8th June 2018, Volume 131 Number 1476

Peter Crampton, Naomi Weaver, Andrea Howard

The benefits to society of having a sociodemographically diverse health workforce are well documented and are based, in part, on the observation that the sociodemographic characteristics of health professional students influence future career choices in terms of place of practice and types of populations served,1–3 leading to better health outcomes for diverse populations. Also well documented are the challenges of achieving sociodemographic representation in health professional student cohorts.4–6

In 2012 the University of Otago’s Division of Health Sciences implemented a policy mechanism to ensure all of its health professional programmes produced graduates that would be equipped to meet the needs of society.7 Recognising that those needs were diverse, the Mirror on Society selection policy was developed to ensure that the student intake was diverse so that, as much as possible, it would reflect the ethnic and socioeconomic realities of the communities which students would go on to serve.

The sociodemographic profile of students in 2010, prior to the introduction of the Mirror on Society policy, was reported in a previous study.7 Six years on, this paper provides an update on the University’s progress towards increasing diversity within the health professional programme student cohorts.

Methods

Health Professional Programmes

All students (domestic and international) accepted into eight health professional programmes in 2016 were included in the study (Table 1).

Table 1: Eight professional programmes included in the study.

Professional programme

School-leaver entry pathway

Tertiary entry pathway

Bachelor of Dental Surgery (BDS)

 

ü

Bachelor of Dental Technology (BDentTech)

ü

ü

Bachelor of Medical Laboratory Science (BMLSc)

 

ü

Bachelor of Medicine and Bachelor of Surgery (MB ChB)

 

ü

Bachelor of Oral Health (BOH)

ü

ü

Bachelor of Pharmacy (BPharm)

 

ü

Bachelor of Physiotherapy (BPhty)

 

ü

Bachelor of Radiation Therapy (BRT)

ü

ü 

Data sources

Student data were downloaded from the University of Otago’s central student records system (which contains routinely collected data). Data were obtained in anonymous, summary form. The coding of data and methods for analysis were consistent for the two time points used in this study (2010 and 2016).

University student data are a mix of verified and unverified fields. Age and sex are verified by the sighting of birth certificates, and data are complete for these fields. Self-reported ethnicity data are complete, and home area statistics are unverified with 0.3% missing for the student population.

Home area data were analysed only for domestic students (not international). Home area statistics are collected by the University in a student’s first year of study only, and are derived from the contact address provided by students when they first enrol.

Student citizenship was classified into the following categories: New Zealand citizens; New Zealand permanent residents; Tokelau/Niue/Cook Island citizens; Australian citizens; international citizens.

For University purposes, based on the allocation of funding by the Tertiary Education Commission, domestic students are those students who are New Zealand Citizens or New Zealand Permanent Residents, or citizens of Tokelau, Niue, Cook Islands or Australia.

New Zealand population data were sourced from 2013 and 2016 estimates provided by Statistics New Zealand.

Ethnicity classification/definitions

When students enrol at the University of Otago they can nominate up to three ethnicities they identify with; these ethnicities are self-declared. Students can change which ethnicities they associate with at any point in time. Ethnic groups were aggregated into the following four categories: Māori; Pacific; Asian; New Zealand European and Other.

As students can nominate more than one ethnicity, the sum of ethnicities in the student population is greater than 100% of students. The ‘Asian’ category, as used in the New Zealand health sector, includes students from East, South and Southeast Asia but excludes people from the Middle East and Central Asia. This category has acknowledged shortcomings because of the ethnic diversity within the category.

The ‘New Zealand European and Other’ category includes students who identified as New Zealand European plus students who did not fall into any of the other categories. The proportion of New Zealand European within the ‘New Zealand European and Other’ category was approximately 96% for the University population and 94% for the Health Sciences population. ‘Other’ includes students who identified as Middle Eastern, Latin American and African.

Rural classification

For the purposes of admission, the University uses Statistics New Zealand’s Urban/Rural Profile Classification to construct a definition of rural. More detailed information is available at: http://www.otago.ac.nz/healthsciences/students/professional/medicine/index.html

Socioeconomic deprivation

Socioeconomic deprivation was measured using the NZDep2013 (NZDep) index of socioeconomic deprivation for small areas.8

NZDep is an area-based measure combining nine variables from New Zealand’s five-yearly census that reflect eight dimensions of deprivation. Each NZDep index is created for small areas built from one or more contiguous meshblocks. Meshblocks, containing around 90 people, are the smallest geographical units defined by the central government statistics agency, Statistics New Zealand. The small areas were constructed with, as far as possible, at least 100 people usually resident. The NZDep indexes were created from the proportions of people in each census-specific small area with each of nine characteristics related to deprivation.

