Connecting Public Health Students to Rural and Underserved Areas: Promoting Health Equity Through Field Placement Experiences

Abstract

Keywords

access to health care health promotion rural health workforce development

Introduction

There is a maldistribution of health care providers in the United States (Goodell, Dower, & O’Neil, 2011). This “shortage” of health care providers in rural and medically underserved areas (MUAs) represents an uneven distribution of the health care workforce with greater numbers of providers concentrated in more populated, urban centers. This disparity will invariably grow as projections of workforce needs continue to increase (Nelson, 2008; Rosenstock et al., 2008). Huicho et al. (2010) observed that the unwillingness of health workers to practice in underserved, remote, or poor areas, remains a persistent problem in achieving equitable access to health services (Huicho et al., 2010). Moreover, limited or insufficient access includes both preventive and direct health care services (Larson & Correa-de-Araujo, 2006; Singh & Siahpush, 2009).

Despite the significant body of literature regarding the scarcity of direct health care providers (e.g., physicians, nurses) in rural areas and MUAs (Baernholdt & Mark, 2009; Burton, Lichter, Baker, & Eason, 2013; Daniels, Vanleit, Skipper, Sanders, & Rhyne, 2007; McGrail, Wingrove, Petterson, & Bazemore, 2017; Weinhold & Gurtner, 2014), less is known about the experiences of public health practitioners in these same underserved areas (Beck & Boulton, 2012). In a seminal position statement by the American Public Health Association (1995), the authors affirmed the critical role of public health in the health care system in the United States: “The public health system focuses on prevention through population-based health promotion-those public services and interventions which protect entire populations from illness, disease, and injury and protection” (para. 4). The purpose of this article is to describe the experiences of emerging public health practitioners who participated in the Pathways to Practice Scholars program (field placement) through the Region IV (R-IV) public health training center.

The primary question that guided this evaluation was “What are the experiences of emerging public health practitioners who participated in a R-IV field placement experience?” Subquestions included the following:

In what ways are field placement experiences aligned with the Council on Linkages (CoL) eight domain areas and related skills?

How did field placement experiences influence emerging public health practitioners’ interest in addressing the needs of rural and/or medically underserved populations (MUPs)?

Quantitative data included confidence scores by CoL competency domain. Qualitative data included a review of survey comments, executive summaries, reflection statements, alumni survey data, and follow-up electronic communication.

Background

Public Health Training Centers

The Health Resources and Services Administration (HRSA) first funded the establishment of public health training centers (PHTCs) in the 1990s to address quality standards and measures for accreditation of public health departments (Bigley, 2016). Since then, the work of PHTCs has focused on strengthening the public health infrastructure through workforce development and training (McCormick, Reel, Alperin, Lloyd, & Miner, 2017). HRSA (2018) tasked its Bureau of Health Workforce with improving “the health of underserved and vulnerable populations by strengthening the health workforce and connecting skilled professionals to the communities in need” (para. 1). To improve the distribution of public health professionals in rural and underserved areas, HRSA charged the Regional PHTCs with establishing a regional field placement program that provides opportunities for public health students to work on behalf of MUPs.

The Region IV Public Health Training Center (R-IV PHTC) was initially funded in 2014 and headquartered at the Rollins School of Public Health at Emory University. The R-IV PHTC established its regional Pathways to Practice Scholars program during its first year of funding. The Pathways to Practice Scholars program provides current public health students an opportunity to gain practical experience through field placement experiences in governmental public health agencies or other organizations that provide public health services in the following eight U.S. Department of Health and Human Service Region IV states: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee.

Region IV Public Health Training Center

The mission of the R-IV PHTC is to develop and implement programming to train and educate current and future public health professionals in U.S. Department of Health and Human Service Region IV. For the duration of the initial 4-year funding cycle (2014-2018), all aspects of the R-IV PHTC, including field placement experiences, were based on the Council on Linkages (2014) Core Competencies for Public Health Professionals a set of foundational skills for the broad practice of public health that cut across public health disciplines. The skills outlined by the CoL are divided into the following eight domains:

Analytical/Assessment Skills

Policy Development/Program Planning Skills

Communication Skills

Cultural Competency Skills

Community Dimensions of Practice Skills

Public Health Science Skills

Financial Planning and Management Skills

Leadership and Systems Thinking Skills.

Assessment of CoL core competencies and related skills was an integral component of the overall evaluation plan for the R-IV PHTC.

