Building the future healthcare workforce: the impact of Oregon AHEC scholars’ program 2018 - 2022

Abstract

Purpose

This study summarizes findings from four cohorts of Oregon Area Health Education Centers Scholars (2018–2022). Area Health Educations Centers (AHECs) aim to expand the healthcare workforce, especially in rural and underserved areas likely to experience workforce shortages. The AHEC Scholars Program, a component of all AHECs nationally, supports health professions learners interested in rural/underserved practice through didactic curricula on core topics about rural/underserved populations and clinical training in these settings.

Methods

A retrospective pre-post survey was administered assessing changes in self-reported perceptions of knowledge of core topic areas and issues related to health and wellness in specific underserved populations, along with intention to practice in rural or under-resourced settings before and after participation in the AHEC Scholars Program. Descriptive statistics and Wilcoxon signed-rank tests were used to assess pre- and post-participation differences in working knowledge and intent to practice in rural/underserved settings.

Results

Participants reported higher ratings following the Oregon AHEC Scholars Program compared to their retrospective pre-program ratings. Differences were found in perceptions of working knowledge ratings for all six core topic areas, and for health and wellness for special populations (p < 0.001). Lastly, perceptions of intention to practice in rural or underserved settings were also rated more highly post-program compared to pre-program ratings for all of the assessed practice settings.

Conclusions

The Oregon AHEC Scholars Program appears to be effective in training healthcare professions learners in core topics in rural/underserved healthcare and health and wellness for specific populations and is associated with an increase in learners’ perceptions of their intent to practice in a variety of rural and underserved settings. These findings have implications for addressing workforce maldistribution and the health of patients living in rural or medically under-resourced areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-08788-6.

Introduction

The nation’s Area Health Education Center (AHEC) program was established in 1972 in response to recommendations from the 1970 Carnegie Commission on Higher Education as a national strategy to address shortages and maldistribution of primary care physicians and other healthcare professionals [1]. Administered by the Bureau of Health Workforce within the Health Resources and Services Administration (HRSA), the AHEC program has three overarching goals: (1) Expanding the healthcare workforce, (2) Improving workforce distribution, particularly for rural and underserved communities, and (3) Implementing practice transformations to enhance healthcare access and delivery [2]. Meeting these goals has the potential to address many well documented social determinants of health that result in poor health outcomes [3, 4]. Currently, only about 10% of physicians choose to practice in rural settings, although 20% of the U.S. population resides there, creating shortages that reduce access to healthcare [5].

To meet these goals, AHECs adhere to their original design, which involves a program “hub” at an academic healthcare center with “spokes” in associated regional centers that deliver programming tailored to local needs. Currently, 57 AHEC program offices and 264 regional centers exist in 47 states, the District of Columbia, and U.S. territories. These are affiliated with more than 120 medical schools, and 600 nursing and allied health schools. Regional centers are important because they connect learners with opportunities to foster interest in pursuing careers in the health professions, as growing up in medically underserved communities is associated with medical students’ intent to practice in such communities [6, 7]. In 2017, HRSA created the AHEC Scholars Program, a requirement for all AHECs, to reduce program variation across the country’s AHECs and measure its collective impact [8].

There are many rural training and rural incentive programs across the healthcare landscape. Those range from rural tracts to state or federal service commitment programs. Individual rural tracts or programs vary widely in their funding, involvement in the admission selection process, the didactic curriculum, and the duration of the rural clinical experience. The National Health Service Corp, also administered by HRSA, provides tuition assistance in exchange for practicing in underserved settings. Scholars for a Healthy Oregon Initiative (SHOI) is a similar program specific to Oregon funded by the Oregon legislature. The AHEC Scholars Program is designed to augment the training of health professions students by providing didactic instruction and clinical experiences in underserved areas. It focuses on interprofessional education, community engagement, and the development of skills necessary to address health disparities. The AHEC Scholar Program complements, rather than replaces, existing rural workforce pathway initiatives by addressing an earlier stage in the workforce pathway.