The NZDep scale runs from 1 to 10 where, for example, a value of 10 indicates that the meshblock is in the most socioeconomically deprived 10% of small areas in New Zealand. At a national level, the number of people in each NZDep category is roughly equal.

In order to link the student and NZDep datasets, the meshblock associated with the home residence of students was attached to individual records in the University’s student dataset (domestic students only). The corresponding NZDep value for each domestic student’s home address was then added.

School socioeconomic scores

The Ministry of Education uses a school rating scale to indicate the extent to which it draws its students from low socioeconomic communities. Decile 1 schools are the 10% of schools with the highest proportion of students from low socioeconomic communities, whereas decile 10 schools are the 10% of schools with the lowest proportion of these students. A school decile does not indicate the overall socioeconomic mix of the students attending a school or measure the standard of education delivered at a school. It is not possible to calculate decile information for students who went to correspondence school or an overseas school.

Results

Geographic location of home area

Auckland is home for 34.4% of the New Zealand population; in 2016, 18.4% of the University of Otago’s student population came from Auckland, and 21.8% of the professional programme population came from Auckland (Table 2). The four regions of Auckland, Canterbury, Otago and Wellington made up around 70% of the University student population and 68% of the professional programme student population.

Table 2: Geographic location of domestic students’ home areas (2010, 2016).

Home area

% of NZ population (2016)

% of Health Sciences Professional Programme population (2010)

% of Health Sciences Professional Programme population (2016)

Trend

Northland

3.7

1.8

2.4

ñ

Auckland

34.4

22.0

21.8

ò

Bay of Plenty

6.3

4.9

5.2

ñ

Waikato

9.6

5.8

6.2

ñ

Gisborne

1.0

0.9

0.8

ò

Hawkes Bay

3.4

2.5

2.8

ñ

Taranaki

2.5

1.8

2.0

ñ

Whanganui-Manawatu

5.0

4.5

4.1

ò

Wellington

10.8

14.0

16.9

ñ

Tasman

2.1

2.4

3.6

ñ

Marlborough

1.0

1.1

1.3

ñ

West Coast

0.7

0.2

0.5

ñ

Canterbury

12.8

22.7

20.3

ò

Otago

4.7

11.9

8.8

ò

Southland

2.1

3.4

3.2

ò

Unknown

0.0

0.4

0.2

ò 

The proportion of students from South Island locations decreased by 4.0 percentage points between 2010 and 2016. While there were no substantial shifts in the home area of professional programme students, the Wellington region saw the largest net gain (+2.9 percentage points), and Otago had the largest decrease (-3.1 percentage points).

Rural classification

Recognising the importance of understanding the unique needs of rural communities and a general shortage of rural health professionals, the University introduced an affirmative rural admission category for medicine in 2004 and for dentistry in 2015 (the number of affirmative rural places is currently set at 55 for medicine and 10 for dentistry). The home addresses of all students have been used for the purposes of this analysis, as there are rural origin students entering via other admission pathways.

The New Zealand population is characterised as largely urban. In 2013, 71.8% of the New Zealand population was located in a main urban area (Table 3), while 28.2% lived in rural locations. The percentage of rural students in the professional programme population grew from 19.2% in 2010 to 22.5% in 2016.

Table 3: Urban/rural classification of domestic student home address (2010, 2016).

 

% of NZ population 2013

% of Health Sciences Professional Programme population 2010

% of Health Sciences Professional Programme population 2016

Main urban area

71.8

80.8

77.6

Urban subtotal

71.8

80.8

77.6

Independent urban community

11.0

7.2

8.4

Satellite urban community

3.2

1.2

1.5

Rural area with high urban influence

3.1

2.0

3.0

Rural area with moderate urban influence

3.8

3.1

3.0

Rural area with low urban influence

5.5

4.2

5.5

Highly rural/remote area

1.6

1.5

1.1

Rural subtotal

28.2

19.2

22.5 

Table 4 shows that the medical student population is more rural than it was in 2010, rising from 18.2% to 22.2%.

