Medical education for African American communities in the rural South: A focus group approach to identify fundamental considerations.

PURPOSE: We sought to understand concerns fundamental to planning medical education specific to rural southern African Americans who are virtually nonexistent in American medical schools. METHODS: A diverse multidisciplinary research team conducted this qualitative study with 3 focus groups, including 17 rural medical educators recruited nationwide, 10 African American alumni of a rural medical education pipeline in Alabama, and 5 community and institutional associates of this pipeline. Analysis of recorded transcripts generated themes fitting an ecological model suggesting concerns and intervention foci at individual, community, and institutional levels. FINDINGS: Three major themes operating at all ecological levels were: (1) How "rural minority student" is defined, with "rural" often supplanting race to indicate minority status; (2) Multiple factors relate to rural racial minority student recruitment and success, including personal relationships with peers, mentors, and role models and supportive institutional policies and culturally competent faculty; and (3) Challenges to recruitment and retention of rural minority students, especially financial concerns and preparation for medical education. CONCLUSIONS: Our findings suggest that individuals, communities, and institutions provide intervention points for planning medical education specific to southern rural African Americans. These spheres of influence project a need for partnership among communities and rural medical educators to affect broad programmatic and policy changes that address the dire shortage of rural African American health professionals to help ameliorate health inequities experienced in their home communities. It is likely that linear thinking and programming will be replaced by integrated, intertwined conceptualizations to reach this goal.

An Exploratory Study of Occupational Safety and Health with Limited Resource African-American Farmers.

Objectives: Limited resource African-American farmers exist at the nexus of several correlates of disparities (e.g., minority, poor, rural, and agricultural) and beyond the reach of most health promotion programs. Minimal research addresses their occupational safety and health. We proposed to explore such concerns with them.Methods: We conducted phenomenological interviews with nine farmers about work practices, farm operations, safety practices, health, and sources of information and assistance. We audio-recorded, transcribed, and analyzed interviews to code topics and identify themes.Results: The farmers varied in background, land ownership, farm products, and degree of resource limitation. We identified six themes: limited capital and sources of information, old unsafe machinery and equipment, a pragmatic resilient attitude, distrust of public institutions and agencies, lack of safety training useful on their farms, and personal health conditions.Conclusion: These themes raise hypotheses about limited resource African-American farmers' experience with agricultural safety and health compounded by various economic, environmental, behavioral, social, and institutional determinants. We recommend that these hypotheses be pursued with effective community engagement and partnership to collect and interpret needed data from samples representative of the population of these farmers, including comparison with other limited resource farmer populations.

Pipeline Programs Can Support Reforms in Medical Education: A Cohort Study of Alabama's Rural Health Leaders Pipeline to Engage Community Leaders.

PURPOSE: To demonstrate for county leaders the utility of rural pipelines to gain physicians and produce health professionals. METHODS: This cohort study, 1993-2018, aggregated 1,051 students in the Rural Health Leaders Pipeline to their home counties (N = 67) to study the relationship between county participation in pipeline programs and outcomes of family physicians gained and health professionals produced. Additional county demographics were included. We conducted descriptive, bivariate, and multivariable linear regression analyses controlling for poverty, race, and rurality. FINDINGS: All 67 Alabama counties participated with means of 9.6 Rural Health Scholars, 2.7 Rural Minority Health Scholars, 3.4 Rural Medical Scholars, 67% rural population, 29.7% Black population, and 21.5% under poverty. Best regression model for gaining family physicians included Rural Medical Scholars involved (b = 0.24, P < .001) with R2 0.30, indicating a county gained 1 family physician for 4 students. Best model for health professionals included Rural Health Scholars involved (b = 0.20, P < .001) with R2 0.31, indicating production of 1 health professional for 5 students. Best model for any professional included Rural Health Scholars involved (b = 0.23, P < .001) with R2 0.35, indicating 1 professional produced for 4 students. CONCLUSIONS: Rural pipeline programs can be useful tools in medical education reform to benefit counties with the gain of family physicians and production of health professionals. Local public officials could use these findings, eg, 1 family physician gained for every 4 students a county involved in the pipeline, to advocate that health professional education employ such pipelines.