Very little research has been published regarding the AHEC Scholars Program. We found two publications, the first of which (published in 2021) describes the development of the South Texas AHEC Scholars Program and outcomes of a 3-month pilot study [9]. More recently, a review of the didactic curricula in the AHEC Scholars Programs of Alabama, Florida, and South Carolina was published [10]. Here, we report on how program participation changed students’ perceptions of their knowledge on core didactic topics and health issues facing underserved populations and their future practice intentions from the first four cohorts of the Oregon AHEC Scholars Program (Academic Years 2018–2022).

Methods

Oregon AHEC Scholars Program

Oregon AHEC has five regional centers, four of which are located in and serve regions designated by the state of Oregon as rural (i.e., geographic areas ≥ ten miles from a population center of > 40,000 people) or by federal guidelines as frontier (i.e., any county with 6 or fewer people per square mile) [11]. In 2017, in accordance with HRSA’s new AHEC Scholars Program requirement, Oregon AHEC transitioned its Oregon Rural Scholars Program, which enrolled on average twelve medical students per year who spent a minimum of ten to twelve weeks at a dedicated rural training site, into the Oregon AHEC Scholars Program (OASP). The OR AHEC Scholars Program, which requires a formal application process, is a two-year longitudinal program for health professions students in dentistry, pharmacy, medicine, and nursing.

Scholars are required to complete at least 40 h per year of community and team-based clinical training in underserved settings and an additional 40 h of supplemental didactic education in six core topic areas: (1) interprofessional education, (2) behavioral health integration, (3) social determinants of health, (4) cultural competency, (5) practice transformation, and (6) current/emerging health issues. AHECs are required to survey students immediately upon program completion and one year post program completion.

The OASP currently enrolls approximately 75–100 learners per year across several public and private institutions. As a result, the curriculum is dynamic and flexible to accommodate different healthcare learners, programs, and participating institutions. A system-wide digital learning platform delivers required didactics and monitors students’ progress. Currently, the OASP does not have scholarships or stipends and does not require a service commitment after graduation. However, participation in the OASP has become a prerequisite for eligibility in the Primary Care Loan Forgiveness (PCLF) incentive program funded by the state of Oregon and administered through the Oregon Office of Rural Health [12]. AHEC Scholars are eligible to apply for PCLF and, if accepted, receive one to two years of tuition reimbursement in return for an equal length of service commitment in rural Oregon.

Study participants

We included 312 health professions students who applied to and were accepted into the Oregon AHEC Scholars Program in four cohorts beginning the following academic years (AY): Cohort 1 enrolled AY2018-2019, Cohort 2 enrolled AY2019-2020, Cohort 3 enrolled AY 2020–2021 and Cohort 4 enrolled AY2021-2022. These students represented four universities and a variety of training programs including medicine (MD or DO), nursing (undergraduate and graduate), physician assistant, pharmacy, and dentistry.

Evaluation instruments and data collection

The evaluation design was a historical cohort analysis. Demographic information was collected from AHEC Scholars Program applications, including age, gender, race, ethnicity, proficiency in language(s) other than English, history of economic and/or educational disadvantage, rural background (Cohort 4 only), military veteran status, future practice plans (e.g., rural, urban underserved), and any service obligations following graduation.

AHEC Scholars’ evaluation followed Kirkpatrick Level Two: Improvement in knowledge and intellectual capability as a result of participating in a training program [13]. All OASP participants were invited to complete a survey (Appendix 1) that assessed working knowledge of core didactic areas (e.g., cultural competency, social determinants of health, practice transformation; n = 6 items) and issues related to health and wellness in specific underserved populations (e.g., the elderly, patients seen in rural health clinics, patients in health professions shortage areas, migrant/seasonal farm workers; n = 10 items). The working knowledge response scale included five options: 1 = non-existent, 2 = very minimal, 3 = moderate, 4 = quite a lot, and 5 = complete. The survey also included a “did not take” option for Scholars that had not yet engaged with work in a particular area. Another question set (n = 9 items) assessed Scholars’ intention to practice in Federally Qualified Health Centers (FQHCs), community-based Rural Health Clinics (RHC), Tribal health clinics, Critical Access (CAH) or rural hospitals, and Veterans Affairs facilities before and after program participation (intention response scale: 1 = none, 2 = minimal, 3 = moderate, 4 = high, 5 = fully).

