Rural Health: The Dirt Road Less Traveled

Introduction

The demographic of older adults living in rural areas of the United States is changing. In fact, the most rapidly aging areas in the United States are rural communities, generally defined as having an urban core of <50,000 people.^1,2 Of the 56 US counties with the oldest populations, 54 are designated as rural areas.³ Compared with urban populations, rural-dwelling populations have more chronic health conditions, higher rates of disability, and higher fall rates.⁴ These medical vulnerabilities are compounded by socioeconomic disparities such as lower educational attainment, higher rates of poverty, and lower rates of broadband internet access.⁵

Physical therapy could play a vital role in improving health and physical function for rural-dwelling older adults; however, maintaining staffing within rural facilities has several challenges.⁶ First, physical therapists may avoid rural practice for a multitude of reasons, including housing, transportation, technology, culture, and educational preparation. Second, there is little evidence to guide preparing students for rural practice or to help rural communities recruit, retain, and support growth of rural physical therapists. Third, therapists seeking professional growth in rural areas may have barriers attending continuing education courses and accessing contemporary research resources or other mentored experiences owing to geographic limitations or technological barriers unique to rural communities (eg, limited broadband internet access). To address these challenges, we will detail contemporary concerns related to education, cultural awareness, and staffing in rural areas. Then, we will outline specific, actionable steps that the profession can take toward ameliorating rural health disparities, including physical therapist didactic and clinical education, supporting lifelong learning for the rural workforce, and advocating for large-scale policy changes to bolster rural physical therapist practice environments.

Contemporary Physical Therapist Education Often Overlooks Rural Practice Challenges

There are 60 doctor of physical therapy (DPT) programs located in rural communities; this accounts for 23% of the fully accredited physical therapist programs in the US (see the Suppl. Appendix).⁷ Of these, 9 have mission and vision statements that include exposing students to rural practice. A lack of focus on rural health care may limit didactic preparedness for rural practice as well as opportunities for clinical education experiences. Additionally, there are no established competencies to reflect physical therapist practice in rural settings.

These limitations are compounded by the lack of physical therapists available to take students in rural areas.^6,8 The evidence in other health care professions suggests that when fewer clinicians are available to educate students in rural areas, students and trainees pursuing specialty practice will gravitate toward urban and suburban centers with more resources to support professional development.^9,10 Consequently, fewer students and new professionals have clinical exposure to rural practice, which may further worsen staffing shortages in rural communities.^6,8

Insufficient Didactic Education to Address Cultural Humility and Cultural Awareness

Access to health care is challenging in rural areas, with disproportionately more hospital and medical facility closures than in urban and suburban areas.⁹ Facility closures mean rural-dwelling individuals must travel further to access adequate health care, which often results in postponing care until a problem reaches a more advanced stage or perhaps foregoing health care altogether.^10,11 When rural-dwelling individuals do seek care outside of their home community, patient-provider parity can be an issue. Rural-dwelling individuals may feel like outsiders in unfamiliar medical settings with health care professionals who do not understand the nuances of living in a rural community.⁵

Challenges in Recruiting and Retaining Rural Physical Therapist Staff

Challenges with recruiting and retaining skilled therapists may be tied to a lack of housing availability or other community resources and being unfamiliar with rural culture. There are 50% fewer physical therapists per 10,000 residents in rural areas compared with urban areas.⁸ When housing is not available in rural areas, clinicians need to live outside the communities where they work, which results in undesirable commute times and problems with wages vs cost of living.¹² When clinicians do find rural housing, rural practice may seem less appealing due to difficulties with mobile phone coverage and internet connectivity.⁵ Lack of familiarity with the cultural norms of rural communities can be a deterrent for clinicians who have not previously lived in those neighborhoods.^13–15 Rural areas are also more likely to be served by contract physical therapist staff—an important but transient workforce—who may have limited familiarity with, and cultural ties to, the communities they serve.¹²

Preparing a Physical Therapy Workforce to Support Rural-Dwelling Older Adults

The inequity in access to physical therapy in rural areas requires urgent action by our profession.⁶ Given the problems described above, there are several actionable solutions for enhancing didactic and clinical DPT education, promoting cultural awareness, and supporting the rural workforce with professional development and large-scale policy change (Table).