Educating Physicians for Rural America: Validating Successes and Identifying Remaining Challenges With the Rural Medical Scholars Program.

PURPOSE: To evaluate the Rural Medical Scholars (RMS) Program's effectiveness to produce rural physicians for Alabama. METHODS: A nonrandomized intervention study compared RMS (1997-2002) with control groups in usual medical education (1991-2002) at the University of Alabama School of Medicine's main and regional campuses. Participants were RMS and others admitted to regular medical education, and the intervention was the RMS Program. Measures assessed the percentage of graduates practicing in rural areas. Odds ratios compared effectiveness of producing rural Alabama physicians. FINDINGS: The RMS Program (N = 54), regional campuses (N = 182), and main campus (N = 649) produced 48.1% (odds ratio 6.4, P < .001), 23.8% (odds ratio 2.5, P < .001), and 11.2% (odds ratio 1.0) rural physicians, respectively. CONCLUSIONS: The RMS Program, contrasted to other local programs of medical education, was effective in producing rural physicians. These results were comparable to benchmark programs in the Northeast and Midwest USA on which the RMS Program was modeled, justifying the assumption that model programs can be replicated in different regions. However, this positive effect was not shared by a disparate rural minority population, suggesting that models for rural medical education must be adjusted to meet the challenge of such communities for physicians.

Medical Education to Improve Rural Population Health: A Chain of Evidence From Alabama.

PURPOSE: To provide evidence that medical education is associated with population health in order to support adaptation of medical school programs to address populations with health disparities. We explored medical education efforts, local physician supply, and life expectancy in Alabama. METHODS: County-level public data of the number of students accepted to medical schools in 2008 and 2011, primary care physicians, life expectancy, and demographic/contextual variables were analyzed to develop a model for hypothesized associations. Correlational analysis, ANCOVA modeling, and path analysis were employed to identify, reduce, and organize significant variables in this cross-sectional ecologic study. FINDINGS: The path model, which met criteria for goodness of fit, found significant relationships among medical students per 10,000 population, primary care physicians per 10,000 population, life expectancy, and contextual variables for rurality and poverty. ANCOVA models showed that geographic region was significant. CONCLUSIONS: Within limitations of the study design, these findings support the proposition that the number of medical students produced in a county is related to the number of primary care physicians, which is related to life expectancy. Recommendations are to confirm the findings in other populations and inform public health policy concerning the utility of medical education to address population health by producing local medical students.

Farmers' concerns: a qualitative assessment to plan rural medical education.

CONTEXT: Limited research suggests that translational approaches are needed to decrease the distance, physical and cultural, between farmers and health care. PURPOSE: This study seeks to identify special concerns of farmers in Alabama and explore the need for a medical education program tailored to prepare physicians to address those concerns. METHODS: We conducted 2 focus groups with 20 farmers from diverse communities, backgrounds, and farming operations. The sessions were audio-recorded, transcribed, coded, and analyzed for determined patterns. FINDINGS: The following categories were developed as areas of importance to farmers: the need for physicians to understand the culture of farming, occupational exposures in farming, and recommendations for improving the health of farmers. CONCLUSION: Findings suggest that to adequately serve farmers, medical students interested in entering practice in rural areas should have or develop a relevant and adequate understanding of farming practices.

Admission factors predicting family medicine specialty choice: a literature review and exploratory study among students in the Rural Medical Scholars Program.

PURPOSE: The Rural Medical Scholars Program (RMSP) was created to increase production of rural family physicians in Alabama. Literature review reveals reasons medical students choose careers in family medicine, and these reasons can be categorized into domains that medical schools can address through admission, curriculum, and structural interventions. We examine whether admission factors can predict family medicine specialty choice among students recruited from rural Alabama. METHODS: We developed a questionnaire to study the ability of admission factors to predict family medicine specialty choice among Rural Medical Scholars (RMS). Eighty RMS graduates were surveyed by mail and 64 (80%) responded. FINDINGS: Student characteristics of humanitarian outlook with commitment to rural or underserved populations, family medicine decision or intention made before or at medical school admission, and community influence were positive associations with RMS choosing family medicine residencies; shadowing in an urban hospital was a negative association. CONCLUSIONS: Statements of interest, intentions, plans, and decisions regarding family medicine should be elicited at the time of RMSP admission interview. Strong attachment to home community and commitment to serving and living in a rural area are also important. Students whose introduction to medicine was informed through shadowing or observing in urban hospitals should be considered less likely to become family physicians. Larger sample size studies are needed to assess the role of gender, race, marital status, size of rural town, and MCAT score of candidates in affecting residency choices of students selected for this rural medical education track.