One of the core functions of the R-IV PHTC is to prepare public health students to work in rural areas and MUAs through field placement experiences. For R-IV, the Pathways to Practice Scholars program allows current public health students to gain practical experience by working with or on behalf of underserved communities or populations. Field placement experiences are intended to enhance a student’s professional skills and knowledge while also affording them the opportunity to use skills learned in the classroom. Placements provide mutually beneficial opportunities for agencies and students to address critical needs among MUPs (Carvalho, McCormick, Lloyd, Miner, & Alperin, 2017). Field placement experiences are structured and include specific elements including a competency-based work plan, agency deliverables, reflective writings, and evaluation surveys (Bryan, Kreuter, & Brownson, 2009). The length of field placements varies between 200 and 400 hours per semester based on university requirements, and students work at one location for the duration of the experience.

Conceptual Frame

Field placement experiences comprise one of the many types of practice-based experiences that colleges and universities in the United States offer to students to enhance their classroom curriculum; field placements are typically characterized as a form of experiential education (Gardner & Bartkus, 2014). While the terms experiential education and experiential learning are often used interchangeably, the former describes an educational philosophy while the latter focuses on a process of learning through reflective experience. Our evaluation team prefers the term experiential learning as it better aligns with the goals of the Pathways to Practice Scholars program by considering the context of field placement experiences as well as the needs of individual learners.

This evaluation was further guided by Public Health 3.0, an initiative by the U.S. Department of Health and Human Services that calls for a broadening of public health practice to solve the fundamental challenges of population health (DeSalvo et al., 2017). This cross-sector collaborative approach to public health encourages public health practitioners, including emerging professionals, to engage community stakeholders to build vibrant, structured partnerships (DeSalvo et al., 2017). Based on this recommendation, the R-IV PHTC strongly encourages field placement experiences be interdisciplinary in nature.

Method

Our evaluation team used a sequential, exploratory mixed methods design to explore field placement experiences (Creswell et al., 2003). We examined pre- and postconfidence scores by CoL competency domain, and survey responses guided our review and analysis of student documents. We selected qualitative responses based on survey ratings and integrated findings in the Discussion section of the study (Plano Clark & Ivankova, 2015). A visual diagram of steps can be seen in Figure 1.

Figure 1

Visual Diagram of Sequential Exploratory Design

Data Collection

All quantitative data were drawn from pre- and postconfidence scores of CoL Core Competency domains. Confidence scores were recorded via SurveyMonkey™, an online survey platform. Qualitative data were collected from student documents related to the Pathways to Practice Scholars program (i.e., survey comments, executive summaries, reflection statements, alumni survey data, follow-up electronic communication) for students who participated in the program between 2014 and 2018. All students were assigned pseudonyms to protect confidentiality. All data were stored as electronic files on password protected and encrypted computers.

Data Analysis

For the quantitative component of this investigation, the evaluation team identified the number of times a competency within a CoL domain was selected by a student. We also calculated levels of pre- and postconfidence and the difference between the two (see Table 1). Quantitative analyses were conducted by the principal investigator of the R-IV PHTC and senior author of this article. This individual holds a terminal degree and has extensive experience with program and outcomes-based assessment and evaluation. With regard to qualitative data, the field placement coordinator compiled key data from student documents in a Microsoft Excel spreadsheet, which the evaluation team reviewed line-by-line to develop emergent codes and themes. Team members discussed disagreements of coding until consensus was reached. Consistent with best practices in qualitative methodology, we used multiple methods of verification to ensure trustworthiness of the data, including peer debriefing, internal memoing, and an audit trail (Creswell, 2007; Patton, 2002).

Table 1

Field Placement Data

Year	No. of Students	Field Placement in Primary Care Setting	Field Placement in Medically Underserved Area	Field Placement in Rural Area
2014-2015	14	7	14	2
2015-2016	22	11	22	10
2016-2017	18	13	18	7
2017-2018	18	5	18	3
Total	72	36	72	22

