Rural communities face many unique public health challenges and this week, Radha and her guests take a look at the behavioral health needs and challenges facing rural America. She talks with Dr. Keith Mueller, head of the Department of Health Management and Policy at the University of Iowa and the director of the RUPRI Center for Rural Health Policy Analysis; PhD student Hannah Rochford; and Dr. Alana Knudson, co-director of the Walsh Center for Rural Health Analysis at NORC at The University of Chicago.

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Radha Velamuri:

Hello, everyone. Welcome back to From the Front Row, brought to you by the University of Iowa College of Public Health. My name is Radha Velamuri. And if this is your first time with us, welcome. We’re a student-run podcast that talks about major issues in public health, and how they are relevant to anyone, both in and out of the field of public health. Today, we’ll be chatting with Dr. Keith Mueller, Ms. Hannah Rochford and Dr. Alana Knudson about the behavioral health needs and challenges facing rural America.

Radha Velamuri:

Dr. Mueller is Gerhard Hartman Professor and Head of the Department of Health Management and Policy here at the University of Iowa. He specializes in rural health policy and accordingly is also the director of the RUPRI Center for Rural Health Policy Analysis and the chair of the RUPRI Health Panel. He has served as president of National Rural Health Association and as a member of the National Advisory Committee on Rural Health and Human Services.

Radha Velamuri:

Ms. Hannah Rochford is a PhD student in the Department of Health Management and Policy here at the University of Iowa. She works with Dr. Mueller and her research interests center around violence against women and its intersection with the healthcare and policy systems.

Radha Velamuri:

Finally, we are joined by Dr. Alana Knudson. She is the director of the Walsh Center for Rural Health Analysis at the National Opinion Research Renter at the University of Chicago, one of the largest independent social research organizations in the United States. She serves as the primary investigator for the Health Resources and Services Administration Bureau of Health Workforce Substance Use Disorder Evaluation. Her expertise includes rural health research, public health systems research, health services research, and evaluation projects. She grew up on her family farm in North Dakota.

Radha Velamuri:

Dr. Knudson is co-author with Dr. Mueller and Ms. Rochford for work done by the RUPRI Health Panel, and today we are excited to talk to these three experts about their research on behavioral health needs and challenges in rural America. Welcome to the podcast. Before we get started, could the three of you take turns introducing yourself and describe how you got involved in the research you do today.

Keith Mueller:

I’ll get us started. Again, I’m Keith Mueller as Radha said, the Head of the Department of Health Management Policy and the director of the Rural Policy Research Institute or RUPRI. I got my start in this field, I like to say decades ago without getting too specific, about how long that is, as I moved out of my original area of work in political science, which was urban politics because I had worked for a big city mayor and into health policy. And as I made that move, coincidentally, I secured a fellowship that was sponsored by the Robert Wood Johnson Foundation in healthcare finance.

Keith Mueller:

And while I was completing that fellowship, the field of rural health services research really got started and spawned by a special national convening the first one that had been done for that particular area of work, and I was invited to that and decided that, okay, if that’s what I’m known as around the country, then that will be my area of work. And for the last 30 years that’s been my area of work. And as I got into it, RUPRI got started in 1992 and I started with the health portfolio at RUPRI and it’s been a long successful ride since then.

Hannah Rochford:

Dr. Mueller, I think, can take credit for why I have involvement in this work. So, Radha as you noted, my research actually centers on violence within families and partnerships. So it feels like maybe intuitively a bit of a leap to behavioral health or rural research. So I stumbled into public health accidentally doing research in another field. And I keyed into the unfortunate outcomes that occur when opportunities for prevention are missed and saw a real opportunity to elevate the preventive systems around certain violence outcomes. Recognizing that there’s a lot of effort, a lot of, again, really wonderful work that happens very locally, right? Within individual communities and systems, but that our policy landscape hadn’t really been examined with respect to its impact on these behaviors and these outcomes.

