges.

“the application process should have checked whether the students were well-rounded or not (ex: volunteering, extracurriculars, passions, etc)”

“I felt like I wasn’t able to mention much around my creativity and arts-based hobbies which have helped me immensely in my stages and assignments when trying to create something for a client or project.”

“I don’t recall there being a lot of room for personal representation.”

Perspectives on the current admissions process

Those against the current CASPer test were mostly visible minorities whose parents did not attend post-secondary education, and those against the video submission were all visible minorities.  However, others appreciated the CASPer test, the video submission, and also wanted the option to include a CV. All respondents who were for the CASPer test and wanted the re-incorporation of the CV had both parents attend post-secondary education. The following quotes represent conflicting views on the video submissions:

“Yes through the inclusion of a video statement where I was able to share about my lived experience with disabilities.”

“A video meant that they knew what I looked/sounded like and that vulnerability left me a little concerned.”

Anticipated lack of diversity and bias

Respondents wished that the diversity of McGill OT were more apparent both at the faculty and student level. One explicitly wished that a statement about a commitment to diversity was available on the McGill OT website, and another wished they had more information about who makes admissions decisions. The signaling of an anticipated lack of diversity was multi-level, including the request to specify pronouns in the application. Respondents expected that admissions committees were composed of “white, middle class, women”, and by extension that the OT program was not dedicated to promoting diversity. Racialized respondents shared:

“I expect most people to be white (both students and committee members), but I don’t generally expect and[sic] application committee to care enough to try to mix things up”.

“If I hadn’t gotten in, I would never know if it was because my grades weren’t good enough, or if it was because some unknown group of individuals deemed me unethical or “bad” in some way.”

“I would’ve been more at ease if there was a more significant presence of POC, queer and/or faculty members with disabilities.”

Overall, those who felt adequately represented by the admissions process and recounted being able to authentically represent themselves were overwhelmingly white.

Discussion

This survey of current and graduated OT students highlighted an admissions process that favors people from higher socio-economic backgrounds. Good financial standing and social networks were key in helping with the admissions process and the decision to apply to McGill, with help from family and friends as essential. The elimination of in-person interviews, the decision to not have references, and inclusion of an extenuating circumstances letter were all positive elements, particularly from the perspectives of equity groups (racialized, disabled, lower economic class). Other areas of the application process were sources of concern. Respondents who identified as visible minorities would have liked to know whether the cohort and admissions committee were diverse and anticipated bias in the process. Many survey respondents mentioned that.

Longstanding and ongoing systemic racism has resulted in a disproportionate number of Black communities in Montreal in low-income households (15). In fact, although most McGill students come from Quebec, most Black students do not (5, 16). As a result, many Black students don’t have the social capital identified as key in the application process. Black students who believe the admissions committee is not diverse may be discouraged from applying (5). Currently, there are no Black or Indigenous members sitting on OTAC faculty (17). This lack of representation can overlap with internalized racism: many Black applicants believe they do not belong in a university setting because of assumed racial inferiority (18). Even before a student gets to the admissions process, many doubt that they should even apply to higher education. In a 2016 report by Stats Canada, 94% of Black youth (15-25 years old) wanted to get at least a bachelor’s degree, but only 60% thought they could (6). This can be reaffirmed throughout the admissions process where a homogenous application committee may unintentionally convey that Black applicants are not valued (5, 17). Further, when admissions committee members are primarily white and from higher socio-economic backgrounds, definitions of excellence are built around a privileged frame of reference (5, 19). If excellence is not re-defined to be culturally inclusive and acknowledged  to take  many different forms, applications will continue to signal that they are “catered to a unique set of people” (5). Although there have been several notable improvements, the current OT admissions process continues to convey only a certain type of excellence – one that requires time and money (5) – rather than explore the multiple skills and knowledges that diverse candidates would want to showcase.

Several actions have already been taken by the OT program in an iterative fashion based on the findings of this project as they emerged. These actions include  increasing the diversity of OT mentors and admissions reviewers, professional development on anti-racism for reviewers of admission applications, a review of the language and transparency of the admissions manual, highlighting the available support for under-represented groups through the admissions process, and the creation of an equity webpage to transparently report on actions and outcomes. Drawing on successful exemplar initiatives (20, 21), the following evidence-based approaches are recommended as next steps based on the specific barriers that historically excluded OT applicants reported.