Delimitations, Limitations, and Ethical Considerations

To be eligible for consideration, students had to be enrolled in accredited schools and programs of public health in the Southeast. The majority of students were pursuing a Master’s in Public Health degree (n = 63). Eligible students could also be enrolled in undergraduate programs of public health or doctoral programs in public health-related fields. Additionally, students had to complete their field placement experience in rural areas or MUAs or on behalf of MUPs between 2014 and 2018 and submit pre- and postconfidence surveys and other required program documents. Data were limited to existing data sources. While this reduced the data burden on students, it did not allow for follow-up questions or clarification, which can be considered a limitation (Hulley, Cummings, Browner, Grady, & Newman, 2013). Findings were based on the perceptions of a small yet purposeful set of students who participated in a field placement experience within a discrete period of time. Findings cannot be generalized beyond the context in which the evaluation was conducted. Due to the small sample size, we were limited in our ability to interpret results of the quantitative data beyond practical utility and program improvement. Furthermore, students who engaged in a field placement may have been predisposed to working with rural or underserved populations before their placement because they elected to participate in this program; therefore, caution should be used in interpreting results. Evaluators did not seek the perspectives of MUPs that may have benefited either directly or indirectly from student involvement in these experiential learning experiences. These perspectives may have strengthened the overall evaluation design. Finally, evaluators did not have grading authority over students who participated in field placement experiences. This evaluation was not classified as human subjects research based on the Institutional Review Board definition of research at Emory University.

Quantitative Results

Since the beginning of the program in 2014, 80 scholars have been placed in positions across Region IV. Matching pre/post data, however, were only available for 72 students (n = 72). Participating students were evenly distributed across academic years, and all of the placements were in MUAs (n = 72). Additionally, half of field placement experiences were in primary care settings (n = 36) and nearly one-third were in rural areas (n = 22). Descriptive data regarding field placement experiences by year can be seen in Table 1.

The average age of the 72 scholars was 25 years (range: 21-37 years). Fifty-eight (81%) of scholars identified themselves as female; 14 (19%) as male. Racial distribution was 45 (63%) White, 21 (29%) Black or African American, 5 (7%) Asian, and 1 (1%) native Hawaiian or Pacific Islander. Seven (10%) scholars identified themselves as Hispanic/Latino. Twenty-five scholars (35%) indicated that they were raised primarily in a rural area, and 12 (17%) indicated they were from disadvantaged backgrounds, defined as having limited access to educational opportunities due to environment or severely limited finances. Nineteen (26%) of the placements were at state health departments, 23 (32%) at local health departments, 12 (17%) at Area Health Education Centers (AHECs), 17 (24%) at other agencies (e.g., primary care settings, academic centers), and one (1%) at a tribal health department. Based on program documents, the top CoL competency domains (Table 2) selected by scholars were analytical/assessment (selected by 69% of scholars), community dimensions of practice (63%), leadership/systems thinking (54%), communication (53%), policy development/program planning (49%).

Table 2

Average Pre- and Postconfidence Scores^a by Competency Domain

Domain	No. of Times a Competency Domain Was Selected by Students^b	Average Preconfidence	Average Postconfidence	Difference
1. Analytical/Assessment	86	3.10	4.45	1.35
2. Policy Development/Program Planning	45	2.78	4.33	1.55
3. Communication	47	3.02	4.57	1.55
4. Cultural Competency	26	3.04	4.38	1.34
5. Community Dimensions of Practice	62	2.92	4.50	1.58
6. Public Health Sciences	18	3.00	4.33	1.33
7. Financial Planning/Management	14	2.21	4.21	2.00
8. Leadership/Systems Thinking	47	3.26	4.74	1.48

Confidence scores (1 = not at all confident; 5 = extremely confident). ^bTable includes data based on 345 competencies that had pre/post matches.

Qualitative Results

Analysis of student documents yielded the following three overall themes regarding field placement experiences: core competency skills, collaborative partnerships, and interest in addressing the needs of MUPs. For each theme, we provide representative quotes to highlight findings.

Core Competency Skills

The Pathways to Practice Scholars program afforded students opportunities to learn and apply knowledge and skills based on the eight CoL Core Competency domains. Students described the acquisition of skills in both general terms as well as related to specific competency domains. For example, in a personal reflection statement, Bethany said, “I believe this internship has equipped me with the necessary skills to be a competent public health practitioner. Each of the skills I have obtained is essential to my desire to work in underserved populations.” Similarly, Mary indicated that she was grateful for the field placement experience and its focus on the “public side of public health.” She said, “(the field placement experience) influenced my desire to put extra effort into community outreach.”

Communication, Policy Development/Program Planning Skills

Students identified a number of CoL core competency skills that were strengthened through their field placement experiences. For example, reflecting on the communication skills domain, Karen observed,

No matter which field an individual is in, there must be communication with all other fields: the education field with the medical field, the medical with the mental (health), the mental (health) with the policy, the policy with the community and so forth.