Table.

Challenges and Potential Solutions for Physical Therapy in Rural Communities^a

	Potential Solutions
Challenges Facing Rural Communities	DPT Didactic Education	DPT Clinical Education	Supporting Lifelong Learning Among Rural Workforce	Policy Changes at State and Federal Level
Contemporary physical therapist professional education often overlooks rural practice challenges.23	Leveraging technology to connect students with rural communities. Prepare students with techniques to support telehealth specific to rural communities, including how to overcome connectivity challenges, user familiarity, and potential distrust.	Establish entry-level competencies for telehealth. Supplement clinical education with telehealth experiences.	Engage rural communities with opportunities for remote continuing education and mentorship. Create pathways for rural practitioners to achieve specialization.	Workforce enhancement grants. Stipends to support rural health education experiences. Education grants to support academic-rural partnerships and research.
Insufficient didactic education to address cultural humility and cultural awareness.5,23	Determine elements and competencies for didactic education to prepare students for rural practice.	Develop clinical competencies for rural practice.	Co-develop education models with rural stakeholders to fill gaps in practice models and specializations.	Develop guidance documents for rural practice to promote broad awareness among health care providers.
Challenges in recruiting and retaining rural physical therapy staff.24	Exposure to rural practice concepts beginning early in didactic education (introduce rural practice as an option, consider challenges and rewards).	Support rural clinical partnerships to increase number of sites and CIs.	Subsidize continuing education and clinical academic partnerships. Create pathways for specialization in conjunction with rural communities.	Loan repayment programs (eg, National Health Service Corps), enhanced reimbursement for services rendered in targeted rural areas prone to worst staffing shortages and staffing instability due to high contract therapist utilization.

^a CI = clinical instructor; DPT = doctor of physical therapy.

Proposed Paradigm Shifts in DPT Didactic and Clinical Education

At a program level, we can engage students in learning about rural health care by being intentional about the development of rural physical therapists. Physical therapist education program mission or vision statements could focus on developing appreciation for rural practice. Such statements, paired with actionable goals, may be a strategy to encourage rural practice. Another strategy might be purposeful recruitment of students from rural areas, as literature shows that prior life or work experience in rural areas is associated with eventually practicing in a rural area.^16,17

Although scant, examples from physical therapist professional education literature include community service, clinical education, and specific rural health curricula as methods for teaching cultural competence about rural health care issues. Jackson indicated that 88% of student survey respondents who participated in rural community service thought it was effective for learning to provide culturally appropriate care.¹⁵ LaPorta found that students who participated in a didactic, 2-part rural health curriculum followed by a full-time, 5-week, rural-health clinical experience reported that the clinical experience was more influential than didactic training for changing students’ attitudes about rural practice.¹⁴ An interprofessional health professions education study with similar findings aimed to address cultural sensitivity in rural practice. Students completed reflective journaling during clinical experiences in rural communities. Upon program completion, students reported greater understanding of the complexities of rural practice and more confidence for working in rural communities.¹⁸

These studies suggest that personal exposure can change how students perceive and value rural practice. Building from the above literature, there are many ways programs can plan meaningful connections with rural communities. One way is the development of pro bono clinics, in-person or virtual, to provide a structured rural learning opportunity within the curriculum (see description below). Collaborative didactic and clinical education experiences that incorporate technology, including telehealth, could be valuable in bridging students’ real or perceived professional development challenges about working in rural areas. For example, students in small groups located at their academic institution can complete a subjective history with a rural-dwelling older adult via a virtual connection (eg, Zoom). This activity requires guidance from faculty who can discuss possible referrals that may benefit the virtual patient (eg, fall prevention resources). Students would then practice finding appropriate resources to share in the virtual forum. Students and faculty should debrief about the experience and consider how this activity could inform future patient encounters, whether virtual or in-person.

