Targeted Rural Health Education Project

Description

With the collaborative support of the North Dakota Rural Health Association (NDRHA), the University of North Dakota (UND) Center for Rural Health (CRH), and the UND Department of Family and Community Medicine, the Targeted Rural Health Education (TRHE) project introduces medical students and other University of North Dakota School of Medicine and Health Sciences (UNDSMHS) health professions students to plain language, health literacy, and health messaging principles. Rural newspaper editors — as community leaders involved with information dissemination, including health information — are also strategic partners.

The project's original design was geared to physicians training in a family medicine residency in Idaho. When the project's designer became the current chair of the UND Department of Family and Community Medicine in 2017, the project was replicated in North Dakota, beginning as an extracurricular activity for medical students completing rural clinical shadowing experiences.

With time, the participant pool expanded to include any UNDSMHS health professions student completing a rural clinical rotation. In 2019, TRHE became a mandatory project within the third-year medical school curriculum for students selected for the longitudinal experience offered by the school's Rural Opportunities in Medical Education (ROME) program.

Although mandatory for ROME learners, elective participation is offered — but limited to only those health profession learners who've participated in rural clinical experiences. For example, occupational doctoral candidates with rural capstone projects have participated. As ROME expanded from an original five students per semester to an average of 10, the program also experienced word-of-mouth growth with elective participants almost equaling mandatory participant numbers, a total of about 20% of UNDSMHS med school class numbers.

Because rural clinical rotations are experience-intense, no didactic sessions are provided. Instead learning occurs by leveraging a just-in-time, need-to-know, on-demand pedagogy — similar to "microlearning" and the learning style medical students will encounter in their future training — initial article drafts are submitted to the writing advisor who provides feedback based on plain language and health literacy principles along with incorporating newspaper writing style guides. Final drafts undergo a separate faculty review and approval followed by the project coordinator working with the rural newspaper editors for final publication. Once published, the students are notified and encouraged to list the publication in their curriculum vitae. The NDRHA hosts all completed TRHE articles on its website.

On the state level, the project aligns with the UNDSMHS's state-codified mission. At the federal level, the project aligns with the Office of Disease Prevention and Health Promotion's Healthy People 2030 declaring health literacy a "central focus.” Additionally, the project aligns with the Center for Medicare and Medicaid's Framework for Healthy Communities priority 4 and its Rural Health Strategy objective 4.

A goal of the original project designer was that the model be replicated in other states, anchored in a collaboration with those states rural health associations, with an eventual repository of articles and student experiences that would lend itself to qualitative or quantitative research. For example, evaluation of the project's impact not just on health profession learners, but rural newspapers' readers.

Currently, the project has no funding and depends on volunteer time and the in-kind support of the project's collaborators.

Services offered

Staffing model and staff roles:

Project coordinator

Engagement activities:

• Student engagement:
  • TRHE promotion in rural-related student forums
  • Coordinates student TRHE introduction session
  • Article publication process tracking
• Community Engagement
  • Rural newspapers editor engagement
    • Pre- and post-publication
    • Reprint request management
  • Incorporates project promotion during rural workforce professional presentations/forums
  • Communication management
• Internal project team member engagement:
  • Regular engagement with writing advisor and faculty advisors
  • Communicates external publication success

Time commitment: 8 hours/published article
North Dakota example: Role found a natural fit within Center for Rural Health's Workforce Specialist outreach activities.

Writing advisor

Engagement activities:

• Internal:
  • Student engagement:
    • Flexible student-centric process providing draft review and edits leveraging this process to ensure accuracy, clarity, plain language use, incorporation of health literacy and rural public messaging standards to ensure suitability for publication in rural newspapers.
  • Internal project team membership engagement:
    • Regular brief check-ins with Project Coordinator as needed to review/update/plan internal and external engagement activities
  • Faculty Reviewers Engagement
    • Learner performance concerns and communication around TRHE project-related concerns and successes
    • Communication around TRHE project-related concerns and successes
• External engagement:
  • Participates with Project Coordinator in external activities promoting program awareness
  • Identifies opportunities to promote project awareness and replication

Time commitment: 32 hours/student
North Dakota example: This position is currently filled by a CRH staff member who is an experienced primary care physician with a journalism degree, extensive rural health writing experiences, and has undergraduate and graduate medical education teaching experience.

Faculty reviewers

• Participate in topic choice review
• Provide final draft review for content accuracy and suitability for the student's specific rural community's culture

Time commitment: About 1-2 hours per final draft
North Dakota example: Currently integrated into the ROME program faculty co-directors workflow.

Newspaper editors

• Review and approve final publication in hard copy and/or online editions of rural community newspapers

Publication process:

Although original program design prioritized community's health needs assessment (CHNA) review as the source for TRHE topics, chosen topics often result from learner's site experiences where repeated encounters have suggested a need for standardized education around the selected topic. If appropriate, topics of great interest to students are approved.

After topic selection, first drafts are written in any style the student finds most comfortable. For example, clinical peer-to-peer language or a language they might use to educate friends and family. Next, the writing mentor — by email or, occasionally, by virtual meeting — provides detailed feedback for subsequent draft revision. This revision process repeats until final draft stage when the Project Coordinator forwards it for faculty review. With faculty approval, the Coordinator then networks with the community newspaper leadership for final publication. The majority of publications occur near calendar year's end.