Kimberly reflected on skills related to both communication and policy development by describing her role in drafting a state level report, “I had to analyze collected data and find a way to summarize it succinctly and clearly to a policy-oriented audience. In crafting this report I focused on de-emphasizing medical information and instead emphasized local policy concerns.” Similarly, Susan depicted “effective, audience-appropriate communication,” as “key to every part of working in government.”

Analytical and Assessment Skills

Both Robert and Patricia commented on the role of the analytical and assessment skills domain in their field placement experiences. Robert said,

The project provided valuable experience in collecting and interpreting qualitative data as well as a better understanding of how substance abuse affects every part of the health care system. . . . The biggest takeaway from my internship was the effect that a community has on an individual’s health.

Expanding on this idea, Patricia noted, “I did learn that collecting and analyzing data has the power to change the way people think and can be used for further implications in the field of public health.”

Leadership and Systems Thinking Skills

Donna observed that the use of data allowed her to support organizational goals and enhanced her approach to leadership and systems thinking. In a personal reflection, Donna intimated that multiple field placement projects encouraged her to grow as a “forward thinker and innovator in leadership.” She described a career goal of pursuing a leadership role in public health and suggested that the field placement experience allowed her to see how organizations grow and change based on new information.

Jonah described his work with a local nonprofit agency as reaching underserved communities and populations and providing them access to resources and benefits such as Medicaid, Tax Credits, Supplemental Nutrition Application Program, Temporary Assistance for Needy Families, financial aid, and Veterans benefits. Jonah observed, “By meeting people where they are in life and addressing their needs holistically, [the host agency and partner sites] have assisted . . . residents and placed them on a path to self-stability.”

Public Health Science Skills

Utilizing both program planning and public health science skills, John described his project as “researching, developing, implementing, and evaluating a worksite wellness program.” In an executive summary, John noted that he designed a 4-week pilot program based on evidence-based research, strategies, and best practices. Key inputs to this project included the Centers for Disease and Control and Prevention’s workplace health model and the Centers for Disease and Control and Prevention worksite health scorecard to assess the strengths and weaknesses of the sponsoring organization.

Similarly, Melanie discussed her role in developing a needs assessment for the state’s first needle exchange program. Results of this assessment and research established sufficient demand for the establishment of a harm reduction program for injection drug users. Melanie stated, “Following the completion of my research, I have been able to design a population-based project and assess other dimensions such as public health policies surrounding needle exchange and the budgeting and marketing that goes into tailoring such projects.”

Collaborative Partnerships

The theme of collaborative partnerships reflects aspects of the CoL competency domain of Community Dimensions of Practice and Public Health Science Skills as well as the call for interdisciplinary and cross-sector relationships outlined in Public Health 3.0. A number of students described their interactions with community partners as a result of their participation in the Pathways to Practice Scholars program.

For instance, Kimberly illustrated the interdependence of organizations working together to positively affect public health. She stated, “Public health involves cooperation between hospital systems, local businesses, local politicians, non-profits (like the AHEC), independent clinics and providers, and regional medical school campuses. For projects to be successful, all of these players must be on the same page . . .” Because of her field placement experience, Kimberly indicated that she was interested in becoming more involved in the local political process and might seek a future internship with a state legislator.

In a personal reflection statement regarding her field placement experience, Linda described a phenomenon that occurs far too frequently in cross-cutting fields:

I realized how easy it can be for different aspects of public health to be siloed. Often, important programmatic functions were occurring, but without focused effort to record them, there was no way to have adequate data collection and epidemiological analysis . . . I saw how having increased communication or at least a basic understanding of the different components involved helped each staff member better focus their efforts and emphasis on certain project activities.

Cynthia reported the benefits of organizational cooperation and indicated that the field placement experience equipped her to “establish partnerships to make a project/program more successful.” Tammy also expressed overall enthusiasm for the collaborative aspect of her field placement experience, “. . . I discovered a love for being involved with different community partners which has made me want to be more involved in my community when I return to college in the fall.”

Interest in Addressing the Needs of Medically Underserved Populations

One of the most frequently cited benefits of the field placement experience was its affirmation of students’ interest in addressing the needs of MUPs. James stated, “After this field placement I do know that I have a very strong desire to work with underserved populations and communities . . .” Similarly, Sandra said, “. . . I believe that this experience has solidified my interests in working with urban and underserved populations.” Additionally, Tammy acknowledged, “I feel more confident about working with underserved populations” as a result of the field placement experience.

Elizabeth noted, “I discovered how complex but rewarding it is to work in the rural health field. This internship has certainly left me wanting to explore career opportunities in rural medicine more in depth now.” Laura also suggested that the field placement experience could expand opportunities for underrepresented students, “I believe that it is necessary to have people of different backgrounds and different lifestyles at the table to ensure we reach all members of our community in a relevant way.”