The survey used a retrospective pre-post (RPP) design, which has been found to have benefits over independent pre- post-designs because it accounts for response shift bias [14]. Although recall bias is a concern with an RPP design, we believe its use here is justified for two reasons. First, RPPs can be warranted when logistics make the administration of a conventional pre-post assessment challenging [15]. The OASP is a collaborative effort involving learners in multiple training programs at several institutions. In this situation, we believe using the RPP supports the collection of more complete data than we could obtain with conventional pre-post assessments. Second, OASP’s curricular structure does not deliver all instruction on each topic area at one time, rather core didactics are woven throughout the two-year program giving students the opportunity to reflect on their learning at multiple points in the program. Rather than asking students to reflect on discrete skills or knowledge for which they might not recall their initial levels, in taking the survey students consider the topics in a more global way and engage in a reflective process that is inherent to learning [15, 16].

It was administered online using Qualtrics at the end of each of the two academic years (May-June) that scholars were in the program to allow for assessment of cross-year differences in learning. All study activities were reviewed and approved by OHSU’s Institutional Review Board (IRB). Upon being accepted to the AHEC Scholars Program, all Scholars received an information sheet explaining the study, the study activities in which they would be invited to participate and their rights as study participants. OHSU’s IRB determined that an information sheet (vs. signed consent) was sufficient for this minimal risk study.

Data analyses

We combined MD and DO students into a single category of “Physicians,” and physician assistants and advanced practice nurses (e.g., Family Nurse Practitioner Psychiatric Mental Health Nurse Practitioner) were combined into “Advance Practice Providers.” Other program categories such as dentistry, pharmacy, and BSN nursing remained in their own categories. Descriptive statistics, including frequencies and percentages were calculated for all study variables, and the Kruskal-Wallis test was used to assess for differences across program years. Paired samples t-tests were used to assess for differences in responses for knowledge related to core didactic areas and health and wellness issues for special populations and intent to practice in rural and underserved settings after participation in year one and then year two of the program.

Responses without both pre- and post-participation ratings were excluded from analyses, as were responses where “did not take” was selected. The number of excluded responses varied by item and ranged between 2.0% and 3.9%. Wilcoxon Signed-Rank Tests were used to assess for differences in working knowledge and intent to practice items from before to after AHEC Scholars Program participation. We also calculated effect sizes to further assist with interpretation. All tests were 2-tailed with alpha set at < 0.05 for statistical significance. We did not adjust for multiple comparisons, as current literature suggests that corrections in observational studies are too stringent and increase the likelihood of Type 2 Errors [17, 18].

Results

Response rates were 79.1% for Cohort 1, 52.6%, for Cohort 2, 66.7% for Cohort 3, and 78.5% for Cohort 4. We found no statistical differences across academic years for AHEC Scholars’ demographic characteristics, except for proficiency in a language other than English (p < 0.001), with more learners in Cohorts 3 and 4 reporting higher proficiencies (63% and 66.3%) respectively (Table 1). While there were gains between the Year 1 and Year 2 surveys, the changes were modest and not statistically significant for working knowledge or intent to practice between Year 1 and Year 2. Therefore, both years of participation were combined in analyses.

Table 1.

