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Running Head: MACHE INTERNSHIP

Final Plan: MACHE Internship

Breana Floyd

The University of North Carolina at Greensboro


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At the Maya Angelou Center, public health professionals as well as professionals in

various other disciplines have collaborated to create health and biomedical science pipeline

programs. The mission of the pipeline program is to enable marginalized populations to enter

health and biomedical careers; ultimately increasing diversity in the workplace. Throughout this

paper, I will define health disparities and give examples of the types of health disparities that

currently exist among American Indian and Alaska Native (AI/AN) populations. I will describe

how my current internship site , the Maya Angelou Center , is using these programs to educate

AI/AN communities in attempt to promote health equity.

Health Problem

Health inequities such as poverty and low income, limited educational attainment, limited

access to quality healthcare and health insurance are detering AI/ANs from entering health and

biomedical careers. According to the Association of American Medical Colleges (AAMC)

(2016), the U.S. Census Bureau report showed that about 15.5% of all Americans were living in

poverty in 2014; meanwhile 28% of American Indians and Alaska Natives (AI/AN) were

impoverished. The national average for median household income was greater than $53,600

which is over $16,000 more than the median household income for AI/AN populations ($37,200)

. According to AAMC (2016), the Indian Health Service reported that American Indian and

Alaska Native populations suffer disproportionately in areas of “heart disease, intrahepatic bile

duct cancer, diabetes, alcoholism, mental health problems, asthma, and chronic liver disease”

(AAMC, 2016; IHS, 2016). These social health determinants are affecting the educational

pursuits of people within these populations; ultimately affecting their health.

As mentioned, social health determinants are affecting the educational pursuits of AI/AN

populations such as poverty causing these groups to lack essential needs such as health insurance
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and higher education, detering individuals from seeking medical care; ultimately causing poor

health within these populations. Nearly 25% of American Indians and Alaska Natives do not

have health insurance compared to 11.7% in the U.S. population overall (AAMC, 2016; IHS,

2016). According to IHS, AI/AN annual per capita spending (approx. $3,100) is $5,000 less than

the general population (approx. $8,100) (AAMC, 2016; IHS, 2016).

Health disparities within AI/AN populations include limited educational opportunities

regarding health care. 83.2 % of the U.S. population versus 71.6% of the AI/AN population

graduated with a High School Diploma in 2014-15 (AAMC, 2016). In 2014, about 20% of

AI/ANs ages 25 and older had earned a Bachelor’s degree compared to 32.5% of all adults

(AAMC, 2016). Poverty can affect community members access to knowledge as well as their

ability to acquire higher education; inadvertently affecting people's abilities to make informed

health care decisions (AAMC, 2016).

As noted, AI/AN populations have experienced great disparities in income and

educational opportunities, depleting many opportunities for AI/ANs to pursue careers in health

and biomedical science. Thus, another health disparity for AI/AN populations is the deficiency

of AI/AN people pursuing health careers including lack of representation in the medical field and

other health care professions (AAMC, 2016).

The health and biomedical science fields are currently lacking AI/AN people ultimately

creating a disadvantage for increased care within these communities (AAMC, 2016). Health

providers that acquire the same cultural values, lifestyles, and spiritual beliefs as their patients

may increase patient care experiences and allow for strong and trusting patient- provider

relationships (AAMC, 2016). Aiming to provide service from health care professionals that

integrate cultural sensitivity into their practice and consider the traditions of the community they
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serve can ultimately improve healthcare for the AI/AN population. AI/AN providers may serve

patients belonging to this community by providing their healthcare needs as well as be able to

understand their spiritual needs. Incorporating personal care into one’s practice as a healthcare

provider may include integrating culture and belief into the patient’s care plan ( i.e. AI/AN

providers may provide options of traditional healing ceremonies into their patient’s care for those

also belonging to this culture within the community) (AAMC, 2016).

According to AAMC, finding strategies to increase AI/ANs within the health field is

imperative (2016). The recruitment as well as retention of AI/ANs in health professions is crucial

and cannot be ignored. If the current rate continues, the number of AI/AN providers will

deplenish completely. Minority representation is vital at all levels of work; and AI/AN health

professionals serve as positive role models, mentors, and minority representation for younger

generations, especially AI/AN youth. Minority representation allows AI/AN youth the

opportunity to see someone who looks like them working in health careers and may provide

inspiration to pursue a career in health.