Participatory research and service-learning among farmers, health professional students, and experts: an agromedicine approach to farm safety and health.

Agromedicine developments in Alabama rest heavily on the interest and support of the farm community. Participatory approaches have been advocated in order to impact the safety and health of farms. The University of Alabama Agromedicine Research Team, working closely with and guided by farmers, places emphasis on identifying areas of farmer concern related to agricultural health and safety and on developing jointly with the farmers plans to address their concerns. Agricultural extension agents were key to developing the trust relationships among farmers, health professionals, and extension personnel required for these successful agricultural safety and health developments. In this article the authors describe how the research team engaged farmers in participatory research to develop service learning activities for graduate students studying Agricultural Safety and Health at The University of Alabama. Accepting farmers' active role in research processes creates an environment that is favorable to change, while providing farmers reassurance that their health and safety is of utmost importance to the researchers.

Undergraduate rural medical education program development: focus group consultation with the NRHA Rural Medical Educators Group.

CONTEXT: Over a decade ago, leaders in rural medical education established the Rural Medical Educators (RME) Group, an interest group within the National Rural Health Association, to support faculty in rural medical education programs. This group has convened an annual RME conclave since 2006. In 2008, this conclave convened 15 national leaders in rural medical education at The University of Alabama. METHODS: In preparation for the conclave, potential participants were e-mailed a set of questions regarding their respective medical education program's initiating motivation, support, resistance, resources, accomplishments, and continuation plans. Analysis of participants' responses resulted in a question guide that was used at a focus group conducted at the conclave. PURPOSE: The purpose of the focus group was to explore the experiences of established rural medical educators related to program development and maintenance. The focus group was recorded and transcribed, and then analyzed using the constant comparative method. FINDINGS: Five essential elements for rural medical education programs emerged from the analysis. The elements were: admit the right student, include curricular elements that occur and are required in rural training sites, establish a cadre of rural physicians who are dedicated to education of their successors, secure financial and relational support for the program, and evaluate program progress. DISCUSSION AND CONCLUSIONS: Discussion about these 5 elements can provide program guidance to neophyte rural medical education programs. Five recommendations are presented in an effort to continue discussion about the essential elements and identify actions that rural medical educators can take to further assist developing programs.

The rural medical scholars program study: data to inform rural health policy.

INTRODUCTION: medical education to produce rural physicians hinges on the characteristics of students, educational programs, and rural experiences. Family physicians are key components of rural medicine. This study tested the effectiveness of multiple, combined strategies of the Rural Medical Scholars Program to produce family medicine residents. METHODS: we compared the relative effectiveness of the Rural Medical Scholars Program, family medicine-oriented branch campuses, and a traditional urban campus to produce family medicine residents using a prospective quasi-experimental design. Logistic regression was used to account for covariates. RESULTS: the relative effectiveness of 3 educational modalities to produce family medicine residents was examined: Rural Medical Scholars Program (44.0%; odds ratio [OR], 15.6), family medicine-oriented branch campuses (18.9%; OR, 5.8), and a traditional urban campus (3.9%; OR, 1). These differences were significant (P < .05) after controlling for sex, race, Medical College Admission Test scores, and graduation rate. CONCLUSIONS: the findings are consistent with the literature, which recommends multiple strategy interventions to produce rural physicians (e.g., admit rural students who have an interest in family medicine, use family medicine faculty, and provide rural experiences). Further study will determine whether rural practice follows training in family medicine among Rural Medical Scholars.

Obesity and blood pressure trends in rural adolescents over a decade.