Table 4: Urban/rural classification of domestic student home address (2010, 2016).

 

% of medicine 2010

% of medicine 2016

% of dentistry 2016*

Main urban area

81.8

77.8

77.9

Urban subtotal

81.8

77.8

77.9

Independent urban community

6.4

7.8

9.1

Satellite urban community

1.0

1.8

0.6

Rural area with high urban influence

2.0

3.2

3.2

Rural area with moderate urban influence

3.8

3.1

2.6

Rural area with low urban influence

3.1

5.4

5.2

Highly rural/remote area

1.9

0.9

1.3

Rural subtotal

18.2

22.2

22.1

* Comparative 2010 data for dentistry are not available. 

Sex

When compared with the New Zealand population females were overrepresented at the University of Otago in general, and professional programmes in particular (Table 5). The programmes with the sex distribution most similar to the New Zealand population were the Bachelor of Dental Technology and the Bachelor of Medicine and Bachelor of Surgery.

Table 5: Sex (2010, 2016; domestic and international students).

 

Male

2010

Male

2016

Male trend

Female

2010

Female

2016

Female

trend

NZ Population (2016 Estimate)

49.0

49.3

ñ

51.0

50.7

ò

NZ Population 15–24 year old (2016 Estimate)*

51.4

51.9

ñ

48.6

48.1

ò

University of Otago student population

43.0

41.6

ò

57.0

58.4

ñ

Health Science Professional Programme student population

40.4

38.7

ò

59.6

61.3

ñ

BDS student population

43.2

34.4

ò

56.8

65.6

ñ

BDentTech student population

47.3

45.5

ò

52.7

54.5

ñ

BMLSc student population

35.0

32.5

ò

65.0

67.5

ñ

MB ChB student population

45.1

43.7

ò

54.9

56.3

ñ

BOH student population

12.9

15.6

ñ

87.1

84.4

ò

BPharm student population

39.6

37.3

ò

60.4

62.7

ñ

BPhty student population

35.5

37.4

ñ

64.5

62.6

ò

BRT student population

14.1

17.1

ñ

85.9

82.9

ò

* 2010 data uses NZ population data for 18–24 year group. 

The professional programme population has a higher proportion of female students compared to 2010, and this is reflected in most of the professional programmes (except for Bachelor of Oral Health, Bachelor of Physiotherapy and Bachelor of Radiation Therapy).

Citizenship

Programmes with the smallest proportion of New Zealand citizens were the Bachelor of Dental Technology, the Bachelor of Dental Surgery and the Bachelor of Pharmacy (Table 6). The Bachelor of Dental Technology had the highest proportion of New Zealand permanent residents. All types of citizenship in the table, except for international, are eligible for government funding and therefore considered to be domestic students.

Table 6: Citizenship status (2016; domestic students).

 

% NZ citizen

% NZ permanent resident

% Tokelau Niue Cook Island

% Australian citizen

University of Otago student population

76.5

8.2

0.0

1.6

Health Science Professional Programme student population

79.8

9.7

0.0

1.0

BDS student population

58.3

10.9

0.0

1.8

BDentTech student population

41.8

21.8

0.0

0.0

BMLSc student population

77.5

13.8

0.0

0.0

MB ChB student population

88.3

6.2

0.0

0.9

BOH student population

68.1

20.7

0.0

1.5

BPharm student population

71.1

15.9

0.3

0.8

BPhty student population

82.1

10.3

0.0

1.7

BRT student population

98.6

1.4

0.0

0.0 

While the University has attracted a greater proportion of international students since 2010 this has not corresponded to international students in professional programmes (Table 7). This is due to total capacity constraints in some programmes as the number of funded domestic places has increased (eg, medicine). There has, however, been an increase in the percentage of international students in the Bachelor of Dental Surgery, Bachelor of Dental Technology, Bachelor of Medical Laboratory Science and Bachelor of Physiotherapy programmes.

Table 7: Citizenship status (2010, 2016; international students).

