WWAMI Rural Health Research Center

Research Products & Journal Articles

Browse the full list of research publications from this Rural Health Research Center.

Products – Freely accessible products include policy briefs, fact sheets, full reports, chartbooks, and interactive data websites.

Journal Articles – Articles in peer-reviewed journals may require a subscription or affiliation with a subscribing library. For these publications, Gateway lists the article citation, a brief summary, a link to additional information and access to the full-text of the article, if available.


  • Understanding and Overcoming Barriers to Rural Training in Family Medicine Obstetrics Fellowships
    Policy Brief
    Date: 06/2023
    This policy brief describes the results of a survey on the characteristics and challenges faced by rurally oriented family medicine obstetrics fellowship programs. All survey respondents reported their programs had a mission to train family physicians for rural practice, yet less than one-third of programs reported they required rural training.
  • Understanding and Overcoming Barriers to Rural Obstetric Training for Family Physicians
    Journal Article
    Date: 03/2023
    Family physicians are the most common health professional providing rural obstetric (OB) care, but the number of family physicians practicing OB is declining. This mixed-methods study aimed to inform policy and practice solutions to address the training landscape and inform sustainable initiatives for rural family medicine obstetrical training.


















  • Registered Nurse Vacancies in Federally Funded Health Centers
    Date: 12/2006
    This project summary discusses the registered nurse vacancy rate in federally funded health centers, which varies by degree of rurality.
  • Results of the 2004 Health Center Expansion and Recruitment Survey for Health Centers: Analyses for Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI States)
    Date: 11/2006
    This report presents a subset of the findings from the larger national study of Federally Qualified Health Center (FQHC) staffing needs of FQHCs located in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) overall and by urban and rural geography.
  • Wyoming Physicians Are Significant Providers of Safety Net Care
    Journal Article
    Date: 11/2006
    Describes the contributions of family and general practice physicians from Wyoming to the health care safety net.
  • Problem Drinking: Rural and Urban Trends in America, 1995/1997 to 2003
    Journal Article
    Date: 03/2006
    Assesses the prevalence of, and recent trends in, alcohol use among adults 18 years and older in rural areas of the United States. The paper finds that heavy drinking was highest and increasing in urban areas, but that binge drinking was greater in rural areas. It recommends tailoring interventions specifically to meet the needs of rural residents.
  • Rural Dental Practice: A Tale of Four States (Full Report)
    Date: 03/2006
    This paper reports the findings of a study investigating rural dentist issues, such as demography, training, practice characteristics, staff, and job satisfaction, in Alabama, California, Maine, and Missouri.
  • Rural Dental Practice: A Tale of Four States (Project Summary)
    Date: 03/2006
    This project summary provides an overview of survey results of rural dentists in Alabama, California, Maine, and Missouri. It provides charts and statistics on dentist demographics, dental hygienist and dental assistant vacancy rates, and dentist participation in Medicaid.
  • The Changing Geography of Americans Graduating From Foreign Medical Schools
    Journal Article
    Date: 02/2006
    Reports the results of a study of U.S.-born international medical graduates, analyzing changes in their numbers and countries of training from the 1960s and before until the early 2000s.
  • Modeling the Mental Health Workforce in Washington State: Using State Licensing Data to Examine Provider Supply in Rural and Urban Areas
    Journal Article
    Date: 2006
    Identifies mental health shortage areas using existing licensing and survey data. Shortages of mental health providers exist throughout the state, especially in rural areas. Urban areas had 3x the psychiatrist full-time equivalents (FTEs) per 100,000 and more than 1.5x the nonpsychiatrist mental health provider FTEs per 100,000 as rural areas.
  • Prevalence and Trends in Smoking: A National Rural Study
    Journal Article
    Date: 2006
    Using data from the Behavioral Risk Factor Surveillance System, the prevalence of smoking between 1994-1996 and 2000-2001 did not change substantially for the United States as a whole. The prevalence of smoking for rural residents decreased by more than 2 percent in six states. However, it increased by 2 percent or more in ten states.
  • Professional Liability Issues and Practice Patterns of Obstetrical Providers in Washington State
    Journal Article
    Date: 2006
    Objective: To describe recent changes in obstetric practice patterns and liability insurance premium costs and their consequences to Washington State obstetric providers (obstetrician-gynecologists, family physicians, certified nurse midwives, licensed midwives).
    Methods: All obstetrician-gynecologists, rural family physicians, certified nurse midwives, licensed midwives, and a simple random sample of urban family physicians were surveyed about demographic and practice characteristics, liability insurance characteristics, practice changes and limitations due to liability insurance issues, obstetric practices, and obstetric practice environment changes.
    Results: Fewer family physicians provide obstetric services than obstetrician-gynecologists, certified nurse midwives, and licensed midwives. Mean liability insurance premiums for obstetric providers increased by 61% for obstetrician-gynecologists, 75% for family physicians, 84% for certified nurse midwives, and 34% for licensed midwives from 2002 to 2004. Providers' most common monetary responses to liability insurance issues were to reduce compensation and to raise cash through loans and liquidating assets. In the 2 years of markedly increased premiums, obstetrician-gynecologists reported increasing their cesarean rates, their obstetric consultation rates, and the number of deliveries. They reported decreasing high-risk obstetric procedures during that same period.
    Conclusion: Liability insurance premiums rose dramatically from 2002 to 2004 for Washington's obstetric providers, leading many to make difficult financial decisions. Many obstetric providers reported a variety of practice changes during that interval. Although this study's results do not document an impending exodus of providers from obstetric practice, rural areas are most vulnerable because family physicians provide the majority of rural obstetric care and are less likely to practice obstetrics.
  • Shortages of Medical Personnel At Community Health Centers: Implications for Planned Expansion
    Journal Article
    Date: 2006
    Examines the status of workforce shortages that may limit Community Health Center (CHC) expansion by surveying all 846 federally-funded US CHCs that directly provide clinical services and are within the 50 states and the District of Columbia.
  • Will Rural Family Medicine Residency Training Survive?
    Journal Article
    Date: 2006
    This report shares the results of a study examining the recent performance of rural residencies in the National Resident Matching Program as an indicator of their viability.