Hannah Rochford:

So that’s how I found myself in the health policy space, and then Dr. Mueller as again, a health policy leader not only within our department, but in the field more broadly, the opportunity presented to work closely with him and the RUPRI panel on a subset of health policy but I was less than familiar with. So I’ve been grateful to have the opportunity to come to understand more dimensions of rural health and behavioral health and have inadvertently found overlap with the outcomes I was originally interested in.

Alana Knudson:

Hello, I’m Alana Knudson. And as you mentioned, I grew up on a farm in North Dakota. In fact, the county where I grew up in this frontier, we had 2.8 people per square mile. There were more cattle than people in my home county, and I knew firsthand about access to healthcare. And so when I went to do my dissertation, I was very interested in access to health insurance. At the time when I was working on my graduate work at Oregon State University in Oregon Health Sciences, it was during the time when Oregon was really exploring a demonstration, looking at what Medicaid would cover directly and what people wanted for coverage. And it really resonated with me because the access to care is paramount when you are living in rural communities, particularly when you have an injury, a catastrophic injury or a major health event and you need access to care.

Alana Knudson:

And so that has really guided my work of these last years. And I’m really committed to working myself out of the job. My primary goal is that rural residents are as healthy and live as long or longer than their urban counterparts. And we are not there yet. So we are collectively still working on looking at how we can improve the health and wellbeing of our residents. So thank you for having us today.

Radha Velamuri:

Of course, we’re glad to have you. You all come from really different backgrounds and you bring such unique perspectives to this area of public health. Today’s topic of discussion really revolves around behavioral health disorders and the challenges facing rural America. Before we dive in, could one of you explain what exactly behavioral health disorders encompasses?

Hannah Rochford:

I’m glad to help with that one. So behavioral health, as a definition, I think is kind of continuing to evolve in the literature, but within the work that Dr. Mueller and Dr. Knudson and myself have been involved in, the definition has encompassed both mental health challenges, or MHCs, and substance use disorders or SUDs. And both of those categories, right, are encompassing categories and include a lot of different challenges.

Radha Velamuri:

Could you discuss maybe how prevalent these behavioral health disorders are in rural populations or more how prevalent the substance use disorders are? Just so we get a little more idea on the numbers and how important of a topic this is to address with your research.

Hannah Rochford:

Yeah, absolutely. Right. When we think about, again, substance use disorders as maybe having dimensions in and of itself, the prevalent statistics that surface vary considerably, not just in terms of the challenge that we’re speaking to be it again, alcohol use disorders or opioid dependencies or again so on, but those are kind of two key examples that are really relevant within rural communities. We have variance within those two, but also it’s important to acknowledge that rural communities are incredibly diverse, right? One is not to be generalized, to represent the experience of another, and even within individual communities, the experiences of different types of individuals can be different.

Hannah Rochford:

Again, racial ethnic groups, different genders experience these challenges differently. Some having disproportionate burdens relative to others. So when we think about maybe alcohol use disorders, particularly we understand that the alcohol consumption norms in rural communities are different than what is observed in some urban areas. So if we’re thinking about the higher use, maybe not totally an alcohol use disorder, but maybe consumption that is again a little higher than what would be ideal, we see that ringing true for, I believe, 40% or so rural adults.

Radha Velamuri:

That’s not a small number, 40%, wow. I’m a little curious as to you mentioned diverse environments and diverse communities, like no rural environment is like another. A question that I have is then, how do you do research with rural communities if they’re all so different? This is open to anyone. All of you have experience with conducting research in rural communities. How do you get over that barrier of everyone being so different? Especially like around the country even. Do you try to focus on smaller areas? Do you focus on one community and try to extrapolate those findings? Anyone want to shed a little insight on that?