 

% International 2010

% International 
2016

International trend

University of Otago student population

12.4

13.6

ñ

Health Science Professional Programme student population

13.8

9.4

ò

BDS student population

22.6

29.0

ñ

BDentTech student population

11.8

36.4

ñ

BMLSc student population

8.3

8.8

ñ

MB ChB student population

15.7

4.6

ò

BOH student population

14.7

9.6

ò

BPharm student population

13.0

12.0

ò

BPhty student population

3.6

5.9

ñ 

Ethnicity

The Health Sciences domestic student population has increased in diversity since 2010, with a 2.7 percentage point increase in Māori students from 271 to 417 students (54% increase), and a 1.3 percentage point increase in Pacific students from 127 to 202 students (59% increase) (Figures 1 and 2). Within the professional programme cohorts the increase is more marked: between 2010 and 2016 the percentage of Māori students increased by 5.6 percentage points from 138 to 309 students (124% increase), while Pacific students increased by 2.4 percentage points from 57 to 126 students (121% increase).

Figure 1: Māori students as a percentage of all domestic students, by programme, 2010, 2016.

c 

Figure 2: Pacific students as a percentage of all domestic students, by programme, 2010, 2016.

c 

In 2016, the professional programme with the highest proportion of Māori students was the Bachelor of Medicine and Bachelor of Surgery, with 15.8% of domestic MB ChB students in this programme identifying as Māori (218 students), a higher proportion than the New Zealand population. Between 2010 and 2016 the proportion of Māori students in the Bachelor of Medicine and Bachelor of Surgery programme rose by 8.2 percentage points from 78 to 218 students (179% increase). The percentage of Māori students in the Bachelor of Dental Surgery programme increased by 6.6 percentage points from 12 to 28 students (133% increase) since 2010.

The professional programmes with the highest proportion of Pacific students were the Bachelor of Oral Health and Bachelor of Radiation Therapy (5.7%, noting a relatively small cohort in each programme), closely followed by Bachelor of Medicine and Bachelor of Surgery (5.6%).

Compared to the New Zealand population, New Zealand European and Other students were slightly overrepresented in the wider University student population, but underrepresented in each of the professional programmes except the Bachelor of Physiotherapy, Bachelor of Medicine and Bachelor of Surgery, and the Bachelor of Radiation Therapy (Figure 3). In the Bachelor of Dental Technology programme, 48.6% of students identified as New Zealand European, and in the Bachelor of Dental Surgery 46.8% of students identified as New Zealand European. Asian students (Figure 4) were overrepresented in the wider University population, Health Sciences domestic population and each of the professional programmes.

Figure 3: New Zealand European and Other students as a percentage of all domestic students, by programme, 2010, 2016. 

c 

Figure 4: Asian students as a percentage of all domestic students, by programme, 2010, 2016. 

c 

Socioeconomic deprivation

There was little change in the overall socioeconomic profile of health sciences professional programme students between 2010 and 2016 (Figure 5).

Figure 5: Health Sciences Professional Programme students by NZDep, 2010, 2016.

c 

At a national level, the number of people in each NZDep category is roughly equal; however, for all eight professional programmes there was a preponderance of students from areas of low socioeconomic deprivation. This pattern was least pronounced in the Pharmacy and Dental Technology programmes (data not shown).

The socioeconomic pattern for Māori and Pacific students differed markedly from the pattern for students who identified as European and Other, with a greater proportion of Māori and Pacific students recording home addresses in socioeconomically deprived neighbourhoods (data not shown).

School socioeconomic scores

Students from schools with a decile rating of less than 4 (socioeconomically disadvantaged) were underrepresented in the University population, the Health Sciences population and the professional programme population (Table 8).

Table 8: School socioeconomic score* (2010, 2016; domestic students).