Black Student Application Program: The admissions process should allow Black students to authentically represent themselves and understand that they are valued. Application committees should have Black and Indigenous members. Students from underrepresented groups should be allowed to write an additional personal essay about challenges they’ve faced and skills they’ve developed. The Black Student Application Program at the University of Toronto has been highly successful: 25 Black students were accepted in 2020 compared to 1 in the year before its launch (21, 22).

Mentorship: Mentorship opportunities are important for Black applicants, especially if community support is unavailable (23, 19, 5). Black OT students and OT clinical preceptors-as-mentors could be paired with high school students to offer assistance before and throughout the admissions process (19). However, the burden should not fall to Black students; Faculty and staff should also be supportive (19).

Resources: Providing resources to Black students throughout the application process and their time as students in the  McGill OT program can considerably improve their well-being and academic success (24). Resources can include listservs for underrepresented student groups listing job opportunities and networking events and linking them to enlarging initiatives within the Faculty and on main campus (19). This includes ongoing supports and links to culturally appropriate mental health services.

Financial Aid and Scholarships: Scholarships for Black and other underrepresented student groups -especially those from LGBTQ+ communities who have been cut off from their families and people from lower socio-economic backgrounds -could provide a meaningful incentive to apply, and lead to their eventual increase in McGill OT (23, 25).

Outreach: Many of McGill’s outreach initiatives have overlooked Black and underrepresented communities in favor of private schools, but this has begun to change (5). Outreach to diverse neighborhoods is crucial for making Black students feel like they belong in the McGill OT program (5, 24, 26). These initiatives should start in elementary school and focus on building long-term, reciprocal relationships with communities and schools that responds to the needs of students, teachers, and communities (5, 17). Workshops can be a way of conducting outreach, where McGill OT representatives go into schools to show students that there are diverse people in this program and explain what it is all about (5).

Hiring diverse Faculty and staff members: Actively hiring and retaining diverse Faculty members is an integral component of making Black students feel welcomed within the university setting (23).

Recognizing and funding equity initiatives: Members of McGill OT who are involved in projects which make diverse students feel accepted, welcomed, and included should be rewarded (27). Grants for projects with an EDI focus could be given, or students working on these projects could be awarded scholarships. By rewarding and recognizing the contributions of those involved in EDI initiatives, McGill OT would be signaling that the inclusion of diverse students is important.

Project Limitations: In this study, only 2 OT students identified as Black from 73 total responses, highlighting the overall low number of Black OT students and graduates. An English questionnaire with limited responses from people whose primary language was French highlighted that even if McGill students and graduates study in English, research should be conducted in a bilingual manner. Finally, the perspectives of prospective applicants who either chose not to apply or failed the application process, were not captured in this project.

Conclusion

Diversity in healthcare is a human right and a dimension of excellence. Inclusion of diverse students must be active and informed, especially within university settings that are widely built by and for white people from higher socio-economic backgrounds (26). This project highlighted that the barriers to admission for underrepresented groups in McGill OT is interrelated. Efforts to recognize and repair the systemic erasure of Black students should also be interested in the same outcomes for Indigenous students, 2SLGBTQIA+ individuals, neurodiverse applicants, and other marginalized groups. Although this report aims to provide data to support Black applicants, people from other equity groups expressed their needs. These statements were at times hopeful, listing the many specific changes to be made, and at times filled with deep hurt, wishing that their needs had been met earlier. Students demand a more comprehensive and empathetic approach to making university spaces more inclusive to all. Increasing the number of diverse students without also increasing the amount of diverse faculty, providing culturally specific resources, and encouraging a sense of belonging among all students is not a successful approach (23, 28, 29). Without these resources, Black students might be exposed to racism-related stress and depression, putting their well-being and academic goals at risk (). This project explored, openly acknowledged, and has begun to address the barriers that currently discourage and impede Black students from admission to the McGill OT program. The OT program continues working towards an informed, comprehensive, and transparent action plan building on current initiatives and changes to suit the needs of Black students and welcome them within their program.

Acknowledgments

Special thanks to the McGill Global Health Program and Dr. Stephen Corber, interviewees, survey respondents, Dr. Hiba Zafran for her guidance and the School of Physical and Occupational Therapy for their support. We also thank Camille Georges, Black Community Outreach Coordinator, for her perspective as an informant.

References

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(5)  Camille Georges, Black Community Outreach Associate.

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(19) Key Anonymous Interviewee 2

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