Health Disparities

The scope as well as the depth of the effects in which health inequities among AI/AN

communities occur is important to describe the lack of minorities in health careers. The pipeline

programming is used as an opportunity to recruit AI/AN youth into health careers with the

intention that the students will return post degree and assist with alleviating health disparities

within their communities. The pipeline program also educate enables students to research

disparities within their communities and allows them to create plans for health equity promotion

through community health assessments.


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Health disparities can be defined as the differences in which people experience health

within and across societies. Health disparities are also dependent on social factors such as race,

geographic location, social position, ethnicity, gender, age, socioeconomic status, educational

attainment, religious affiliation, sexual orientation, disability, etc. (NCHS, 2016). People that

suffer from lack of access to healthcare, health insurance, and nutritious foods are also affected

by health disparities (Marmot et al., 2008). An increase in health disparities exists among

disadvantaged populations and directly relates to the distribution of economic, social, political,

and environmental resources among these groups (NCHS, 2016).

According to the Center for Native Health (2017), CDC reports show that AI

communities carry the greatest burden of experiencing health risk factors and chronic diseases.

As an effect of the aging baby boomers, there is an increase in the number of tribal members

diagnosed with chronic diseases such as diabetes, heart disease, etc. Currently, about 35% have

been found to have diabetes; and numbers are increasing among tribal youth (CNH, 2017). In

2003 61.9% of male children (ages 6-11) were considered overweight or obese while 58.6%of

female children (ages 6-11) were considered overweight or obese.

AI youth are four times as susceptible to commit suicide in the U.S. than all other racial

groups. About 12% of North Carolina residents as well as are living at or below the poverty line.

Approximately 23% of the enrolled members of the ECBI are living at or below the national

poverty line (CNH, 2017). 15% of non-natives living in western North Carolina are at or below

the poverty line. Only 65% of high school students living in Western North Carolina graduate,

including Cherokee Central Schools. In 2000, about 12% of AI earned a bachelor’s degree or

higher. Less than 2% of enrolled EBCI students are pursuing health careers.

The Maya Angelou Center (MACHE)


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The Maya Angelou Center for Health Equity (MACHE) at Wake Forest School of

Medicine (WFSM) is my internship site. MACHE is partnering with the Mountain Area Health

Education Center (MAHEC), Center for Native Health (CNH), and Eastern Band of Cherokee

Indians (EBCI) for the Medical Careers and Technology Pipeline (MedCat). MACHE is also

collaborating with the Wake Forest Institute for Regenerative Medicine (WFIRM) at WFSM and

North Carolina American Indian Educators for the American Indian BioMedical Sciences

(AIMS) Academy. MedCat and AIMS is health and biomedical pipeline programming for

American Indian (AI) high school students from tribal communities throughout western and

eastern North Carolina. The MedCat and AIMS programming align with the mission to counter

the effects of health inequities among this population. Specifically, the health problem includes

increasing the number of American Indians in health and biomedical careers. The programs use

translational research navigation and community involvement to increase minority representation

in health research and decrease health disparities among these populations.

Mission

The purpose of the MedCat and the AIMS Academy programming is to decrease the

health gap and increase minority representation by providing AI high school students with tools

enabling them to pursue careers in health and biomedical sciences; by building on existing

missions of each partner to enhance resources and tools available to the community. MedCat and

AIMS reaches to increase competency and knowledge, enthusiasm, and interest and ability

among AI high school students to pursue health and biomedical careers.

“Goals of the MedCat program include: “increasing AI and Appalachian high school

student knowledge of and educational preparation to pursue health and biomedical

science careers, providing mentorship for AI and Appalachian high school students
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during undergraduate health and biomedical science education or entrance in the

workforce, increasing high school health science teacher knowledge of and ability to

implement interactive pedagogy through problem-based learning, and providing

mentorship for high school health science teachers to enable them to better engage

students in health and biomedical science education by utilizing relevant science,

technology, engineering and mathematics (STEM) curricula and technology tools.”