Keith Mueller:

There are a couple of different approaches that we use. One is at a very, very general level, just comparing urban and rural and being careful about how we define each. And there are just a myriad, it’s another area of work that we’ve been involved in. There are a myriad of definitions, but it starts just in your mind, think about cities and non-cities. And in the technical jargon, we use metropolitan and non-metropolitan. That still leaves way too much in that metropolitan bucket to understand. So another way we tease that out is look at the region of the country because there are large regional differences as you move from Southeast to Northwest. And there are ways we can do that with data sets that enable us to compare different census regions or other ways of grouping regions.

Keith Mueller:

Another thing we do is look at the distance from any city or any metropolitan areas. So in a lot of our work at our research center, we use the term non-core, which means you’re not right next to a metropolitan area. You’re not even right next to what are called micro-politan areas of 15,000 to 50,000. That you’re really more remote.

Keith Mueller:

And then the last way that particularly important in this topic to try to break apart rural is looking at the economic characteristics and the economic research service at the US Department of Agriculture as ways of helping us understand what’s the economic basis. Is it a mining-dependent area? Is it an agricultural-dependent area? Is it a manufacturing-dependent area? And those characteristics help us distinguish across rural areas.

Keith Mueller:

It all comes back to what’s the question we’re trying to answer or the issue we are trying to address. So if it’s behavioral health, you might want to do what we just completed doing that you mentioned at the top of this podcast, and look at a particular sector within rural. We chose to look at the agricultural sector and even a more particular focus on farming. So we’re not generalizing to everyone else, and yet some of what we talk about of how you help families in crisis, and in farming we can link that to the economic condition of farming, applies to families in crisis for other reasons. So it might be that with the sort of economic shocks going on now with the unfortunate global problems that we’re having, you can see where that might generate again, families and crisis that are in industries that are affected by that. And it’s a way of looking at it that we’ve used through the two years of the pandemic.

Alana Knudson:

And I would just add one component to that is that we like to do mixed method studies. So the quantitative piece is really important as is the qualitative piece in getting a geographic representation because what you learn in the Northeast is very different than what you might hear in the Southwest. Or what you might hear in Iowa versus Washington. So also thinking about diversity in collecting the qualitative pieces are really helpful to help us better understand what we’re seeing in some of our data analysis.

Alana Knudson:

So it gives it a richer and a more nuanced interpretation for us so we can better understand how these different issues are actually affecting the people in those areas. And sometimes that’s kind of tricky trying to get a representative sample, but one thing that works really well is partnering with people at the state or the community level where you’re wanting to get information because they’re the people who can best connect you to the local folks who really know what is happening or what is happening to a population.

Radha Velamuri:

Of course. Yes. Thank you so much for sharing those methods. It really helps put into perspective how this research is conducted and how you come up with the findings that we are going to talk about today. I was curious, what are the barriers to behavioral healthcare in rural America?

Hannah Rochford:

That’s a great question, Radha. So as Dr. Mueller noted a lot of the challenges that we see in rural areas generalize to other underserved communities, but within rural particularly, a few different types of access challenges exist. The first being geographic. If I’m in a rural area, perhaps the population density makes it more difficult for healthcare systems, especially when volume-based payment models are employed, for those systems to sustain. That is true of different types of healthcare including primary healthcare, which we think of as kind of a foundation, but then those challenges can be exacerbated within certain types of more specialized care like behavioral healthcare. Or mental healthcare access.

Hannah Rochford:

Another challenge that perhaps is a factor within rule settings in particular is confidentiality, right? These are really small communities and you tend to be more well acquainted with the folks that you’re surrounded by maybe more so than what we would see in a larger or more metropolitan area. And given there’s an unfortunate stigma surrounding both mental health challenges and substance use disorders, that can create another big barrier where individuals are concerned that they’ll be identified and associated with those challenges.