AHEC scholars demographic characteristics

Characteristics	Total n = 312	Cohort 1 Scholars n = 70	Cohort 2 Scholars n = 69	Cohort 3 Scholars n = 81	Cohort 4 Scholars n = 95	p-value*
Gender a	n (%)	n (%)	n (%)	n (%)	n (%)	p-value*
Female	216 (68.6)	50 (71.4)	41 (62.1)	57 (70.4)	68 (71.6)	0.590
Male	91 (28.9)	19 (27.1)	24 (36.4)	23 (28.4)	25 (26.3)
Age Category in Years b	n (%)	n (%)	n (%)	n (%)	n (%)	p -value*
20–29	231 (73.3)	54 (77.1)	47 (71.2)	63 (77.8)	67 (70.5)	0.662
30–39	69 (21.9)	14 (20.0)	16 (24.2)	14 (17.3)	25 (26.3)
40 and older	11 (3.5)	1 (1.4)	3 (4.5)	4 (4.9)	3 (3.2)
Race	n (%)	n (%)	n (%)	n (%)	n (%)	p -value*
Asian/Pacific Islander	36 (11.4)	11 (15.7)	9 (13.6)	10 (12.3)	6 (6.3)	0.902
Black	2 (0.6)	0 (0)	1 (1.5)	1 (1.2)	0 (0)
Indigenous People	10 (3.2)	2 (2.8)	1 (1.5)	2 (2.4)	5 (5.3)
White	230 (73.0)	53 (75.7)	46 (69.7)	60 (74.1)	71 (74.7)
More than one race	16 (5.1)	0 (0)	5 (7.6)	3 (3.7)	8 (8.4)
Prefer not to answer	7 (2.2)	2 (2.9)	2 (3.0)	1 (1.2)	2 (2.1)
Other race	3 (1.0)	2 (2.9)	0 (0)	1 (1.2)	0 (0)
Missing	8 (2.5)	0 (0)	2 (3.0)	3 (3.7)	3 (3.2)
Ethnicity	n (%)	n (%)	n (%)	n (%)	n (%)	p -value*
Hispanic	31 (9.8)	4 (5.7)	8 (12.1)	6 (7.2)	13 (13.7)	0.377
Non-Hispanic	272 (86.3)	58 (82.9)	58 (87.9)	74 (91.4)	82 (86.3)
Missing	9 (2.9)	8 (11.4)	0 (0)	1 (1.2)	0 (0)
Proficiency in languages other than English	n (%)	n (%)	n (%)	n (%)	n (%)	p -value*
Yes	163 (51.7)	23 (32.9)	26 (39.4)	51 (63.0)	63 (66.3)	< 0.001
No	132 (41.9)	31 (44.3)	40 (60.6)	29 (35.8)	32 (33.7)
Missing	17 (5.4)	16 (22.9) c	0 (0)	1 (1.2)	0 (0)
Veteran of the U.S. Military	n (%)	n (%)	n (%)	n (%)	n (%)	p -value*
Yes	22 (7.0)	2 (2.9)	7 (10.6)	7 (8.6)	6 (6.3)	0.407
No	280 (88.9)	59 (84.3)	59 (89.4)	73 (90.1)	89 (93.7)
Missing	10 (3.2)	9 (12.9)	0 (0)	1 (1.2)	0 (0)
Rural area residence growing up	n (%)	n (%)	n (%)	n (%)	n (%)	p -value*
Yes	41 (13.0)	Not collected	Not collected	Not collected	41 (43.2)	--
No	38 (12.1)				38 (40.0)
Missing	16 (5.1)				16 (16.8)
Economically disadvantaged†	n (%)	n (%)	n (%)	n (%)	n (%)	p -value*
Yes	68 (21.6)	12 (17.1)	14 (21.2)	16 (19.8)	26 (27.4)	0.669
No	227 (72.1)	42 (60.0)	52 (78.8)	64 (79.0)	69 (72.6)
Missing	17 (5.4)	16 (22.9) c	0 (0)	1 (1.2)	0 (0)
Educationally disadvantaged††	n (%)	n (%)	n (%)	n (%)	n (%)	p -value*
Yes	96 (30.5)	19 (27.1)	22 (33.3)	19 (23.5)	36 (37.9)	0.237
No	199 (63.2)	35 (50.0)	44 (66.7)	61 (75.3)	59 (62.1)
Missing	17 (5.4)	16 (22.9) c	0 (0)	1 (1.2)	0 (0)
Future practice plans d	n (%)	n (%)	n (%)	n (%)	n (%)	p -value*
Rural	251 (79.7)	41 (58.6)	58 (87.9)	69 (85.2)	83 (87.4)	0.193
Urban underserved	186 (59.0)	23 (32.9)	43 (65.2)	56 (69.1)	64 (67.4)	0.007
Unsure	54 (17.1)	14 (20.0)	10 (15.2)	15 (18.5)	15 (15.8)	0.400
Receiving or planning to apply for service obligation after graduation	n (%)	n (%)	n (%)	n (%)	n (%)	p -value*
Yes	185 (58.7)	29 (41.4)	43 (65.2)	50 (61.7)	63 (66.3)	0.461
No	111 (35.2)	25 (35.7)	23 (34.8)	31 (38.3)	32 (33.7)
Missing	16 (5.1)	16 (22.9) c	0 (0)	0 (0)	0 (0)
If yes, service obligation in OR	163 (51.7)	25 (35.7)	39 (59.1)	43 (53.1)	56 (58.9)	0.893
Program	n (%)	n (%)	n (%)	n (%)	n (%)	p -value*
Physicians	93 (29.5)	36 (51.5)	14 (21.2)	17 (21.0)	26 (27.4)	1.00
Advanced Practice Providers	150 (47.6)	28 (40.0)	37 (56.1)	34 (42.0)	51 (53.8)	1.00
Dentistry	28 (8.9)	5 (7.1)	5 (7.6)	14 (17.3)	4 (4.2)	1.00
Pharmacy	28 (8.9)	1 (1.4)	5 (7.6)	10 (12.3)	12 (12.6)	1.00
Nursing (BSN)	13 (4.1)	0 (0)	5 (7.6)	6 (7.4)	2 (2.1)	1.00