Health and Biomedical Pipeline Programming

Students begin the pipeline program in high school and may return as mentors. The

pipeline is intended to be a process that occurs in stages throughout their academic career and

students should be able to develop the necessary skills to become a health professional over time

(i.e. middle school, high school, undergraduate, postgraduate, and career pipelines). The sooner

students within these populations begin the pipeline process the better. It allows students the

opportunity to realistically be able to prepare for college prerequisites and other requirements

needed to enter their chosen career path. Although students within these communities currently

begin the pipeline program in high school (for purposes of current funding) they would benefit

even more from starting in middle school. It would allow students more time to gain self-efficacy

and grant them greater opportunities toward entering health programs. The goal is for high

school students to attend an undergraduate program upon completion of the pipeline, eventually

move on to a postgraduate degree, and into a health or biomedical career.

Several reasons exist for why pipeline programs for underserved communities are

necessary. Some reasons include to provide care, to do research, and to engage communities, in

culturally relevant ways. Culturally relevant practices will allow for better care (the provider can

relate better to the patient), research accounts for population specific factors, and engagement
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tailored and led by the community; ultimately, creating better health outcomes for the target

population.

Mache as well as other organizations use pipeline programs as a method of recruitment

for minority health and biomedical professionals. Students joining the pipeline come with a

mission to be able to serve their communities. The pipeline provides participants with the

necessary skills, tools, education, and experience to improve individual self-efficacy and prepare

students for their undergraduate career in health and biomedical science. During their post

graduate careers, students prepare for health and biomedical careers through internships, entering

entry-level jobs, and shadowing. Ultimately, the goal of the pipeline is for students to return to

their community as a provider, researcher, educator, etc.

Lack of minority representation within health research is an impediment to decreasing

health disparities. Researchers believe that inclusion of more minorities into medical and health

careers will assist in decreasing the health gap (Duffus et al., 2004). In the Duffus et al. (2004)

article, out of all the minority students that were involved in the pipeline curriculum 100 percent

earned a bachelor’s, 53 percent earned a master’s, 11 percent earned a medical degree, 7 percent

earned a doctoral degree, and 60 percent entered public health careers. The Maya Angelou

Center hopes to reverse health disparities by creating opportunities for minority youth to become

professionals in the Health and Biomedical Sciences (MACHE, 2017); including AI/ANs.

Non-Health Problem- Education

The non-health problem is education. The Maya Angelou center focuses their pipeline

program on educating youth through learning labs. The MedCat and AIMS programs cover

various topics related to health and biomedical sciences.Many of the health disparities discussed
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through my final poper are used as health topics in which students are expected to conduct

research and assess the health issues.

SWOT Analysis

Figure 1 contains a SWOT Analysis of the program. After gathering research connected

to MACHE and the various aspects of the organization, I could put together an informal analysis

listing some strengths, weaknesses, opportunities, and threats.

Figure 1: SWOT Analysis

Problem Analysis

Racism as a system of power is a root cause for many societal issues (Hinson, Healey,

and Wiesenburg, n.d.). Structural inequities are systemic differences among groups in their

opportunities to reach optimal health; leading to discriminatory and avoidable differences in

health outcomes (National Academies of Sciences, Engineering, and Medicine [NASEM], 2017).

Social identity and location are used to determine which groups will receive health resources;

such as race and ethnicity, geographic location, socioeconomic status, educational attainment,
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employment, immigration status, etc. (NASEM, 2017). Health equity influences, determines

one’s access to quality health conditions, healthcare, health insurance, healthy and nutrient dense

foods, clean water, housing, schools, a quality education, etc. (NASEM, 2017). In this analysis, I

will use the Socio-ecological Model (SEM) to analyze the health and non-health problems that

will be addressed during my internship at the Maya Angelou Center for Health Equity

[MACHE]. It will also include a concept map of the root causes of health disparities, a

changeability matrix, as well as my internship activities for the MedCat and AIMS

programming, such as translational research navigation.