Hannah Rochford:

Dr. Mueller noted that our most recent work centered in particular on farming communities. And when we think about the nature of that sector, it’s also difficult in particular for folks in that sector to have access to affordable insurance, right? Given these are self-employed individuals, they don’t have access to employer-sponsored insurance. So then more expensive private health insurance is generally what they have to find a way to access. And in the event that insurance coverage is out of reach, then there’s also a financial barrier to reaching those services.

Alana Knudson:

And I would just add exactly to what Hannah said. The challenge with farmers and health insurance, although sometimes we see… In one study we did, 9 out of 10 farmers were insured. A number of them have very high deductibles and that results in about 20% of farmers that are carrying medical debt from year to year. And so when you already have medical debt, you are very much less likely to access additional care because that will just add to your debt. And in addition, a number of those behavioral health services are not covered by their health insurance. So to Hannah’s point, it really makes it challenging from a financial access point to be able to get those behavioral health services, even if they were available.

Radha Velamuri:

I also want to put this in the perspective of the times we’re in today, specifically the era of COVID. I was wondering how COVID-19 has impacted the prevalence of behavioral health disorders and substance use disorders with these already existing barriers?

Keith Mueller:

That’s a great question, Radha, and with our researcher hats on, I think we’re forced to say we don’t quite know yet what all the implications are going to be because that is… The behavioral health outcomes of living through an outbreak of COVID in your community are not going to manifest immediately. They’re going to show up over time as you move out from that. But if you just think this through a little bit. What Hannah said earlier about the nature of rural communities and people know each other, and I use the term outbreaks.

Keith Mueller:

If you have an outbreak of any condition and in particular, one with all the uncertainty that we’ve had over two years with the COVID pandemic, that takes a psychological toll on people. And if you layer on top of that the economic consequences from the initial year, March 2020 to early 2022 really, before we started getting the vaccines more widely utilized. You have conditions very similar to what we just finished studying with the economic distress on farm families. Now you compound that with the uncertainty of a pandemic that people can’t seem to be able to predict accurately, and that’s undoubtedly taking a toll. And again, it takes us a while in the data world to catch up to that. Logically, it’s just there.

Radha Velamuri:

Do you use any historical context from influenza epidemic from the 1920s or situations like that?

Hannah Rochford:

So I think that’s an interesting question, Radha, right? To look to historical examples for insights as to what we might be able to expect within our a current context. So as Dr. Mueller noted and Dr. Knudson as well, the skill sets that we have in our tool boxes as researchers entail larger quantitative data sets, but also qualitative data, right? Where we engage folks to get their experiences and perspectives. Thinking back to right, the pandemics, epidemics within the past century, the data infrastructure that was present when were experienced is considerably different than what we have access to now. So we’re a little bit limited to make comparisons, at least empirical ones, between what was experienced then and now. However, the again, recent work that was kind of centered on farmers specifically did draw from some insights that we have as to what was experienced after the economic crisis in the 1980s and what that meant for the mental health and the behavioral health outcomes of particularly individuals and families within the farm sector.

Hannah Rochford:

And again, we understand that having extreme economic related duress is challenging for everyone. But within farm context specifically, given the farming trained tends to be passed down generationally. There’s this added stress, right? When we’re facing economic hardship of not only am I losing maybe my job, but also my lifestyle and this really precious gift that the generations before me kind of handed and entrusted to me, and when, right, at least the economic consequences, not only of the pandemic, right, but of the other global challenges that the Dr. Mueller named right, are all on the shoulders of our farmers specifically, but also on our rural communities, it’s foreseeable, right, that the implications for mental health and substance use outcomes would not be ideal.

Alana Knudson:

And there may be some interesting opportunities, particularly in Iowa, to study this because we know that we had a lot of slaughter houses and packing plants had to close, and many farmers during COVID had to slaughter their hogs and their cattle because there was no market for them, and they did not have the feed for them. So there may be some very interesting things to study so that we can better understand in the next economic disruption, what people are experiencing and find different ways to mitigate some of the challenges that they incur.

