Interview

Streamlining Research Access

Per Ostmo, MPA, Rural Health Research Gateway

Please tell us about the mission of the Rural Health Research Gateway.

The Rural Health Research Gateway (Gateway) is a research dissemination program funded by the Health Resources and Services Administration’s Federal Office of Rural Health Policy (FORHP). The primary purpose of Gateway is to share the work of the FORHP-funded Rural Health Research Centers (RHRCs). There are several of these research centers housed within different universities across the United States, each with their own research teams, areas of expertise and websites. Gateway streamlines the process of accessing research by making all research across all RHRCs available in one place. The Gateway website is a free, searchable online repository for FORHP-funded rural health research. Users can browse research by topic, date, research center and author. Gateway also disseminates research through webinars, exhibiting and presenting at rural health conferences, posting key findings on social media and notifying subscribers when new research is published.

As the program director what does your work entail?

My primary focus is maintaining the Gateway website, ensuring that new research is archived and made easily accessible in a timely manner. When a new publication is added to Gateway, an email notification is sent to our subscribers that includes a brief description of the research, key findings and a direct link to view the full publication. Keeping the Gateway library up-to-date with new research from nine RHRCs and additional policy analysis initiatives requires careful coordination with the research teams.

As a research dissemination program, it is important that research findings are presented in ways that are easily understood by a broad audience. Gateway isn’t just for researchers. Our users include policymakers, educators, public health employees, hospital staff, students and more. Rural Health Research Recaps have been developed by Gateway as a point-of-entry to the research world. These one-pagers identify key findings from all the RHRCs on specific rural health topics. For example, in the past five years the RHRCs have produced 42 research publications on mental and behavioral health. That’s both impressive and daunting for readers. Our new recap, Rural Mental Health “Rural Mental Health,” is a succinct and easy-to-understand starting point.

Dissemination is also about stakeholder engagement. We want our stakeholders to be well-informed on critical rural health issues, but we also need to know which issues our stakeholders care about most.

How do you engage with rural health stakeholders?

Gateway webinars are an opportunity for attendees to engage with researchers directly during the Q&A portion, and these discussions often highlight additional research needs. Last year, the Southwest RHRC presented on the Rural Healthy People Initiative, looking back at key findings from Rural Healthy People 2010 and 2020. At that time, the Rural Healthy People 2030 survey was ongoing, and our audience could choose to complete the survey.

Gateway also exhibits at various rural health conferences to share new research with attendees. The National Rural Health Association’s Annual Meeting is an excellent place to get engaged. At the 2022 Annual Meeting, researchers from the Maine RHRC were presenting early findings from a research project on ambulance deserts. The research lead was discussing how their team currently had data on 44 of the 50 U.S. states, with hopes of acquiring data for the remaining states within the next year. That’s when an audience member spoke up and said, “I can help you get that data.”

We also field questions via phone or email. I frequently hear from students looking for resources, journalists seeking key findings for stories they are working on and from aspiring researchers hoping to begin a career in rural health. If our team can’t answer a question directly, we’ll point you in the right direction.

Please tell us about some of the research projects you and your members are working on now.

Each year, FORHP assigns new research projects to the RHRCs. Between the larger research centers and the smaller policy analysis initiatives, we see approximately 40 new research projects per year. All ongoing and completed research projects and their related publications can be viewed on Gateway. The size and scope of projects vary. Some result in single page data briefs while others result in 40-page chartbooks, publications in peer-reviewed journals, case studies, policy briefs or any combination of these final products.

The University of Minnesota RHRC is currently investigating differences in health and health care access for LGBTQ+ adults. One key finding is that rural LGB adults reported the highest rates of depression and anxiety disorder diagnoses, as well as the highest levels of depressed feelings, compared with urban LGB and rural and urban heterosexual adults. Rural LGB adults also reported the lowest levels of having their social and emotional needs met.

The Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) RHRC specializes in the health care workforce. WWAMI’s current project examining trends in behavioral health workforce supply in the rural U.S. has found that while the per capita supply of psychiatrists declined over the past decade, the supply of psychologists, psychiatric nurse practitioners, social workers and counselors increased in both rural and urban counties. 

Rural for one population may not look the same as rural for a different population.

What are ways physicians and clinics can utilize your research?

There is a tremendous amount of freely accessible research on Gateway, but not every publication will be relevant to every user. If someone wants to stay up to date on a wide variety of rural health topics, then they should subscribe to Gateway’s research alerts. These emails highlight key findings when new research is published and only take a minute to read.

Other users might prefer a narrower focus. In that case, browsing Gateway by topic is best. DEA waivered physicians may want to browse “opioids.” A study by WWAMI RHRC found that over half of physicians with a 30-patient waiver were not treating any patients with buprenorphine. Psychiatrists might browse “mental and behavioral health.” Research conducted by the Rural and Underserved Health Research Center found that, in 2019, 32.4% of non-metropolitan and 35.7% of metropolitan adults with serious mental illness received no mental health treatment in the prior year. Administrators may be more interested in the topics of “health care financing” and “workforce.” Another study by WWAMI RHRC found that between 2010 and 2016, the nurse practitioner workforce in the U.S. grew at an annual rate of 9.4%, while the overall physician workforce grew at 1.1%.

Gateway makes it easy to find research relevant to any rural health stakeholder. We hope that our users share research with others, cite it for their own research projects, implement findings into practice and get engaged with the rural health research enterprise. 