This study determined the association between overweight and obesity, demographic variables, elevated blood pressure, and frequency of health care referrals in rural adolescents. Annual school health screenings were conducted. Analysis is limited to student observations from 1996-2005, grades 9 through 12 (4,263 observations), using a repeated-measures, cross-sectional model. A significant upward trend revealed the odds of being overweight to be 1.43 times greater in 2005 compared to 1996. Rates of overweight and obesity were 23% and 17%, respectively. The greatest prevalence of obesity was among young adolescent non-Caucasian males. The odds of having elevated blood pressure was 6.9 times higher in obese versus normal-weight students. A significant association between overweight and receipt of referral for care was observed. Being overweight was significantly associated with poverty and the low education level of the head of the household. Interventions prior to adolescence are needed to reduce the rate of obesity and cardiovascular complications.

Rural health leaders pipeline, 1990-2005: case study of a second-generation rural medical education program.

A pipeline model has been suggested to increase the rural physician supply. This study is an institutional case report used to describe the context, development, and in-house evaluation of the University of Alabama Rural Health Leaders Pipeline, 1990-2005. This program was developed at a University of Alabama School of Medicine branch campus to target rural students at multiple levels, elementary schools through residency, and includes a minority focus. Requirements to enter the medical program include living 8 years in rural Alabama, meeting admission requirements, and affinity for rural lifestyles. Twenty-six percent of 316 high school participants, all 40 students in the minority-focused college program, and 3% of 90 medical program students were African American. The program includes (1) puppet shows in elementary schools depicting different health professions, (2) Rural Health Scholars Program for 11th-grade students, (3) Minority Rural Health Pipeline Program for college students, (4) Rural Medical Scholars Program, a 5-year track of study in rural community health and medicine, and (5) assured admission to family medicine residency. Outcomes studied in this case report included medical school performance, graduation rate, selection of family medicine specialty, and rural practice location. Medical scholars were anticipated to experience academic difficulty, select family medicine specialty, and locate in rural practice more often than peers. Compared to peers, medical scholars showed lower scores on preclinical courses and USMLE steps 1 and 2, reflective of their lower MCAT and GPA scores, but had (1) similar graduation rates (95% vs peers 84%), (2) higher family medicine selection rate (47% vs Huntsville 27% vs Tuscaloosa 12% vs Birmingham 4% [OR compared to Birmingham 22.7, 95% CI 10.5-49.4]), and (3) higher rural practice rate (67% vs peers 14% vs national group 9%) in the first RMSP classes. Based on these important outcomes being better than or equal to the traditional student cohorts, the institution concluded that the Rural Health Leaders Pipeline demonstrates successful use of the rural pipeline model.

Medical connections: use of the internet and traditional sources of health information by rural Alabama households.

Rural household adoption of the PC and Internet for accessing medical and healthcare information was investigated using survey data collected from 305 households randomly selected from non-metropolitan, rural counties across Alabama. The diffusion-adoption model for new technologies was employed to create five adoption stages relevant to this technology and its applications to communication of information in the health field. Descriptive household characteristics of age, education, income, and children revealed differences between adoption stages, with age and education having major impacts. Use of traditional sources of health information and the Internet were compared in relation to age and availability of medical services. Older, less educated households lagged behind in use of the Internet for health information. Medical professionals, doctors and pharmacists, were the most utilized information source by rural households; but those households connected to the Internet used on-line sources, even e-mail to communicate with their doctors.

Physicians for rural America: the role of institutional commitment within academic medical centers.