Socio-ecological Model

The Socio Ecological Model (SEM) can be used as a tool to explain health behavior. An

approach to addressing health behaviors can often be based solely upon the actions of the

individual, without regards to context. Although health behavior can be affected by individual

actions it is also vital to consider things that can alter one’s health that are outside of one’s

control. The SEM broadens the lens to view sources outside of the person themselves to see the

root causes of health issues. SEM provides a systematic perspective on health equity at the

intrapersonal, interpersonal, institutional, and political levels. Application of the socio-ecological

framework gives a broader understanding of the social determinants of health such as social,

socio-economic, and physical environment as well as personal actions and characteristics (World

Health Organization [WHO], 2017).

Individual factors of the Medcat Pipeline programming includes students personal

decisions whether or not to enter into health careers such as an obtained desire to serve one’s

community. The students that apply to the MedCat and AIMS programs come with a mindset of

giving back and wanting to help others. Regarding interpersonal factors, MedCat is attempting to
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recruit students to become healthcare providers and serve in their communities. Educators and

professionals of various fields are collaborating to teach the children the skills that they need to

know, both native and non-native professionals. Intentionally placing thoughts into AI youth

earlier on that they can be health professionals along with allowing them to see professional that

look like them and are a part of their culture is used as motivation and encouragement. Support

from family and friends as well as staff members (Maya Angelou Center) can provide lifetime

support for AI youth seeking to enter health careers. MedCat pipeline programming is supplying

students with the tools and education needed to navigate institutions in order to obtain their

degree and enter into the workforce. Organizational factors include health plans and insurance,

healthcare systems and academic medical institutions, tribal urban health clinics, etc. The Maya

Angelou Center at Wake Forest as well as multiple other partner organizations are working to

provide obscene amounts of resources to AI high school students as well as other students within

these rural areas in order to invest in their future careers in health and biomedical science. The

MedCat pipeline is building trust with the youth as well as the community as a whole. By

creating sustainable relationships the Maya Angelou Center is attempting to counter the effects

of low rates of health insurance, historical distrust of the government and healthcare

professionals, and low access to culturally competent and quality healthcare. Community factors

include employers, worksite wellness, health disparities collaboratives, community/state/regional

organizations, media, community-based organizations The Maya Angelou Center is also

integrating needs assessments with the tribal communities. Organizations have gathered to create

collaboratives such as MedCat that will eliminate health disparities within AI communities.

SEM and Health Disparities


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In process of creating these pipeline programs, it is important to acknowledge racism and

discrimination as an inhibitor to health equity to prevent disparities among minority groups.

Although racial inequities occur most frequently they are often the hardest inequities to resolve

(NASEM, 2017; Williams and Mohammed, 2009). Intrapersonal factors of health disparities

regarding race include racial stereotypes. The threat of one acknowledging the occurrence of

racial stereotypes toward their racial group or ethnicity may lead to health inequities (NASEM,

2017; Glossary of Education Reform, 2013). Someone can have internal misconceptions about

themselves due to societal stereotypes. An example being, performing lower than one’s potential

during testing due to low academic expectations set for the person solely because of their race

(NASEM, 2017). An interpersonal factor of health equity includes implicit bias. Racial bias

produced by behavior and attitudes without knowledge or intention of doing so can cause health

inequities such as racial profiling (NASEM, 2017; Staats et al., 2016). The MedCat pipeline

programming can help to alleviate the effects of racism, racial profiling, racial stereotypes,

implicit and explicit biases by leveling the playing field for marginalized groups and

encouraging diversity and inclusion within professional and academic institutions.

Policies exists that can either create health inequities rooted in racism or attempt to

remedy them (NASEM, 2017). Policies and societal factors that support institutional level health

disparities include housing discrimination and redlining creating race and class differentiated

schools and neighborhoods. Separating people into resource-rich and resource-poor

neighborhoods and schools can contribute to health inequities based on race and SES (NASEM,

2017; Woolf et al., 2007). The conditions of one’s neighborhood and school can significantly

impact one’s quality of life; especially, regarding equal distribution of resources to minority

populated communities (NASEM, 2017). Policies such as these still have an effect on minorities
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to this day. Strategies like the pipeline program are attempting to counter the effects of

historically damaging policies that account for generations of health inequalities toward entire

populations by recruitment of AI/AN youth into healthcare fields.