Radha Velamuri:

Absolutely. Sometimes it’s hard to remember that data has changed so much. Data collection, the type and amount of data we have, even in the past 20, 30 years, how much research has changed. We’ve been talking a lot about the problems, and now I was wondering if we could switch to the solutions. What are some current programmatic strategies that you guys think are viable solutions to address behavioral health needs, perhaps at the state federal level, whatever you guys have been really focusing on?

Keith Mueller:

Well, one immediate strategy is timely because Congress just passed last week, the budget bills for this coming year, the appropriation bill. Not this coming year, the year that we’re in. One immediate thing is making sure that we’re supporting as best we can, the safety net that we already have in place. And by that, I mean, our federally qualified health center, people know them as community health centers all around the country, our rural health clinics and our region of the country those are particularly important points of access. And neither of those because they are safety net by definition of safety, net provider disproportionately takes care of people who can’t otherwise get care. Either financially or in case we’re off clinics, physical access points. So being able to do that requires a lot of public support in funding. So that’s an immediate action to take, is be sure the safety net is adequately supported.

Keith Mueller:

A second action to take is work short term and long term to build the workforce that we have available, the healthcare workers, both clinicians and non-clinicians in our communities. And there’s legislation being developed federally to increase funding for local residents in the clinical training world. So the residency programs and locate those in some of those centers that I just mentioned.

Keith Mueller:

And then the third thing that I would say again, because it’s very timely right now is there are several funding sources trying to increase the access to high speed communications. Broadband is that term that everyone uses. We need to be sure that there’s follow through on the appropriate use of a lot of the funds that are now being made available and that we get coordination across state and local agencies doing that. And that would help with the behavioral health because one of the key ways that we can reach a lot of the people in the kinds of areas that all three of us have talked about is use of telehealth.

Keith Mueller:

And with help with professionals at one end and well trained people at the other end so it’s still something of a workforce issue, but it helps you deal with that. And we can’t do that without appropriate investments in the technology, and not only in the initial technology, but in then the cost of keeping that technology in place, the operational telephone bill, if you will, which is much higher for use of broadband in a lot of our remote rural areas. So I’ll stop there with those three ideas of what we could be doing right now. And right now it literally means right now since appropriation bills are now going to be rolled out.

Hannah Rochford:

Right. And thinking back to one of the challenges that we noted earlier in terms of confidentiality, right? The privacy that can be afforded when I’m accessing something within my own home, versus having to be physically present somewhere mitigates that concern a little bit. And then another strategy, and I think was implicit within Dr. Mueller’s statements, is making use of a model that I believe the WHO offered first with the mental health pyramid, right? And we can generalize that to our behavioral health resources where, right, hopefully we have resources on hand to connect as many folks with baseline services, preventive services, similarly making use of our primary care workforce, to be sure that the kind of basic mental behavioral health needs of folks are being met. And also leverage to that workforce as kind of a referral point.

Hannah Rochford:

So if again, behavioral health needs are a little bit higher for an individual, that they are then connected to more specialized, more supportive services, and that pyramid shape is helpful, right? Because most folks will have some small level of need access on the bottom of the pyramid, but the folks that do have right, those more extreme needs, particularly within times of crisis also, right, get connected to those more intensive resources. And as we were developing this paper, I think it was actually Dr. Knudson who also raised the importance of helping our communities have kind of a surge capacity, right? Understanding that as we go through different chapters, different kind of ebbs and flows in terms of economic security, for example, that the needs of our communities are also going to change. So having the tools that we need to kind of boost our ability to extend support, but also conserve resources and times where that need isn’t as intense.

Radha Velamuri:

Absolutely. For our listeners looking to get involved in public health research or health policy research, how do you think they could get involved with this? Where should they start? Do you have any resources is that they might want to look into, or how can they stay up to date on this topic?