Population

Decile <4 (%) 2010

Decile <4 (%) 2016

Decile between 4 and 7 (%) 2010

Decile between 4 and 7 (%) 2016

Decile >7 (%) 2010

Decile >7 (%) 2016

Decile unknown (%) 2010

Decile unknown (%) 2016

University of Otago students

3.5

4.8

29.8

35.4

43.0

49.8

23.7

10.0

Health Science Professional Programme students

3.4

5.3

27.1

33.0

50.9

54.6

18.6

7.2

BDS students

2.7

4.3

19.9

27.2

51.7

55.3

25.7

13.2

BDentTech students

4.3

2.9

17.2

37.1

58.1

42.9

20.4

17.1

BMLSc students

10.0

6.8

38.3

43.8

43.3

45.2

8.3

4.1

MB ChB students

2.4

4.7

26.0

30.7

50.7

58.5

20.8

6.2

BOH students

6.9

4.9

32.8

39.3

37.9

44.3

22.4

11.5

BPharm students

3.4

7.3

29.7

34.3

47.7

52.0

19.3

6.4

BPhty students

4.2

5.6

32.5

38.9

55.7

48.4

7.5

7.1

BRT students

7.0

8.6

31.0

37.1

62.0

51.4

0.0

2.9

*1 (lowest socioeconomic level schools) – 10 (highest socioeconomic level schools). 

Discussion

Key findings

There has been an encouraging increase in the diversity of the health professional student cohort between 2010 and 2016. This increase in diversity is temporally associated with changes in the University of Otago’s selection policies for health professional students, and may as well have been influenced by external factors such as, for example, an increase in the number of tertiary-qualified Māori and Pacific students graduating from secondary schools.The principal changes included a marked increase in the proportion of Māori (124% increase) and Pacific (121% increase) students in health professional programmes, more pronounced in medicine and dentistry; and an increase in the proportion of students from rural areas from 19.2% to 22.5%. The increases in Māori and Pacific student numbers have been driven by specific strategies aimed at achieving increased engagement with Māori and Pacific communities and investment in structures and processes for supporting academic attainment.9 Within the domestic student cohort, the majority of students in the professional programmes self-identified as being within the New Zealand European and Other category (70.9% compared with 72.7% of the national population). In other ethnic categories, students identified as Asian (29.8% compared with 11.1% of the national population), as Māori (11.9% compared with 14.1% of the national population) and as Pacific (4.7% compared with 7.0% of the national population).

Disappointingly there has been little change in the overall socioeconomic profile of health professional students. A large proportion of students came from socioeconomically advantaged areas and only 3.4% of students had attended secondary schools with a socioeconomic decile of less than 4. The increased number of students living in areas categorised as NZDep 9 is probably due to some students, particularly those who are permanent residents, listing Dunedin North as their ‘home’ address.

The trend of a continued increase in the proportion of female students (from 59.6% to 61.3%) is noteworthy and is counter to the policy intent for overall demographic representation in the health professional student cohort. In some programmes, such as oral health, physiotherapy and radiation therapy, the heavily female-dominated student cohorts reflect historical role patterns and wage distributions.

The results show that in 2016, students studying in health professional programmes at the University of Otago were largely from outside the Otago region (91.2%), and were either New Zealand citizens or permanent residents (89.5%). It is important to note that the distribution of citizenship by programme is significantly influenced by government funding decisions. Both the New Zealand population (71.8%) and professional student population (77.6%) were characterised as largely urban, and rural categorisation was similar across the two populations.

Significance and future challenges

The University’s Mirror on Society policy has been successful in increasing the sociodemographic diversity of its health professional students. This is good news because the international evidence indicates that diversity among health professionals is beneficial for meeting the health needs of diverse populations. In 2017 the University included two further categories as ‘affirmative’ pathways—low socioeconomic groups and refugees. It is hoped that the inclusion of these two categories will in the future lead to increasing participation in health professional programmes by these demographic groups.

A challenge in the future will be to consider the implications of, and policy responses to, the increasing feminisation of some health professional student cohorts. For some professional groups, such as medicine and dentistry, feminisation represents a complete reversal of historical gender patterns. Indeed, the University still has a special prize each year for the top graduating female medical student. While this prize may be viewed as anachronistic, it serves as a reminder of the misogynistic structures of opportunity that were prevalent in the education system and wider society until recent decades. The role of the education system in adequately meeting the educational needs of boys and men is a matter of wider policy significance. Other challenges for the future could include, for example, the consideration of the role of selection policies in promoting the participation of students with disabilities and in increasing gender diversity (LGBTQI).

Limitations

This study is based on analyses of routinely collected student data. The data are considered to be of high quality and the proportion of missing data is small. As detailed in the methods section, the data are a mix of verified and unverified fields and, as a consequence, there may be some error in the home address field. It is not possible to quantify the magnitude of any such error.

Conclusion

Good progress has been made in increasing the diversity of the health professional student cohort at the University of Otago. The recent introduction of new affirmative categories will hopefully in the future see an increase in socioeconomic diversity and in the number of refugee students studying in health professional programmes.