Structural inequities can affect other factors of health such as life expectancy (NASEM,

2017). Studies show that geographic location is a better indicator of health outcomes than genes

(NASEM, 2017; Robert Wood Johnson Foundation [RWJF], 2009). The severity of structural

inequities can impact people’s lives from birth to death (NASEM, 2017; Braveman, 2008;

Hamilton et al., 2016; Mathews et al., 2015). The effects of these racial neighborhood targeted

resources accounts for the health gap between populations. The pipeline programming will assist

to promote health equity among minority populations through equitable resources to education

and employment for minorities.

Resources among AI communities are vital. Pursuit of a high school diploma and higher

education may affect one’s employment, income, and individual and intergenerational wealth

(NASEM, 2017; Olshansky et. al., 2012). The SES and household income can effects the

individual and their entire household. The pipeline program is assisting people with stepping out

of the cycle of poverty that minorities are most often placed into by structural effects.

Policy level factors, such as, implicit and explicit racial biases during the hiring process

can also inhibit persons from receiving employment (NASEM, 2017). Racially bias lending

policies can restrain people’s opportunities of home ownership, business ownership, and asset

development (NASEM, 2017; Pager and Shepard, 2008). Policy, political decision-making, and

voting imbalances are often used to inhibit people of color and underprivileged person’s voices

from being represented (NASEM, 2017; Blakely et al., 2001; Carter and Reardon, 2014). The
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pipeline programming is attempting to intentionally make sure that AI/ANs are represented at all

levels by realistically preparing them for the workforce.

Health care policies can fail to integrate cultural competency. Implicit bias can cause a

differentiation both in the quality of care and healthcare delivery dependent on race (IOM and

NRC, 2003; Sabin et al., 2009). Although biases have allowed minorities to suffer health

disparities throughout history, governmental policies were created attempting to remedy health

inequities caused by racism. Some policies formed to counteract health disparities include the

Civil Rights Act of 1964, the Voting Rights Act of 1965, the Fair Housing Act, Title IX of the

Educational Amendments of 1972, and the Patient Protection and Affordable Care Act (NASEM,

2017). Although we have these policies in place the pipeline programming is needed to assist

AI/AN populations as well as all minorities and the interpersonal and community level in order

to allow them to enter into health and biomedical careers. The pipeline program does this

through local community assessments, education learning labs, organizational collaborations,

etc.

Table 1. Concept Map: Health Equity


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Table 2. Changeability Matrix: Health Equity


Most Changeable Least Changeable
Most Important ● Increased representation of ● Eliminating racial/health
people of color in health disparities
and biomedical careers ● Eliminating
● Increased health equity racism/discrimination at
research efforts the political, institutional,
● Community Health and societal levels
Assessment ● Belief
● Integrating cultural racism/discrimination does
competency into occur
workplaces, institutions, ● Policy change
and organizations ● Increased funding
● Health equity trainings and ● Societal Attitudes
education programs
Least Important ● Researching how ● Eliminating
increasing health equity racism/discrimination at
for minorities would affect the individual level
majority groups/ groups ● Individual attitudes and
with power. behaviors
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Mission, Attempts and Outcome Objectives

The concept map in tables 1 and changeability matrix in table 2 above, show ways in

which health equity can be affected among minorities and lists these things according to its

importance and changeability. My recommendations include promoting health equity among

minority populations such as the AI/AN populations at each level. During my internship with

MACHE, I hope to assist with furthering strives in creating program evaluations, for the MedCat

and AIMS programs to assist with furthering the mission of increasing AI/ANs within health

careers.

MACHE Internship Methodology

During my internship with MACHE, I will be assisting with the student learning lab

evaluations, MedCat Partnership Process Evaluation and interviews, MedCat application

screenings, and AIMS student evaluations. MedCat is a year-round program with two sessions in

the spring referred to as “Learning Labs,” in which I will be accountable for creating student

evaluations as well as data collection. I assisted Dr. Meg Hanshaw in developing the student

mixed methods evaluation for the February MedCat Learning Lab, hosted by i.b.mee and AHEC.

I also created the MedCat Partnership Process Evaluation led by Dr. Rebecca Lasher. MACHE is

developing a grant proposal for the AIMS pipeline program; in which I was responsible for

collecting research on health and biomedical pipeline programs for AI/AN populations.

Regarding program implementation, I will be assisting in implementing the “Learning

Labs” this spring semester. MedCat is available to students throughout their high school career.