† Defined as family income at or below federal poverty level and includes whether your family received public assistance – Aid to Families with Dependent Children, food stamps, Medicaid, public housing

†† Defined as the first in your family to attend college, or if you graduated from a high school where 50% or less go to college, or college is not encouraged, or graduated from a high school where many of the students were eligible for free or reduced lunches

^*Kruskal-Wallis test

^a Data suppressed due to low cell counts for non-binary, other gender, and prefer not to answer response options

^b Data combined due to low cell counts for ages 40 and above and suppressed for prefer not to answer response options

^c Missing data are for medical students that participated in the AHEC Scholars program for the 2018–2019 academic year, but did not provide full demographic information

^d Categories not mutually exclusive

A majority of Oregon AHEC Scholars were female (68.6%) and between 20 and 29 years of age (73.3%). Approximately 22% identified with a race other than White, 9.8% identified as Hispanic, and 51.7% indicated they were proficient in a language other than English. Experiencing economic disadvantage was reported by 21.6% of scholars, and 30.5% identified as educationally disadvantaged. 7% were military veterans. Beginning with Cohort 4, Scholars were queried about residency in a rural area while growing up with 43.2% reporting having a rural background (Table 1). Nearly 80% (79.7%) reported interest in practicing in a rural setting after training, and 59.0% reported interest in practicing in an urban underserved setting. Over 58% (58.7%) of Scholars reported having a service obligation post-graduation, and 51.7% of these were in Oregon.

Participants reported higher ratings relative to their retrospective pre-participation ratings for all six core didactic areas (p < 0.001, Fig. 1). Cohen’s d ranged from 0.75 to 0.83 reflecting the pre- to post-participation differences in perceived knowledge across the core didactic areas. The largest differences were for Practice Transformation (Mean D = + 1.10), Current and Emerging Health Issues (Mean D = + 1.07), and Behavioral Health Integration (Mean D = + 1.01), while the smallest were for Cultural Competency (Mean D = + 0.78) and Interprofessional Education (Mean D = + 0.75).