What are ways physicians in out-state areas could contribute to your projects?

I have two recommendations. First, physicians who are interested in getting involved in rural health research should reach out to Gateway. If someone has a particular research topic of interest, then I can help connect them with an RHRC that specializes in that topic. Second, if physicians want to become more “tuned-in” to the general field of rural health, I recommend checking out the Rural Health Information Hub (RHIhub)–another FORHP-funded program. While Gateway is specifically focused on research, RHIhub covers rural health more broadly. Users can find funding opportunities, news stories, a calendar of rural-oriented events and a huge library of resources. Like Gateway, RHIhub is 100% free to use.

What are the biggest challenges facing rural health care delivery today?

Access to health care services is a perennial issue facing rural health. According to the North Carolina RHRC, 183 rural hospitals have closed since 2005, 140 of which have closed since 2010. Of these 183 closures, 99 have been complete closures, where facilities no longer provide any health care services. 84 have been converted closures, meaning facilities no longer provide in-patient care, but continue to provide some health care services, such as primary care or skilled nursing care.

When a rural hospital closes, the travel burden to receive care increases for that geographic area. The Southwest RHRC examined travel burdens to receive care and found that in 2017, rural residents traveled, on average, more than twice the distance for medical/dental care than urban residents, (urban 8.1 miles one-way; rural 17.8 miles one-way). Rural residents also spent more time in travel (urban, 25.5 minutes one-way; rural, 34.2 minutes one-way).             

Telehealth services can help alleviate some of the challenges related to health care access. However, telehealth comes with its own set of challenges. Large swaths of rural America lack broadband internet service. South Carolina’s RHRC found, in 2016, only 61.4% of rural and 78.0% of urban American Indian/Alaska Native households reported having broadband internet service. By comparison, 82.5% of rural and 89.1% of urban non-Hispanic White households reported having broadband.

What are some solutions to these challenges?

The North Carolina RHRC explored alternatives to complete closures by conducting a national survey of critical access hospital executives. Conversion to a Rural Health Clinic, Urgent Care Center or a Federally Qualified Health Center were considered the most viable alternatives to complete closure of a critical access hospital, while long-term care facilities were rated as the least viable alternative. The North Carolina RHRC is also studying Rural Emergency Hospitals, which were established by the Consolidated Appropriations Act of 2021, but it is too early to tell how many rural hospitals might convert to this new designation. Of course, all the various hospital designations have workforce requirements, and it can be difficult to attract new health care professionals to rural areas. We can look to the University of North Dakota and the University of Minnesota Duluth as exemplars in rural training tracks for physicians and other health care professionals.

Expansion of broadband infrastructure is one possible path toward increased access to health care services, but the existence of infrastructure alone does not guarantee household access. South Carolina RHRC found that income and education level of the household are major predictors of broadband access. When considering telehealth implementation, health care facilities should be cognizant of populations that cannot afford or do not know how to operate a smart device needed for telehealth services.

Since Gateway started in 2007, you have completed over 600 research projects. What were some of the most dramatic findings?

The Rural Health Research Gateway was launched in 2007, but our oldest archived research publication was published in 1996. The RHRC program is even older, having been initiated in 1988. As that program grew, it became more important to have one centralized place to access all the research across all RHRCs. Thus, Gateway was born.

I don’t think I could pinpoint the most dramatic findings coming out of the RHRCs, but there are three general themes that I would like to mention. First, as rural health stakeholders, we should be cognizant of dual disparities in health. Location (living rural vs urban) is only one dimension of analysis. The RHRCs also examine health disparities by race/ethnicity and other social determinants of health. Rural for one population may not look the same as rural for a different population. Second, health care solutions for urban areas do not necessarily work in rural areas. The U.S. is vast and diverse. Accordingly, there are different environmental and cultural factors that influence health status and need. Third, the phrase “older, sicker, poorer” is often used to describe rural populations. This is unfortunate, because rural populations are also resilient, diverse, generous and community oriented. A more well-rounded view of rural that includes these positive aspects is needed to attract investment in infrastructure and workforce.

With so many publications freely accessible through Gateway, do you have a favorite that you’d like to recommend?

I am particularly enamored with a few publications. First, the University of Minnesota RHRC published a chartbook, in 2020, titled “Rural-Urban Differences among Older Adults.” It examines demographics, socioeconomic characteristics, health care access and use, and health characteristics across rural and urban older adults. Key findings are represented across 44 easily understood charts. When it comes to disseminating research, a simple chart or figure is hard to beat. This chartbook from Minnesota is a masterclass in representing data graphically without being complicated.

Another favorite of mine is a 2019 project from South Carolina’s Rural and Minority Health Research Center, titled “Social Determinants of Health Among Minority Populations in Rural America.” The project is comprised of four policy briefs examining American Indian/Alaska Native, Asian American/Pacific Islander, African American, and Hispanic populations. This is the research that I would share if someone asked me, “What exactly are social determinants of health?”

Per Ostmo, MPA, is the Program Director of the Rural Health Research Gateway (Gateway) is housed at the Center for Rural Health at the University of North Dakota School of Medicine & Health Sciences. Gateway is funded by the Federal Office of Rural Health Policy (FORHP) to disseminate research conducted by the FORHP-funded Rural Health Research Centers. He earned his Master of Public Administration degree from the University of North Dakota.