Depending on when students enroll for the program they could potentially participate for up to 4

years. MedCat is in process of planning a curriculum for undergraduate students in which I will
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be responsible for assisting in planning this program as well. I will also be helping review all

program applications. Lastly, I will be helping MACHE to conduct focus groups.

MedCat objectives will be met throughout the year with culturally appropriate task goals.

MedCat goals include: learning labs during the academic year (hosted by local, community-

based organizations), mentoring sessions, and AIMS summer academy. A mixed method

evaluation will be used for assessing the MedCat pipeline program. The purpose of the post-

program evaluation is to review for program effectiveness. In which, MACHE and community

partners can ensure that program objectives are being fulfilled. The evaluation is specifically

assessing acquired knowledge and skill of program participants following program

implementation. It is also looking to see if the program implementation is relevant to the health

issue being addressed; and inclusiveness regarding the intended population. It is reviewing the

implemented curriculum as well as workforce strategies. The evaluation benefits MACHE by

providing with program participant feedback. The evaluation allows MACHE to see if their

objectives are being met, participant’s enjoyment and growth. Most importantly it allows

MACHE to see whether the program needs improvement and in which areas.

The MedCat program aims to create a versatile curriculum that can be molded to fit other

communities in need of a pipeline workforce program. Essentially, MedCat plans to alter the

curriculum and implement it within other marginalized communities. MedCat and the partner

organizations have created a strategy that will make MedCat sustainable for many years to come,

using supportive student cohorts, professional development for instructors, and nurturing

relationships between academic and community-based partnerships. I will assist MACHE in

developing the curricula for both students and instructors. I will also help to engage student

cohorts with interactive activities. I will assist MACHE in brainstorming ideas to keep local
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community partnerships intact. Student cohorts can assist in creating student bonds and student

support to the program after completion. Professional development for teachers continues their

knowledge; and nurturing partnerships will ensure community investments.

Logic Model

Figure 2 below shows the logic model for MACHE’s MedCat pipeline. It goes into detail

about the inputs, activities, outputs, and outcomes of the program. Mache’s resources include

their community partnerships, grant funding, student and high school (hs) health science teacher

participants, MACHE staff, researchers and experts, and MedCat and AIMS workforce

programs. These are the current inputs currently available that make the MedCat program

possible. The MedCAt activities, outputs, and outcomes can also be found in the logic model

below.

Figure 2. MedCat program: Logic Model


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Figure 3 below includes the MedCat program timeline. The timeline shows the sequence

of tasks for the academic year as well as the summer. As mentioned the MedCat pipeline

program will take place throughout the academic year. The AIMS summer academy is an

extension of the MedCat program available to students throughout the summer. MACHE

performs an evaluation from inside the organization on MedCat performance while the program

is in progress. This helps with maintenance of the program and immediate changes that cannot

wait until after the program is complete. Local organizations have a role within the program by

facilitating learning labs to MedCat student participants throughout the program. Both student

and teacher participants engage in mentoring activities. Student- student and teacher- teacher

mentoring happens throughout the program to increase a positive experience for participants.
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High School health science teachers will participate in professional development session for

increased knowledge and preparedness in STEM education.

Figure 3. MedCat: Timeline

In my search process, I used both Google Scholar and the University of North Carolina at

Greensboro (UNCG) Library Databases. The key terms used for my research included: “health

disparities,” “race and health equity,” and “incidence and prevalence of racial health disparities.”

Some other key terms included: “education and American Indian Youth”, “health and

biomedical science,”and “population health.”

Appendix:

My data collection methods involve document review. I am responsible for reviewing

current program documents for further program insight. Current literature on the MedCat

program will prepare me to assist with program evaluation. As mentioned, I will be expected to

review MedCat’s participant applications; and program session templates for content. I am also

responsible for evaluating the program through data collection and analysis. I will assist in
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developing the MedCat and AIMs evaluation(s). Post-evaluations will grant access to participant

feedback of their program experiences and will be compared to student pre-evaluations. The

Institutional Review board for the Maya Angelou Center for Health Equity at Wake Forest

School of Medicine (WFSM) is the Clinical and Translational Science Institute (CTSI).

References

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