From Collaboration to Cause: Breaking Rural Poverty Cycles Through Educational Partnerships

Background

Rural practice poses multiple challenges that vary from those found in urban and suburban practice settings (Trépanier et al., 2013). In particular, recruiting and retaining rural practitioners can be problematic. The “failure to retain health professionals in rural areas contributes to the poor health status of these communities through an inability to deliver reliable and consistent services” (Mills & Millsteed, 2002, p. 170). To address the complex and unique needs of rural communities, an equally unique and innovative health education program needed to be developed that was scalable and sustainable in nature.

The top two reasons for leaving practice in rural settings are relocation and the challenging work environment (Wielandt & Taylor, 2010). Conversely, practitioner success in rural settings has been linked to having a rural background, which provides a foundation for understanding the unique nature of these specialized work environments (Playford, Larson, & Wheatland, 2006; Trépanier et al., 2013; Wielandt & Taylor, 2010). On the basis of these findings, recruitment of practitioners whose values and skills are complementary to the culture and community in which they work may positively contribute to a sustainable, highly qualified rural health care workforce. Rural health care has suffered from limited qualified applicants possessing those characteristics that would optimize success in these settings. In addition, the retention of allied health professionals in rural areas is historically problematic (O’Toole, Schoo, Stagnitti, & Cuss, 2008), warranting the need to identify innovative strategies to train professionals whose characteristics complement work in rural practice. It is, however, possible to effectively develop educational programs that prepare practitioners for these settings as well as to recruit students who prefer to live, work, and remain in these rural communities.

To attract health care professionals to rural settings, recruitment efforts have typically involved financial incentives such as loan repayment programs (Renner, 2010). However, financial incentive programs often suffer from lack of visibility and do not address longitudinal retention and sustainability (Jackson, Shannon, Pathman, Mason, & Nemitz, 2003). An additional drawback to this approach is that incentive programs are not the strongest indicator for job choice. Instead, the location of a position and its proximity to family members and partners have been identified as the strongest factors influencing recruitment (Crowe & Mackenzie, 2002). This finding may indicate that recruitment and retention efforts would be most effective if focused on identifying quality applicants who are vested community members of the same rural environments facing workforce challenges.

Developing health education programs that are accessible to students without requiring relocation is an effective way not only to recruit future health care professionals but also to optimize retention of health professionals in rural practice. The benefits of this approach are twofold: Programming designed to reach place-bound students produces career opportunities typically not realized by this population and also addresses concerns related to low retention rates and market demand. The MHPC has approached workforce recruitment and retention efforts by targeting students embedded in rural communities and structuring educational opportunities that reach them where they live.

Innovative Program Design

The MHPC was formed in 2008 by five community colleges, in affiliation with the University of Missouri’s School of Health Professions, to address the unique challenges faced by Missouri’s rural health professions workforce. These combined institutions serve most of the rural areas of the entire state. Figure 1 provides a visual of the regions served by the consortium programs. MHPC provides access to affordable select degree programs in the health professions, including occupational therapy assistant programs. MHPC member schools share the costs of these programs equitably and use a unique, cost-effective delivery model. At any time, as many as five community colleges provide professional coursework to avoid infrastructure and personnel duplication that contribute to additional costs. Rural, place-bound students enroll at one of the consortium community colleges and live at home without commuting long distances to existing programs in urban areas. “Since communities are actual, organic, empirical realities, morality begins in experience, not outside it,” which again supports the concept of experiential learning established in the community served (Hester, 2001, p. 32).

OPEN IN VIEWER

Figure 1.

Map of locations served by college members of the Missouri Health Professions Consortium.

The MHPC OTA Program hybrid delivery model includes a classroom lecture component in the spring and summer semesters that is taught by University of Missouri faculty from a classroom at one location and is broadcast to the occupational therapy assistant classrooms located at the campuses across the state using interactive television (ITV) technology. In addition to ITV, other Web-based instructional formats such as Blackboard, Tegrity, Collaborate, and video streaming are used to teach course content. For the laboratory component of the program, an instructor meets face-to-face each week with the students. Three simultaneous labs are convened at campuses located across the state to reduce travel time for students who are required to attend the lab closest to their residence.

The Level 1 and Level 2 fieldwork components of the MHPC OTA Program take place in an off-campus clinical setting in the home campus area and are also chosen on the basis of the student’s home residence to minimize drive time. Local health care and occupational therapy clinicians serve as the fieldwork educators and supervise the occupational therapy assistant students during the required fieldwork rotations. Fieldwork experience is not only influential in determining future practice preference, it is a key indicator of where and how graduates will practice (Crowe & Mackenzie, 2002). Training programs are focused in these rural communities in contrast to models in which students are displaced from their homes. In traditional educational models, students often do not return to their rural communities after graduation (Horvath & Mills, 2011). After all classes and fieldwork requirements are completed within the MHPC OTA Program, students graduate from their home campus.

Although the prerequisite coursework is not tied to a schedule or timeline, the MHPC OTA Program professional year is full time, with courses offered in a specific sequence. The professional year of the program is designed to be completed within 12 mo (three 16-wk semesters), beginning in January and ending in December. A one-plus-one program model was chosen for the MHPC OTA curriculum because it better meets the needs of students living in rural communities, improves access to educational opportunities through increased flexibility, and has demonstrated a low attrition rate. Low attrition has been linked to the expedited time frame of the program’s professional year and mitigation of financial barriers related to reduced suspension of income. This model was adopted to minimize financial barriers, which rank at the forefront of obstacles contributing to poor access to higher education for rural students (Sewell, 2006).