Alana Knudson:

Well, I’ll plug for a commercial break. Our Rural Health Research Gateway, you can find all of the Federal Office of Rural Health Policy funded research on that one stop shop, if you will, for Rural Health Research. There’s also the Rural Health Information Hub that has a lot of really great resources, particularly if you’re looking for those community or state programs that may be of interest to implement or to make change. And I would also suggest, consider getting involved in your State Rural Health Association and also the National Rural Health Association. Dr. Mueller was the former president of the National Rural Health Association, and can share a bit more about that wonderful organization.

Keith Mueller:

Yeah. I would certainly concur with everything Dr. Knudson said. Those are all great places to look to. There are student associations that parallel those, particularly in public health. As you all know, there are student associations that you can get engaged in. And then looking to link up with the particular faculty wherever you are in saying that I have an interest in this. Do you have opportunities in your research center or in your research program for student engagement? And I do think being involved locally through organizations like the rural health associations, as Dr. Knudson said, I’ve been president of the national, I’ve also been president of the Iowa Rural Health Association, and there are lots of opportunities for engagement at that level.

Hannah Rochford:

Sure. And I’ll, I guess, follow briefly, right? When we think about involvement in health policy research, there’s kind of two dimensions of that in my opinion, I should say, right? There’s content knowledge, right? Having kind of the baseline amount of understanding that allows you to ask the appropriate research questions and interpret your findings appropriately. And then, right, as Dr. Knudson raised in terms of methods and Dr. Mueller raised in terms of data, there’s understanding… The data that is available to you, to answer those research questions and being able to select the method. That is most appropriate for, for the question that you’re asking. And so when we’re thinking about involvement in health policy research, what comes to mind for me, right, as a bias is doing the research itself, but even if you’re not feeling a passion for conducting research necessarily still being connected with the health policy research that is being done I think having some baseline content knowledge, right, helps consume that research effectively.

Hannah Rochford:

And I know, like for example, within the department that Dr. Mueller and I are a part of a considerable amount of students are training to complete masters in health administration degrees. And while that’s not a research degree, this is the subset of professionals that will kind of be the boots on the ground, right, in terms of implementing certain key health policy use, and also recognizing maybe what are gaps that health policy can or should be looking to fill. So that would be, an initial answer to that. Having content research helps us again, involve ourselves in health policy research by consuming it, but in the event we’re really hoping to get our hands dirty in some of the research than having a better understanding of the data available, and the methods, skill sets needed to answer those research questions becomes important.

Hannah Rochford:

The, again, professionals that we have on our campus in my experience have all been extremely supportive, right? And helping students connect to either the content knowledge and or the skill sets necessary to answer the questions that they’re interested in. And again, the organizations that have been elevated in terms of student specific organizations, one of the ones that comes to mind is academy health. And that is a right when we’re thinking of health policy, I think as it’s traditionally defined is kind of healthcare-specific policies, but is increasingly becoming a little bit more expansive. So that’s another again, great way to start becoming involved with, with that type of content.

Radha Velamuri:

I think that’s a wonderful place to wrap things up. Thank you all so much for taking the time out of your day to talk to us about your invaluable research in rural health. And I want to wish you the best of luck with your paper and best of luck with Ms. Rochford in finishing your PhD. Do any of you have any closing remarks you’d like to say, or any main key point that you really want our audience to know?

Hannah Rochford:

Rural is cool.

Radha Velamuri:

Absolutely. No, you’re right. If anyone has any more questions about Rural Health Research, Dr. Knudson, Dr. Mueller, and Ms. Rochford have provided some links that will be in the description of this podcast. Otherwise, we hope you have a wonderful day and thank you for tuning in to From The Front Row.

Alexis Clark:

Big thanks to Dr. Mueller, Dr. Knudson, and Hannah Rochford for coming on with us today. This episode was hosted and written by Radha Velamuri and edited and produced by Alexis Clark. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcasts and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues. Our team can be reached at cph-gradambassador@uiowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Stay happy, stay healthy, and keep learning.