Fig. 1.

Mean changes in working knowledge for AHEC Scholars in core didactic areas from before to after participating in the OR AHEC Scholars Program. All perceptions of change in working knowledge are significant (p <0.001, Wilcoxon signed ranks test). Response scale: 1=non-existent, 2= very minimal, 3=moderate, 4=quite a lot, and 5=complete. Abbreviations: Social Determinants/Drivers of Health (SDOH)

Similarly, there were differences in working knowledge from before to after program completion for all special populations measured (p < 0.001, Table 2). Cohen’s d ranged from 0.76 to 0.94 again reflecting the differences across the special population types. In this category, the largest mean differences in working knowledge were for patients seen in rural health clinics (Mean D = + 1.33), populations in health professions shortage areas (Mean D = + 1.19), and medically underserved populations (Mean D = + 1.00), while the smallest differences were for domestic violence victims (Mean D = + 0.55), patients with HIV/AIDS (Mean D = + 0.55), and residents of public housing (Mean D = + 0.58).

Table 2.

AHEC Scholars retrospective pre-post assessment: mean (SD) for retrospective pre-post student knowledge assessment for health and wellness issues among special populations

Core Didactic Area:	Before AHEC Scholars	After AHEC Scholars	Mean Change	p-value*	Cohen’s d
	Mean (SD)	Mean (SD)
Patients seen in rural health clinics (n = 320)	2.44 (0.92)	3.77 (0.71)	+ 1.33	< 0.001	0.94
Populations in health professions shortage areas (n = 321)	2.55 (0.83)	3.74 (0.65)	+ 1.19	< 0.001	0.85
Medically underserved populations (n = 324)	2.78 (0.83)	3.78 (0.63)	+ 1.00	< 0.001	0.82
Migrant and seasonal farm workers (n = 311)	2.23 (0.89)	3.14 (0.97)	+ 0.91	< 0.001	0.97
Those with substance abuse problems (n = 322)	2.71 (0.86)	3.61 (0.71)	+ 0.90	< 0.001	0.88
Those who are homeless (n = 316)	2.63 (0.92)	3.33 (0.78)	+ 0.70	< 0.001	0.85
The elderly (n = 321)	2.83 (0.79)	3.42 (0.65)	+ 0.59	< 0.001	0.79
Residents of public housing (n = 308)	2.27 (0.84)	2.85 (0.86)	+ 0.58	< 0.001	0.76
Those with HIV-AIDS (n = 311)	2.34 (0.71)	2.89 (0.78)	+ 0.55	< 0.001	0.76
Those who are victims of domestic violence (n = 313)	2.41 (0.81)	2.96 (0.83)	+ 0.55	< 0.001	0.79

Response scale: 1 = Non-existent, 2 = Very minimal, 3 = Moderate, 4 = Quite a lot, 5 = Complete

*Wilcoxon Signed Ranks Test

Lastly, there were pre-to post-participation differences in intent to practice across all rural and underserved settings assessed (p < 0.001, Fig. 2). Cohen’s d ranged from 0.53 to 0.97 across the different practice settings. The largest pre-post differences were for the following settings: FQHCs (Mean D = + 0.80), certified Rural Health Clinics (Mean D = + 0.77), and Critical Access or Rural Hospitals (Mean D = + 0.74). The smallest were for Community Mental Health Clinics (Mean D = + 0.41), County or State Correctional Facilities (Mean D = + 0.32), and State Mental Hospitals (Mean D = + 0.22).

Fig. 2.

Mean changes in perceptions of intent to practice in rural/underserved setting for OR AHEC Scholars from before to after participating in the OR AHEC Scholars Program. All changes in intent to practice are significant (p <0.001, Wilcoxon signed ranks test). Response scale: 1=none, 2=minimal, 3=moderate, 4=high, 5=fully. Abbreviations: Federally Qualified Health Center (FQHC), Critical Access Hospital (CAH), Community-based rural health clinic (CBRHC), Community Mental Health Center (CMHC)

Discussion

This study is unique in that it included data from four cohorts of learners and included many different health professions training programs across the state of Oregon. Most participants (> 77%) were medical students or advanced practice provider students, which is important as shortages of these professionals is of great concern. Measuring an educational program’s long-term impact on the workforce is challenging, especially for physician training because residency is often followed by sub-specialty training, which takes several years to complete. However, an initial step is to develop a curriculum that educates health professional learners about underserved populations, ignites their interest in rural/underserved practice, and evaluates the curriculum’s influence on both perceived knowledge and intention to practice in rural and underserved settings when training is complete.

Findings from this study suggest that OASP appears to be accomplishing this step and is meeting HRSA’s goals and core requirements. Knowledge about the health and wellness issues for special populations (e.g., the elderly, medically underserved populations) and other core didactic areas, including interprofessional collaboration, cultural competency and practice transformation have been demonstrated to have positive effects on patients [19, 20], and it is possible that exposure during training will support Scholars as they move into independent clinical practice. Importantly, findings indicate that participating in the OASP curriculum appears to have influenced students’ perceptions of their future intent to practice in a variety of rural or underserved settings following training, and this effect was seen across all areas assessed, with large differences between pre- and post-program perceptions of intentions and large effect sizes for intent to practice for FQHCs, certified Rural Health Clinics and Critical Access/rural Hospitals, which reflect the magnitude of those differences. Moreover, these differences were noted across all schools, programs and professions that are part of the OASP, which is important because the rural and underserved workforce is often team-based across a wide variety of health professions that mirror those in the OASP.

Assessing intention is important because, as noted in the literature on the Theory of Planned Behavior, the stronger the intention to engage in a behavior, the more likely the behavior will be performed [21]. This is because intention acts as a mediator between personal attitudes towards the behavior, subjective norms, and perceived behavioral control, essentially reflecting the individual’s motivation and readiness to act. One of the goals of Oregon’s AHEC Scholars Program is preparing students to more fully understand factors that affect the health of vulnerable populations while also witnessing how such factors are managed in underserved settings. These experiences are designed to affect personal attitudes, illustrate subjective norms and increase perceived behavioral controls.

As mentioned, MD/DO students in the initial cohorts are just now finishing residency, and their employment data are not yet available. Follow-up efforts to evaluate practice settings post training are in progress for AHEC Scholars in other programs (e.g., dentistry, nursing, pharmacy) and will provide valuable information about program impacts on practice types/locations and ultimately help us determine the extent to which participation in AHEC Scholars impacts the healthcare workforce serving rural and underserved populations, which will add evidence to evaluate the relationship between intention and actual practice choices. Additionally, investigating which of learners’ demographic characteristics (e.g., rural background, disadvantage indicators, additional language proficiency) may predict intention to practice and post-training practice settings could provide more information about factors that influence health providers’ choice to practice rurally or in an underserved setting.

Our findings align with other studies that have demonstrated how positive experiences in rural rotations can influence students’ intent to practice in rural settings or reinforce that intention among students already interested in rural practice [22, 23]. Healthcare workforce shortages across medicine, dentistry, nursing and pharmacy in rural and underserved areas mean that these patients may postpone seeking care and have less access to preventative care (e.g., routine physicals, screenings, dental hygiene). As a result, they are more likely to experience negative effects from chronic conditions and poorer health outcomes overall and incur a greater economic burden when seeking care compared to patients in well-resourced areas. While there is substantial investment to incentivize (e.g., service commitment loan forgiveness programs) healthcare professionals to practice in rural and underserved settings, this study suggests more upstream educational based programs may also influence future healthcare professionals in their thinking about where to practice post-training. These findings underscore the importance of continued support and funding for rural/underserved pathway programing in the environment of federal and state budgetary reductions and increasing tighter profit margins in healthcare systems.