Results

Participation Growth:

Currently offered to all health profession students, word-of-mouth communication from previous medical student participants has led other health profession faculty to encourage their students to take advantage of participating in the program in order to disseminate their original research and health information unique to their specialty. For example, UNDSMHS Occupational Therapy doctoral candidates have shared practical information specific to the activities of daily living.

Publication Growth:

By January 2024, about 60 stories had been published by rural newspapers in 3 states. In the subsequent two years, total stories now number 100 and more rural newspapers have joined the publication ranks:

• North Dakota:
  • Beulah, Bowman, Devils Lake, Dickinson, Grafton, Hazen, Hettinger, Jamestown, Mayville, Northwood, Oakes, Park River, Valley City, Wahpeton, Williston, Wishek
• Minnesota:
  • Benson, Ortonville, Pelican Rapids, Perham, Thief River Falls, Waconia
• Montana:
  • Sidney

Additionally, the project is experiencing an increasing number of reprint requests from other rural North Dakota newspapers and from several North Dakota health advocacy organizations, professional societies, and health agencies for their magazine and newsletter inclusion.

Previous students have leveraged their TRHE research and published on UND's Scholarly Commons platform.

Student feedback

Because the TRHE project is mandatory for ROME students, TRHE staff recognized the need for formal project feedback. Results from September 2019 through December 2020 were:

• 10 respondents/15 surveyed
• Effective for understanding community needs:
  • 8/10 = somewhat
  • 2/10 = yes, a lot
• Participation if TRHE were an elective opportunity:
  • 5/10 = would participate
• Overall experience (1=unsatisfactory, 10=excellent):
  • 7/10 = rated 8 to 10
  • 3/10 = rated 5 to 7

Additional survey responses included statements such as: "This was a genuinely fun project and as I'm sure you know advocacy is a big thing for me, I feel I learned some solid skills that I'll use in the future."

Informal feedback from some students completing the mandatory TRHE project indicated that although they do not like to write, the project has made them more aware of the importance of plain language use not just for written but verbal conversations.

Currently offered to all health profession students, it is word-of-mouth from previous participants that has led other health profession faculty to encourage their students to take advantage of participating in the program in order to disseminate their original research.

Rural newspaper leadership and relationship building

With time, repeated coordination has created a smooth publication process.

Several examples of newspaper editor feedback:

Regarding a 2021 TRHE submission, one editor shared: This is a fantastic article and one that suits some of the content we've been hyper-focused on here in southwest North Dakota. We've recently completed a series of stories centered on the lack of mental health services in our area and I think this is a great tie-in to that piece. We'll publish this in our print edition, digital e-edition and online at our website.

A more recent publication discussion included an editor's comment that TRHE articles' references to their local rural county's health data made the information uniquely different from what consumers can already find online.

Informed replication in New York:

As of 2025, the North Dakota project has informed a similar project created with collaboration SUNY Upstate Medical University Norton College of Medicine, the S.I. Newhouse School of Public Communications at Syracuse University, and New York State Association for Rural Health Association (NYSARH). After receiving the New York replication request, the North Dakota TRHE team shared program insights with the faculty leader of Upstate Medical University's Rural Medical Scholars Program (RMSP). Several of North Dakota's TRHE model elements have been modified to meet their student and state needs with articles already published on the NYSARH website.

• Learn more about the New York project:
  The Informed Patient Podcast (transcript available) episode, a production by SUNY Upstate Medical University.

For more on the North Dakota program:

• Hear from TRHE participants and rural newspaper editors in this video:

News Articles:

Kusler, S. Targeted Rural Health Education: A New Writing Project Gives Medical Students a Better Understanding of Rural Community Health Needs. North Dakota Medicine. Fall 2017.

Criswell, W. Bridging gaps in health knowledge through local news. UND Today. July 2023.

Presentations:

Delage, B., Kusler, S., Schmitz, D., Sherman, K., Miller Temple, K. (2019, June 27). Targeted Rural Health Education[Webinar]. Rural PREP.

Kusler, S., Miller Temple, K. "Targeted Rural Health Education Project." May 2023. Joint North Dakota and South Dakota Newspaper Associations Annual Meeting.

Schmitz, D., Miller Temple, K. Promoting Health Literacy through Culturally and Linguistically Appropriate Services (CLAS). June 2023. CMSHHS.gov video.

Schmitz, D., Miller Temple, K. Meeting Rural Communities Where They Are. November 2023. CMSHHS.gov video.

Challenges

North Dakota model challenges:

• With designated time for preliminary didactic teaching sessions unavailable, students express difficulty in prioritizing writing time during their intensive clinical training settings
• Interested and eligible UNDSMHS health profession students exceeds project staff capacity
• Lack of financial support for the project now heavily dependent on volunteer efforts

Replication

To accomplish the TRHE goals of providing students a real-time opportunity to leverage plain language and health literacy principles to create a final health information article understandable and actionable for rural readers, the North Dakota model can be modified in many ways, as exemplified by the New York program.

Any replication interest of the North Dakota model can connect with the program contact.

Contact Information