Patricia concluded,

I have always wanted to be able to work in a setting where I can help people and be a servant to my community. This experience has taught me that there are many ways that (this) can be done. You can be out in the field and constantly engaged with the community and you can just as easily work more behind the scenes.

Discussion

As demonstrated by student confidence level ratings as well as student documents, scholars participated in meaningful and enriching field placement experiences. These experiential learning opportunities connected students to rural and underserved areas and introduced them to many of the challenges of serving MUPs, including issues of health access and equity. Moreover, placements appeared to affirm students’ interest in addressing the needs of these communities in the future, a concern previously raised in the research literature.

Students noted that field placement experiences provided them with ample opportunities to learn or enhance their understanding of skills articulated by the CoL Core Competencies for Public Health Professionals. Thus, field placement experiences were clearly influenced by the CoL Core Competency domains and related job-embedded skills. Nevertheless, students identified some CoL domains and skills more than others. Given the shifting racial/ethnic demographics of the United States (Perez & Hirschman, 2009), we encourage field placement site coordinators to look for ways to further develop student skills related to the CoL domain of cultural competency.

Similarly, when appropriate, field placement experiences should introduce students to the basic skills of financial planning and management. As a shrinking public health workforce continues to be asked to meet the needs of more people with fewer resources, emerging public health professionals will be called upon to exhibit mid-level management skills, like budgeting, at earlier points in their careers, especially in rural and MUAs (Association of Schools of Public Health, 2008).

Consistent with recommendations from Public Health 3.0, the Pathways to Practice Scholars program serves as one strategy for attracting and retaining a reliable public health workforce, an important consideration given the high turnover rates in local public health agencies and projected workforce shortages in underserved, remote, and poor areas in the United States. Furthermore, students were provided opportunities throughout their field placement experiences to develop leadership and collaboration skills. Finally, the Pathways to Practice Scholars program raised student awareness of health inequities among MUPs as well as strategies to begin to mitigate the social determinants of health.

Conclusion

There is an increasing demand for public health workers due to the unmet needs of the poor and underserved populations. However, through field placement experiences, students can actively engage in their own learning while also addressing critical needs of individuals who live in rural or MUAs. Results of this evaluation demonstrated that students who participated in the R-IV PHTC’s Pathways to Practice Scholars program learned and applied valuable skills to practice settings, based on CoL Core Competencies for Public Health Professionals and informed by Public Health 3.0. Across all eight competency domains, students recorded increased pre- to postconfidence scores as a result of their participation in the R-IV Pathways to Practice Scholars program, and for many, the field placement experience affirmed their interest in addressing the needs of underrepresented communities on graduation. These findings are of critical importance for addressing issues of health equity. This evaluation demonstrates how professional competencies can shape students’ field-based learning experiences. Moreover, it is an important first step in better understanding of how opportunities like the Pathways to Practice Scholars program can influence student interest in addressing the needs of rural and underrepresented populations. Future researchers and practitioners are encouraged to build on these findings by exploring how applied learning experiences can help address the public health workforce shortages in rural and MUAs of the United States.

Footnotes

ORCID iD

Matthew Fifolt

References

American Public Health Association. (1995). The role of public health in ensuring healthy communities (Policy No. 9521). Washington, DC: Author. Retrieved from https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/30/10/48/the-role-of-public-health-in-ensuring-healthy-communities

Associations of Schools of Public Health. (2008). ASPH policy brief: Confronting the public health workforce crisis. Washington, DC: Author. Retrieved from https://www.healthpolicyfellows.org/pdfs/ConfrontingthePublicHealthWorkforceCrisisbyASPH.pdf

Baernholdt

Mark

B. A.

(2009). The nurse work environment, job satisfaction and turnover rates in rural and urban nursing units. Journal of Nursing Management, 17, 994-1001.

Beck

A. J.

Boulton

M. L.

(2012). Building an effective workforce: A systematic review of public health workforce literature. American Journal of Preventive Medicine, 45(Suppl. 5), S6-S16.

Bigley

M. B.

(2016). Transforming public health training. Public Health Reports, 131, 4-6.

Bryan

R. L.

Kreuter

M. W.

Brownson

R. C.

(2009). Integrating adult principles into training for public health practice. Health Promotion Practice, 10, 557-563.