Of additional significance to the program design is the direct correlation between low retention and poor community health marked by “inability to deliver reliable and consistent services” (Mills & Millsteed, 2002, p. 170). With a primary program goal to promote economic development in rural communities, a key factor in developing a sustainable and employable workforce was to incorporate the values of employers and client populations. Degrees developed with employer involvement that incorporate skills specific to the needs of the workplace “provide an ideal framework for the development of education for the assistant workforce” (Priestley & Selfe, 2003, p. 505). Initial MHPC program start-up costs were underwritten by RehabCare Group, Inc., a provider of rehabilitation services based in St. Louis. The company pledged $1.3 million in April 2008 to help fill the state’s need for allied health professionals. This commitment of a primary employer of rehabilitation professionals demonstrated the significant workforce need, especially in rural settings in Missouri. Although the MHPC programs are now sustained without ongoing financial support, they still value the ongoing involvement of employers who continue to provide information regarding workforce trends and graduate performance. Through annual advisory board meetings, the program maintains strong academic and industry partnerships focused on meeting workforce and health-related needs of communities served.

This educational model serves as a practical way to assist Missouri employers in understaffed areas to obtain a steady supply of practitioners, leading to improved economic development benefits important for the state. Ensuring access to health care as well as the economic benefit of reducing unemployment by training place-bound students can drastically improve the economic status of rural communities. In relation to the health status of the community, recruitment and retention of health care practitioners is viewed as a primary contributor to local economic development (MacDowell, Glasser, Fitts, Nielsen, & Hunsaker, 2010). Review of graduate outcomes suggests that the MHPC OTA Program has indeed assisted in addressing the workforce needs of rural Missouri and has also mitigated economic barriers that perpetuated a poverty cycle for many place-bound students and their families.

Method

To assess the impact of this program designed to meet the needs of rural underserved communities, a mixed-methods survey composed of multiple closed-ended, quantitative items as well as qualitative questions was disseminated 3 and 6 mo postgraduation to identify challenges to educational access experienced by students. Data collection included employment status pre- and postgraduation, including information related to geographic location of employers, compensation rates of program graduates, and qualitative data related to student perceptions of life change upon program completion. The review and use of survey data for this study was granted exemption by the University of Missouri Health Sciences institutional review board because the research was conducted in established and commonly accepted educational settings involving normal educational practices. In addition to collecting data related to the program delivery model and student learning outcomes, an online survey of MHPC OTA Program graduates was designed specifically to assess program outcomes associated with the program’s mission of serving rural, underserved communities. The MHPC Program administrative associate provided support with questionnaire formatting and entry using SurveyMonkey, as well as survey release using graduate email lists. The survey was typically released at 3 mo postgraduation with a follow-up survey sent 6 mo postgraduation. The time frame was chosen to reflect the typical trend of when graduates sit for the National Board for Certification in Occupational Therapy (NBCOT) certification exam. Of 102 graduates to whom surveys were distributed from 2010 through 2012, 55 (54%) responded.

Results

Those MHPC OTA graduates responding to the survey reported a higher than 98% employment rate. More than 90% of graduates reported working in rural health care environments, and 90% of graduates were working in the State of Missouri. The pass rate for the NBCOT certification exam exceeded 93% for first-time new graduate test takers. The program has served as a platform for career laddering, with 25% of graduates reporting seeking out a higher degree postgraduation. However, most staggering was the change in household income for program graduates and their families.

Respondents reported a preprogram salary average of $9/hr and a postgraduation salary average of $25/hr. In many instances, graduates reported that their family’s household income more than doubled, with the average graduate seeing compensation rise by more than 60%.

Of the 18 quantitative questions related to graduate demographics and employment status, those most related to life change pertained to preprogram income and barriers to accessing educational opportunities. The quantitative questions were required, so all respondents completed this section of the survey (N = 55). More than 56% of the respondents to the question “What was your employment status prior to entering the MHPC OTA Program?” reported an income of less than $13.00/hr, and 30% of responses indicated students had income at or below poverty level. The top three reported barriers faced before entering the program were low income (27%), displaced worker (11%), and single parent (7%).

The qualitative data collected from these surveys speak to the life-changing outcomes associated with degree attainment. A large number of graduates (N = 51) responded to the final survey question, which was open ended: “Tell us how the MHPC OTA Program has impacted or changed your life.” Results of the qualitative analysis are presented in Table 1. Responses were coded for themes, and the frequency of each theme was then estimated. The following five themes emerged, beginning with that most frequently noted:

Limitations and Future Research

Future studies are planned to assess graduate performance outcomes related to practice in rural settings. In particular, program goals are to identify whether the curriculum is successful in producing graduates who have demonstrated success in addressing community barriers related to access, advocating for underserved patient populations, consistently implementing evidence-based therapy interventions, and navigating ethical conflicts unique to rural practice. Specifically, the program is also part of a larger study designed to improve the care that health professionals provide by comparing their ethical orientations with those of underserved patient populations and using that information to construct a better ethics curriculum that prepares students to meet the ethical needs of patients.

Implications for Occupational Therapy Practice

The MHPC has established relationships with the health industry to enhance economic and workforce development in regions of Missouri. Also addressed are the needs of both individuals and businesses so that Missourians have affordable health care delivered by well-paid, competent providers and businesses have access to a steady supply of skilled health professionals. Program outcomes suggest that in addition to improving the health status of communities through improved access, the program has realized multiple unforeseen benefits related to breaking the poverty cycle for program graduates and their families. This model could be duplicated in additional contexts and has the following implications for the occupational therapy profession and larger health care services workforce: