Southwest Rural Health Research Center, College of Nursing, School of Public Health partner effectively to better rural health

At Texas A&M, several rural-focused research projects and public outreach programs are tackling rural health disparities. Notably, the Southwest Rural Health Research Center, established in 2003, is one of only eight centers of its type in the nation. The center is currently under the direction of Director Alva Ferdinand, DrPH, JD, and co-principal investigator Jane Bolin, BSN, JD, PhD. The center has partnered with the Texas A&M University College of Nursing and the School of Public Health rural-focused outreach programs to serve the needs of rural populations, including:

• Nurse-led Collaborative Integrated Behavioral Health Rural Network (N-CIBHR)
• Texas Teleforensic Remote Assistance Center (Tex-TRAC)
• Texas Cancer Screening, Training, Education, and Prevention (Texas C-STEP)
• Rural-focused cancer prevention programs
• National Rural Health Association
• Community health workers training
• Vulnerable Rural Hospital Technical Assistance Program
• Texas A&M Forensic Nursing Training Program

Federally funded and located primarily at the School of Public Health and College of Nursing, researchers working together have launched several projects over the last two decades and currently serve 27 rural counties in Texas. Their research explores topics ranging from premature birth rates and domestic violence to integrating behavioral health into primary care, N-CIBHR to preventive cancer screenings, and Texas C-STEP to address the needs of rural populations. Currently, the center is running seven programs to improve or better understand rural health.

Integrating behavioral health care into rural primary care offices

Cynthia Weston, DNP, RN, FNP-BC, Robin Page, PhD, MS, RN, CNM, and Elizabeth Wells-Beede, PhD, RN, C-EFM, have implemented a unique integrated primary behavioral care clinic model in rural areas through a new Nurse-led Collaborative Integrated Behavioral Health Rural Network (N-CIBHR). The program, an academic-practice partnership with several rural clinics, aims to increase access to interprofessional, family nurse practitioner-led primary care or integrated behavioral health. With a specific emphasis on opioid use disorder prevention and treatment, the program utilizes both in-person and telehealth care for underserved populations in central Texas.

Screening for common cancers in rural areas

Another rural-focused program is the Texas A&M Texas Cancer Screening, Training, Education, and Prevention (Texas C-STEP). Currently, three cancer-focused projects at the Texas A&M College of Nursing, Family Medicine Residency and School of Public Health are funded by the Cancer Prevention Institute of Texas (CPRIT).

Texas C-STEP offers colorectal, breast and cervical cancer screenings to uninsured, low-income Texans through the College of Nursing’s family nurse practitioner training program and the Texas A&M Health Family Care clinic. Family nurse practitioners (FNPs) and family medicine practitioners in this program are able to gain more experience conducting cancer screenings for rural uninsured populations that cannot access preventive health screenings due to lack of insurance or shortages of providers.

For example, Texas C-STEP, working in collaboration with a free health care clinic in Bryan, Texas, called Health For All, has served 229 women to date. Of these women, all have received a clinical breast exam, most have been screened for cervical cancer, and almost 20 percent of them have been referred to a physician for a mammogram or colonoscopy.

Training and educating future health professionals

Much like other Texas A&M rural health projects, Texas C-STEP benefits participating students as well. Coming from both the family nurse practitioner and bachelor of nursing programs at Texas A&M, 126 nursing students have worked with an underserved population through Texas C-STEP and practiced their skills in a real-world setting.

Nurse practitioners are not only essential to increasing access to care in rural areas, they are licensed and fully prepared to reach rural populations, said Bolin, associate dean for research at the College of Nursing and current deputy director of the Southwest Rural Health Research Center. But Bolin says nurse practitioners’ capabilities as health professionals are often overlooked. “It’s time that the medical establishment recognizes that nurse practitioners are skilled in their areas,” Bolin said. “Not permitting family nurse practitioners to practice at the level that they’re skilled takes away an option for rural communities.”

Bolin is not alone in believing nurse practitioners should be granted more freedom. Weston, an assistant professor in the Texas A&M College of Nursing and one of the main researchers in the Texas C-STEP project, expressed concern over the limitations nurse practitioners face. “We need to modernize practice laws in Texas and support nurse practitioners as they go out into rural areas,” Weston said.

Currently, nurse practitioners in Texas do not have full practice authority and, consequently, cannot use the full extent of their education, experience and credentialing. And despite the existence of incentive programs for physicians to work in underserved regions of Texas, Bolin said “we don’t have doctors moving in droves to rural areas,” making nurse practitioners a more realistic option for such communities.

In addition to nurse practitioners, Texas C-STEP uses community health workers to make cancer screenings more accessible, affordable and culturally relevant. From Weston’s experiences with underserved women, she has found that “roots in rural areas run deep.” In a tight-knit, rural community, people are more trusting of a familiar face than an outside researcher, which makes community health workers of particular value. “Rural care is community-based and you have to be embedded within the fabric of a community to really have the ultimate impact on health,” Weston said.

Serving the underserved

With an increase in hospital closures, financially disadvantaged community members cannot travel far to receive care and instead utilize Texas C-STEP. The spike in hospital closures could be a result of trying to fund and manage all hospitals the same way, Bolin suggests, when rural and urban hospitals need to operate very differently.

Page, an assistant professor in the College of Nursing and another researcher who has worked on projects through the SRHRC, notes how hospital closures have affected maternal and prenatal health in rural communities. “Some of these women who have started coming to the prenatal clinic in Bryan, Texas, say, ‘When the hospital closed in my community, I needed to find a new provider,’” Page said.

Poor access to hospitals can be especially problematic for pregnant women because they need frequent prenatal check-ups (with the Office on Women’s Health recommending a grand total of 14 appointments throughout a 40-week pregnancy). When lack of transportation to an urban hospital prevents a woman from attending these appointments, she is at a greater risk of premature birth. “If a pregnant woman doesn’t have access to care, problems get missed and she ends up delivering early or worse,” Page said.

That’s why programs created through the SRHRC are so crucial in increasing access to care for everyone in a rural community, Bolin says. Likewise, ignoring the disparities in these communities is like “leaving the poorest of the poor to fend for themselves,” Bolin said. Page is confident, however, that compiling research on rural health outcomes—and the financial implications of such outcomes—could influence policymakers, at least in terms of premature births.

“We can take data to policymakers and say, ‘Look. Look what’s going on here,’” Page explained. “We can tell them, ‘Look at the costs of this premature infant that could have been prevented if the woman had had access to care.’”

Women in rural areas who experience such disparities—whether it be related to maternal, cervical, breast or other health—come from diverse backgrounds. Marvellous Akinlotan, a research assistant professor at the College of Nursing who worked with Texas C-STEP, says this research experience helped her understand the impact of “the county’s racial composition and the type of services needed based on the people in the county.”

Akinlotan’s research conducted at the Health For All clinic, for example, found that Hispanic women in Hispanic-dominant communities were more likely to be screened for cancer compared to black women in these communities. When investigating this difference, the researchers found that the materials promoting cancer screenings were written in Spanish, which excluded many non-Hispanic community members. “I am now more attuned to the racial composition of the recipients of these grant-funded programs,” Akinlotan said. “If you have a county with a lot of Hispanic women, what will you do to reach black women? What about white women?”

Not only is it important to acknowledge diversity in rural populations, but Akinlotan said increasing awareness about rural health disparities plays a critical role as well. Further, the researchers involved in Texas C-STEP emphasize that more people need to know about the issues riddling rural health care. “We need to increase awareness about the gaps in care so that we can effect policy changes and legislation,” Page said. “In my view, that’s the only way that we can fix this problem.”

Bolin and other researchers at the SRHRC are trying to raise this awareness through a campaign called Rural Healthy People 2030—a counterpart to Healthy People 2030. This initiative, funded through the School of Public Health, identifies rural health priorities at the national level by surveying rural populations directly. The leading concerns voiced by rural stakeholders will then be presented to policymakers, ultimately shining a light on the health care issues present in rural America.

Other rural-focused initiatives include two grants recently awarded for projects, Rural Community Opioid Response Program Implementation and Neonatal Abstinence Syndrome. These two grants, totaling $3 million, serve the rural Gulf Bend/Golden Crescent region and are directed by Nancy Downing, PhD, RN, SANE-A, SANE-P, FAAN, associate professor at the College of Nursing, Jodie Gary, PhD, RN, assistant professor at the College of Nursing and Bolin.

Story written by Sarah Allen