CONTEXT: Prior study suggests that contextual characteristics of medical schools (e.g., state demographics, public vs private, NIH research effort) predict output of rural physicians without also considering the effects of the medical schools' own policies and programs. PURPOSE: This study examines medical school commitment to rural policies and programs and its relationship to contextual characteristics and rural physician output. METHODS: A survey of 122 U.S. allopathic medical schools provided data to construct a 32-item Rural Commitment Index for each medical school. Data for other characteristics were linked from published sources. Correlations, t tests, and multiple regression analysis were used to study the association between variables and percentage of medical school graduates (1988-1996) who were in rural primary care practice in 2000. FINDINGS: Among 90 medical schools (response rate, 73.8%), the Rural Commitment Index correlated with the percentage of the state population that is rural and whether the school is public or private, and it joined percentage state population rural, public vs private, and National Institutes of Health support in correlating with percentage of graduates in rural primary care. In a regression model that explained 48.4% of variation in the percentage of graduates in rural primary care, the Rural Commitment Index explained most variation, followed by percentage state population rural, public vs private, National Institutes of Health support, and the interaction between the Rural Commitment Index and public vs private. CONCLUSIONS: The findings support the proposition that observable institutional commitment affects rural physician output and provide justification for a definitive study to verify that a change in medical school commitment to rural medicine produces a change in rural physician output.

What's in a name? Revisited: terms used to describe activities related to the health and safety of agricultural-associated populations and consumer.

The fundamental role of an academic journal is to facilitate a dialogue among scholars to advance the knowledge and art of practice related to the journal's subject, and consequently, to raise the human condition. As the Journal of Agromedicine begins to chart a course under new management and to enlarge the numbers of contributing scholars and sustaining subscribers, the editor has discovered a variety of concepts, historical developments, and terms used by scholars and practitioners in pursuit of health and safety of agriculture-associated populations and consumers. Each of these concepts, developments, and terms reflect the interests of different scholars and practitioners, who represent a surprisingly broad set of disciplines committed to this large endeavor.

Health inequity: the plight of uninsured children in a rural Alabama county and the plan to cure it.

Many children in the United States do not have access to health insurance. Providing health insurance for children has been particularly challenging in rural America. This article describes and evaluates a local plan to provide access to health care for school children in a rural Alabama county. A triangulated methodology (personal interviews, ad hoc survey focus groups, US census and health fair data) was used in the evaluation. Gains were made in enrolling children despite some limitations, especially in rural outreach. The most successful aspect of the program was a partnership between local leaders, health providers, and educators to provide impetus for a coordinated plan. The stability of the program is uncertain because of diminishing resources and the negative effects of economic recession.

The Southern Rural Access Program and Alabama's Rural Health Leaders Pipeline: a partnership to develop needed minority health care professionals.

Rural Health Leaders Pipeline programs are intended to increase the number of youth interested in and pursuing health professions in rural communities. This paper presents 2 complementary approaches to Rural Health Leaders Pipeline programs. Two different organizations in Alabama recruit students from 18 specified counties. One organization is a rural, community-based program with college freshmen and upperclassmen from rural communities. Students shadow health professionals for 6 weeks, attend classes, visit medical schools, complete and present health projects, and receive support from online tutors. The second organization is a university-based program that supplements an existing 11th grade-medical school rural medicine pipeline with 10 minority students from rural communities who have graduated from high school and plan to enter college as premedical students in the following academic year. Students participate in classes, tutorials, seminars, and other activities. Students earn college credits during the 7-week program, maintain contact with program staff during the school year, and by performance and interest can continue in this pipeline program for a total of 4 consecutive summers, culminating in application to medical school. Each organization provides stipends for students. Early experiences have been positive, although Rural Health Leaders Pipeline programs are expensive and require long-term commitments.

Premedical education: the contribution of small local colleges.

CONTEXT: Small local colleges may be sources of medical students with the gender, ethnicity, and background that promote identity with and empathy for underserved populations. PURPOSE: This study examined the impact of attendance at these premedical colleges on outcomes of medical education. METHODS: Data for 2508 matriculates to the University of Alabama School of Medicine, a state-supported medical school, were examined according to premedical colleges attended. FINDINGS: Medical students who had graduated from small local colleges were more diverse in gender, race, and rural background than other students. They had slightly lower academic performance in medical school, were more likely to drop out (10.6% versus 5.3% overall), and were more likely to locate in rural areas of the host state. CONCLUSIONS: Small local colleges may be rich sources of student diversity and medical students who choose rural practice, outcomes that are gained at a cost in terms of drop-out rate. Compared with other students, minor differences in performance and larger differences in the drop-out rate raise the question of cultural context and social support during medical school as points for intervention.