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The power of rural health research

Over the last decade, the national perception of rural America has started to change. Gone is the antiquated idea that all rural people are white, poorer, and less educated than their urban and suburban counterparts, with small towns being more accurately portrayed as innovative, diverse, and rich in culture and community. That shift in mentality has been bolstered by a corresponding increase in rural health research, which has helped people across the country gain a clearer and more objective picture of who lives in rural America and what they need to thrive.

“In recent years, more people have realized the importance of rural communities and what rural residents need – and rural communities are not a monolith,” says Whitney Zahnd, PhD, University of Iowa College of Public Health assistant professor and NRHA Journal of Rural Health (JRH) Editorial Board chair. “There’s research showing rural America is becoming more diverse. That has helped some of the narratives around rural people and places start to change.”


While enterprising individual researchers and academic and federally funded organizations have drawn much-needed attention to rural health care disparities and helped propel legislative action and policy changes, many emerging issues require a fresh or renewed focus to develop a greater understanding of how they impact the health and well-being of rural residents.

Areas that need more attention

Over the last few years, rural health care has changed drastically, due largely to the COVID-19 pandemic. This has caused researchers to work even harder to stay abreast of changes, gaps in care, and emerging needs in rural communities.

"There’s research showing rural America is becoming more diverse." – Whitney Zahnd

“We have our ear to the ground all the time on challenges and successes in rural areas. What’s in the news? What are people talking about in conferences or in webinars?” says Kristine Sande, program director at Rural Health Information Hub (RHIhub), which is funded by the Federal Office of Rural Health Policy (FORHP) and offers a wealth of resources, topic guides, and publications on rural health issues. “Some things are going to be around for a long time – and sometimes there are things no one is talking about, and you have to dig to find out more.”

RHIhub relies on research to tell the stories of what’s happening in rural health care across the country. Recent topics RHIhub has covered include telehealth in long-term care facilities, rural kidney health and disparities, and rural health literacy gaps, which became more apparent during the pandemic. RHIhub is also working to understand more about long COVID in rural communities, which Sande says has been challenging due to a lack of available data. Tracking down recent research on rural health topics has been a persistent issue for Sande and her team.


“People expect very current data, and as time goes on the expectation is becoming more prevalent,” Sande says. “People don’t want information that’s 10 years old, they want to know what’s happening now – and sometimes pre-pandemic information isn’t relevant anymore. In rural research we have limited resources, so sometimes 10-year-old research is the best there is.”

Per Ostmo, program director at Rural Health Research Gateway, is also at the forefront of rural health research dissemination. Hosted at the University of North Dakota Center for Rural Health, the Gateway aims to provide easy and timely access to research and findings of FORHP-funded Rural Health Research Centers from 1997 to present. Going forward, Ostmo says more research is needed on rural and urban differences in health and health care access for LGBTQ+ adults, as well as the rural emergency hospital (REH) designation.

“As REH conversions begin taking place, new research will be needed to evaluate successes and challenges, quality of care provided, and financial viability of REHs,” Ostmo says. “The North Carolina Rural Health Research Program will be investigating fixed and variable costs of REHs in the coming year. This will be important because REHs will likely have relatively low patient volumes and patients who are older and more likely to be uninsured than the average CAH.”


Zahnd says that Medicare Advantage, rural nursing home closures, rural cancer control, oral health care, and maternal health shortage areas are also topics that also deserve a closer look. Sande adds that preventive and public health concerns are also vital – along with making sure rural areas have the necessary workforce to provide these services.

“There’s a lot related to public health that’s important going forward – but is there the political will to take a look at what we need for preparedness?” Sande says. “Workforce has always been an area where frequent research is important. Now the workforce situation has gotten worse and will be evolving as people make decisions on whether they want to stay in health care.”

Research and health equity

As the diversity of rural areas continues to grow, health equity has become elevated in national discussions, particularly since the pandemic shed light on rural health disparities and the ways small towns are uniquely vulnerable to certain social determinants of health and health-related challenges. Sande notes that the intersection of race and rurality remains an important research focus to encourage policy changes that will promote equitable health care access and quality.