The potential of the AHEC Scholars program to mitigate the negative health effects associated with social determinants of health, such as access to care and social and economic stressors, is striking. Scholars receive training in best practices and health issues facing patients in rural and underserved areas and, in this study, demonstrated an intent to practice in these settings. Further, the AHEC Scholars program’s focus on training learners across healthcare disciplines, particularly advance practice providers (e.g., physician assistants, nurse practitioners) could also support better health outcomes as they can provide high-quality care and are more likely to practice in under-resourced settings [24, 25].

Strengths of our analysis include a robust evaluation of all OR AHEC Scholars Program curricular elements and consistent findings across four cohorts of learners. Although our data suggest student perceived effectiveness across the breadth of the core curriculum, the lack of a randomized control design or a causal pathway limits our ability to fully attribute our findings to the training that OASP participants received. The strength of this program is that it spans programs and universities across Oregon. In doing so, survey administration is difficult as students can receive correspondence from outside their home institutions, thus reducing survey response rates. The use of the retrospective pre-post design means that learners may not have accurately recalled their baseline knowledge and intentions or may have over-reported their post-program knowledge and intentions, thereby introducing the possibility of recall and/or social desirability bias, which would impact the validity of the findings. Future work should include a baseline assessment of learners’ knowledge and future practice intentions to allow for testing the RPP against a traditional pre-post design. Additional research is also needed to discern which program components are most effective, and what content best supports learners in caring for patients as they move from training to practice. Our response rates to the survey ranged from 52.6% to 79.1%, indicating that response bias may affect these findings. Lastly, while our study evaluates students across many health profession programs, it involves only one state AHEC organization which limits generalizability. A valuable future analysis would involve incorporating data from AHEC Scholars Programs beyond Oregon.

Whereas programs like the National Health Service Corps (NHSC), rural training tracks or programs, and loan repayment programs primarily address practice location decisions after professional training, AHEC Scholars intervenes upstream, during formative phases of professional identity development, by providing structured rural clinical exposure, longitudinal engagement, and interprofessional education addressing rural health issues and determinants. AHEC Scholars Programs may increase the effectiveness of NHSC by expanding the pool of graduates who enter NHSC with prior rural experience and a realistic understanding of rural practice, which could improve retention beyond NHSC required service periods. Moreover, AHEC Scholars may serve as a feeder pathway to rural training tracks by identifying and preparing students with early interest in rural practice. And while community-based pathway programs offer a valuable entry for high school and undergraduate students, AHEC Scholars extends these pathway efforts by providing continuity of rural engagement during professional training, a period when career intentions often shift or solidify.

Conclusion

Findings of this study suggest that OASP succeeded in increasing students’ perceived knowledge related to the teaching core topics set forth by HRSA and increased students’ perceptions of their intent to practice in rural and/or underserved areas. The findings were consistent across educational programs and a diversity of healthcare professions students. This study represents an important first step in understanding how the AHEC Scholars program informs and supports learners’ journeys from sparking interest in rural or underserved practice to ultimately delivering care in these settings.

Authors’ contributions

EW, GA, CT completed background literature search and review and were major contributors in the writing of the manuscript. CT analyzed all data and prepared all tables and figures. ES, KS, JD, PC all contributed edits of the manuscript and contributed to the work itself. All authors read and approved the final manuscript.

Funding

Oregon AHEC is funded in part by grant HRSA #U77HP03052-23‐00 from Health Resource and Services Administration with matching funds from the State of Oregon and Oregon Health and Science University.

Data availability

Data generated and analyzed for this study can be accessed upon reasonable request to the corresponding author (Eric Wiser).

Declarations

Ethics approval and consent to participate

This study was approved by the Oregon Health & Science University Institutional Review Board, study #18471.

Consent for publication

Not applicable as this manuscript does not contain any individual person’s data.

Competing interests

The authors declare no competing interests.