Clinical education in rural areas could more regularly place more than 1 student with a clinical instructor. This is an opportunity to develop students’ skills for collaborative learning and support clinical instructors who use these models with continuing education and other development opportunities. Where available, partnerships with local community centers or other locations that have internet access could help academic institutions to form virtual connections with clinical instructors, students, and older adults in rural areas who may have limited access to the internet at their homes.

Finally, improving students’ readiness by establishing formalized telehealth competencies could help to address the unique needs of rural communities. At an individual level, students and professionals can engage in cultural humility and life-long learning to better understand the needs of rural-dwelling older adults. Establishing competencies rooted in cultural awareness and community needs could enhance practice and build relationships with rural communities.

Better Support of Lifelong Learning Among the Rural Workforce

Supporting online and in-person lifelong learning is a necessary professional commitment the physical therapy profession should make to the rural workforce. Listening to the actual needs of rural physical therapist staff is an important first step to providing this support. Potential examples of supporting lifelong learning include reduced or no-cost continuing education and specialization pathways as an outgrowth of clinical-academic partnerships. Board certification mentorship, academic teaching assistant opportunities, collaboration on scholarly products, and access to medical libraries are also possibilities. Responding to specific needs with appropriate resources can build professional relationships and foster learning for all involved.

Policy Changes at the State and Federal Level

Financial support for professional development could enable continuing education and specialization for the rural workforce (Table). We can address recruitment and retainment issues in the rural workforce by promoting programs that incentivize rural clinical practice such as the National Health Service Corps. The National Health Service Corps student loan repayment program excludes physical therapy providers, and many state-level programs have similar exclusions.^19–21 Higher reimbursement for physical therapy services delivered in rural communities could support the physical therapist workforce and improve access to care for patients in rural areas.²²

Community Engagement as a Strategy for Improving Rural Physical Therapist Practice

Finally, the individual needs of rural communities and the older adults who live in them must not be overlooked. Despite some of the challenges described earlier in this paper, rural communities are often rich with close-knit residents, a sense of duty and service to neighbors, and appreciation for health care professionals who grew up in rural communities. Therapists working and living in rural areas may find many appealing community attributes and form meaningful relationships with their neighbors and patients. As a profession, we would be wise to seek a deeper understanding of the people in rural communities and how we can emphasize community strengths to improve trust and, ultimately, improve care. Community-based service-learning projects, while potentially effective, must be thoughtfully constructed to account for actual community needs and be the outgrowth of carefully nurtured partnerships rather than 1-way or hierarchical relationships marred by deficit-based perceptions of rural communities.

Conclusion

The scarcity of physical therapists in rural areas is a significant concern facing the profession and the public, especially given the complex health care needs of an increasingly complex population of rural-dwelling older adults. Despite current limitations, we can be change agents, moving beyond documenting inequities and towards collective and community-driven action to make rural communities a place where physical therapists can flourish personally and professionally. This problem will not be solved quickly; however, with many advocates acting locally, individual communities can benefit from a focus on rural health care. In addition, physical therapist education programs can consider formal partnerships with rural communities to grow outreach efforts and develop novel learning experiences. Successful models in and outside of physical therapy offer insight into evidence-based opportunities for progress. Intentional planning on the part of DPT programs and thoughtful outreach to understand rural communities’ specific needs could meaningfully impact care accessibility and care delivery. We urge the physical therapy community to continue to pursue solutions for this important issue.

Author Contributions

Concept/idea/research design: C.E. Felter, K. Zalewski, R. Jermann, A.E. Baier, J.R. Falvey

Writing: C.E. Felter, K. Zalewski, P.L. Palmer, A.E. Baier, J.R. Falvey

Data collection: K. Zalewski

Data analysis: K. Zalewski

Project management: C.E. Felter

Clerical/secretarial support: A.E. Baier

Consultation (including review of manuscript before submitting): C.E. Felter, R. Jermann, A.E. Baier, J.R. Falvey

Funding

J.R. Falvey was supported during this work by grants from the National Institute on Aging (K76AG074926 and P30 AG028747).

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.