“Research is really important for decision-making. If you don’t know what the situation is, it’s awfully hard to make decisions and educate others,” Sande says. “The general understanding of the situation helps everything you do and helps other people understand the context of rural.”

Ostmo echoes that rural-specific research is necessary to have a well-rounded view of health care, particularly because rural and urban health care facilities differ in so many ways. To ensure rural health remains top of mind, last year FORHP assigned 33 new rural health research projects on topics including pandemic-related physician burnout and excess COVID-19 deaths in rural areas. The North Carolina Rural Health Research Program recently released its rural population health chartbook, which includes 33 measures of population health across counties, states, and regions. An upcoming chartbook from the Maine Rural Health Research Center will explore ambulance deserts across the US.

"We’ve seen a lot of people who are really happy to share their successes." – Kristine Sande

“Health care solutions utilized in urban areas may not be appropriate in rural areas,” Ostmo says. “Additionally, rural areas themselves are diverse, so rural solutions in South Carolina may not be appropriate in Montana. There is no one-size-fits-all solution, so ensuring stakeholders at all levels of government are educated on the latest rural health research is necessary to inform decision-making.”

According to Zahnd, more rural-specific research also draws attention to what rural communities are doing right. To continue this trend, Zahnd has encouraged researchers from more diverse backgrounds to submit their work to NRHA’s journal, and a wide range of perspectives are represented on the JRH Editorial Board, including dental health professionals, economists, and representatives from various federal agencies. This has helped the journal grow its impact factor and reach a wider audience.

“It’s exciting how much rural health research has grown in the last 10 years as more people are recognizing what’s working well in rural communities,” Zahnd says. “Obviously we want to understand what’s not working so we can provide the evidence base for addressing it, but projects that demonstrate what has worked and what assets or strengths exist in rural communities is a real need.”

Changing the rural narrative

When it comes to changing the conversation about rural people and places, research plays a powerful role – but Ostmo notes that this shift can only happen if people are aware of the information that is available. To give rural research a boost, Gateway provides free access to hundreds of publications and hosts regular webinars to allow stakeholders to hear directly from researchers.

“If we care about having an impact, then research doesn’t end with publication,” Ostmo says. “Research must be consumed to be impactful, and that is where dissemination comes into play. The dissemination of research is vital because stakeholders who are educated on the latest rural health research findings will be better equipped in rural health decision-making.”

For Sande, the power of rural health research is most evident when she travels and talks to people living and working in rural communities. She is from a small town, so she believes strongly in RHIhub’s mission of maintaining access to care and improving population health. She also notices that people want to talk about the constructive things happening in their hometowns.

"There is no one-size-fits-all solution." – Per Ostmo

“When we can tell the stories of what’s good and innovative and the creative things people have done – that’s where I feel the joy and the passion in helping people get ideas from each other,” Sande says. “We’ve seen a lot of people who are really happy to share their successes.”

Zahnd agrees that changing the rural narrative to highlight diversity and focus on assets is essential, as rural communities have an inherently collaborative culture that can help them address their challenges. As a member of NRHA’s Research and Education Constituency Group and Rural Health Policy Congress and as faculty advisor to the Student Association for Rural Health at Iowa, Zahnd also sees an increasing number of students engaged in rural health research, leadership, and practice, which gives her hope for the future.

“For me that’s exciting because people want to continue to do this work. In rural health research, everybody is very passionate about what they do, and there’s a willingness to work together – we don’t work in silos,” Zahnd says. “We’re working toward the same goal – improving the health of rural communities and highlighting rural assets and strengths.”


Who do you see when you think of rural?

Rural America is incredibly diverse, innovative, and constantly evolving in culture and community. That's why NRHA is proud to announce our Faces of Rural Campaign to better showcase the diversity and power of rural communities.

Our hope is this campaign can be used as an educational tool to create a more accurate picture of rural communities and the dialogue used to discuss and celebrate them.

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