Burton

L. M.

Lichter

D. T.

Baker

R. S.

Eason

J. M.

(2013). Inequality, family processes, and health in the “new” rural America. American Behavioral Scientist, 57, 1128-1151.

Carvalho

McCormick

L. C.

Lloyd

L. M.

Miner

K. R.

Alperin

(2017). Enhancing public health practice through a regional student field placement program. Pedagogy in Health Promotion, 3(Suppl. 1), 73S-80S.

The Council on Linkages. (2014). Core competencies for public health professionals. Washington, DC: Public Health Foundation. Retrieved from http://www.phf.org/resourcestools/Pages/Core_Public_Health_Competencies.aspx

10.

Creswell

J. W.

(2007). Qualitative inquiry and research design: Choosing among five approaches (2nd ed.). Thousand Oaks, CA: Sage.

11.

Creswell

J. W.

Plano Clark

V. L.

Gutmann

M. L.

Hanson

W. E.

(2003). Advanced mixed methods research designs. In Tashakkori

Teddlie

(Eds.), Handbook of mixed methods in social and behavioral research (pp. 209-240). Thousand Oaks, CA: Sage.

12.

Daniels

Z. M.

Vanleit

B. J.

Skipper

B. J.

Sanders

M. L.

Rhyne

R. L.

(2007). Factors in recruiting and retaining health professionals for rural practice. Journal of Rural Health, 23, 62-71.

13.

DeSalvo

K. B.

Wang

Y. C.

Harris

Auerbach

Koo

O’Carroll

(2017). Public Health 3.0: A call to action for public health to meet the challenges of the 21st century. Preventing Chronic Disease, 14, 170017. doi:10.5888/pcd14.170017. Retrieved from https://www.cdc.gov/pcd/issues/2017/17_0017.htm

14.

Gardner

Bartkus

K. R.

(2014). What’s in a name? A reference guide to work-education experiences. Asia-Pacific Journal of Cooperative Education, 14(1), 37-54.

15.

Goodell

Dower

O’Neil

(2011). Primary care workforce in the United States (Policy Brief No. 22). Cambridge, MA: Robert Wood Johnson Foundation.

16.

Health Resources and Services Administration. (2018). Bureau of health workforce. Washington, DC: Author. Retrieved from https://www.hrsa.gov/about/organization/bureaus/bhw/index.html

17.

Huicho

Dieleman

Cambell

Codjia

Balabanova

Dussault

Dolea

(2010). Increasing access to health workers in underserved areas: A conceptual framework for measuring results. Bulletin of the World Health Organization, 88, 357-363.

18.

Hulley

S. B.

Cummings

S. R.

Browner

W. S.

Grady

D. G.

Newman

T. B.

(2013). Designing clinical research (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

19.

Larson

Correa-de-Arajujo

(2006). Preventive health examinations: A comparison along the rural-urban continuum. Women’s Health Issues, 16, 80-88.

20.

McCormick

L. C.

Reel

J. J.

Alperin

Lloyd

L. M.

Miner

K. R.

(2017). Strategic approach to assess training needs across a diverse region. Pedagogy in Health Promotion, 3(Suppl. 1), 28S-34S.

21.

McGrail

M. R.

Wingrove

P. M.

Petterson

S. M.

Bazemore

A. W.

(2017). Mobility of US rural primary care physicians during 2000-2014. Annals of Family Medicine, 15, 322-328.

22.

Nelson

(2008). USA faces severe shortage of public-health workers. Lancet Infectious Diseases, 8, 281. doi:10.1331/JAPhA.2012.12072

23.

Patton

M. Q.

(2002). Qualitative research and evaluation methods (3rd ed.). Thousand Oaks, CA: Sage.

24.

Perez

A. D.

Hirschman

(2009). The changing racial and ethnic composition of the U.S. population: Emerging American identities. Population and Development Review, 35, 1-51.

25.

Plano Clark

V. L.

Ivankova

N. V

. (2015). Mixed methods research: A guide to the field. Thousand Oaks, CA: Sage.

26.

Rosenstock

Silver

G. B.

Helsing

Evashwick

Katz

Klag

. . . Suamaya

(2008). On linkages: Confronting the public health workforce crisis: ASPH statement on the public health workforce. Public Health Reports, 123, 395-398.

27.

Singh

G. K.

Siahpush

Widening rural-urban disparities in life expectancies, U.S., 1969 2009. American Journal of Preventive Medicine, 46, e19-e29.

28.

Weinhold

Gurtner

(2014). Understanding shortages of sufficient health care in rural areas. Health Policy, 118, 201-204.