Summary

This paper describes the sociodemographic characteristics of students accepted into eight health professional programmes at the University of Otago in 2016 and compares them with a similar 2012 paper to illustrate progress towards increasing diversity among health professional students. Between 2010 and 2016 there was: a marked increase in the proportion of Māori (124% increase) and Pacific students (121% increase) in health professional programmes, more pronounced in medicine and dentistry (increases of 179% and 133% respectively); an increase in the proportion of students from rural areas from 19.2% to 22.5%; an increase in the proportion of female students from 59.6% to 61.3%; and little overall change in the overall socioeconomic profile. The recent introduction of new affirmative categories will hopefully result in the future in an increase in socioeconomic diversity and in the number of refugee students.

Abstract

Aim

1) To describe the sociodemographic characteristics of students accepted into eight health professional programmes at the University of Otago in 2016. 2) To provide an update on an earlier (2012) paper to illustrate progress towards increasing diversity within the health professional student cohort.

Method

Student data were obtained from the University of Otago’s central student records system. Data were obtained in anonymous, summary form. New Zealand population data were obtained from Statistics New Zealand. Descriptive statistics were calculated.

Results

Between 2010 and 2016 there was: a marked increase in the proportion of Māori (124% increase) and Pacific students (121% increase) in health professional programmes, more pronounced in medicine and dentistry (increases of 179% and 133% respectively); an increase in the proportion of students from rural areas from 19.2% to 22.5%; an increase in the proportion of female students from 59.6% to 61.3%; and little overall change in the overall socioeconomic profile.

Conclusion

Between 2010 and 2016 there was an overall increase in diversity in the health professional student body, with strong growth in Māori, Pacific and rural students. The recent introduction of new affirmative categories will hopefully result in an increase in socioeconomic diversity and in the number of refugee students.

Author Information

Peter Crampton, Pro-Vice-Chancellor, Division of Health Sciences, University of Otago, Dunedin; Naomi Weaver, Senior Analyst, Institutional Service Performance, University of Otago, Dunedin; Andrea Howard, Director, Policy and Programmes, Division of Health Sciences, University of Otago, Dunedin.

Acknowledgements

We are grateful for comments made on earlier drafts by Tim Wilkinson and by the anonymous reviewers.

Correspondence

Professor Peter Crampton, Division of Health Sciences, University of Otago, PO Box 56, Dunedin 9054.

Correspondence Email

peter.crampton@otago.ac.nz

Competing Interests

Nil.

References

  1. Puddy I, Playford D, Mercer A. Impact of medical student origins on the likelihood of ultimately practicing in areas of low vs high socio-economic status. BMC Medical Education. 2017; 17.
  2. Komaromy M, Grumbach K, Drake M, et al. The Role of Black and Hispanic Physicians in Providing Health Care for Underserved Populations. New England Journal of Medicine. 1996; 334:1305–10.
  3. Grobler L, Marais BJ, Mabunda S, Marindi P, Reuter H, Volmink J. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev. 2009; 1.
  4. Larkins S, Michielsen K, Iputo J, et al. Impact of selection strategies on representation of underserved populations and intention to practise: international findings Medical Education. 2015; 49:60–72.
  5. Puddy I, Mercer A, Carr S, Louden W. Potential influence of selection criteria on the demographic composition of students in an Australian medical school. BMC Medical Education. 2011; 11.
  6. Mathers J, Sitch A, Marsh J, Parry J. Widening access to medical education for under-represented socioeconomic groups: population based cross sectional analysis of UK data, 2002–6. British Medical Journal. 2012; 341:d918.
  7. Crampton P, Weaver N, Howard A. Holding a mirror to society? The sociodemographic characteristics of the University of Otago’s health professional students. New Zealand Medical Journal. 2012; 125. 
  8. Salmond C, Crampton P. The development of New Zealand’s deprivation index (NZDep) and its uptake as a national policy tool. Canadian Journal of Public Health. 2012; 103 (Suppl 2):S7–S11.
  9. Bristowe Z, Baxter J, Fruean S, Latu A. Weaving Our Worlds, Maori learner outcomes from an equity-focused & strengths-based programme in health sciences. Wellington, 2016.