  • Dentist Vacancies in Federally Funded Health Centers
    Date: 12/2005
    This project summary presents results for dentists from a study of staffing needs at Federally Qualified Health Centers (FQHCs). It provides information on dentist vacancy rates by rural and urban location and compares dentist vacancies to other healthcare provider vacancies at FQHCs.
  • Family Physician Vacancies in Federally Funded Health Centers
    Date: 11/2005
    This project summary presents results for family physicians from a study of staffing needs at Federally Qualified Health Centers (FQHCs). The summary provides information on family physician vacancy rates by rural and urban location and compares family physician vacancies to other physician vacancies at FQHCs.
  • Washington State Hospitals: Results of the 2005 Workforce Survey
    Date: 10/2005
    A survey of nonfederal acute care hospitals found growth in Washington's hospital sector is keeping demand for healthcare occupations high, even when vacancy rates for some jobs appear to be lower than in the past. This growth, and the shift away from contracting employees, should be considered in future workforce supply and demand projections.
  • The Impact of U.S. Medical Students' Debt on Their Choice of Primary Care Careers: An Analysis of Data From the 2002 Medical School Graduation Questionnaire
    Journal Article
    Date: 09/2005
    Examined results from questions on the Association of American Medical Colleges' 2002 Medical School Graduation Questionnaire that focused on students' debt and career choices to examine the hypothesis that medical students' rising debt is one of the factors that explains the recent decline in students' interest in family medicine and primary care.
  • Pathways to Rural Practice: A Chartbook of Family Medicine Residency Training Locations and Characteristics
    Date: 08/2005
    This chartbook discusses the characteristics and geography of family medicine residency programs' rural locations, types of rural family medicine training by location, and rural mission of family medicine residencies.
  • Rural Definitions for Health Policy and Research
    Journal Article
    Date: 07/2005
    Defining "rural" for health policy and research purposes requires researchers and policy analysts to specify which aspects of rurality are most relevant to the topic at hand and then select an appropriate definition. Rural and urban taxonomies often do not discuss important demographic, cultural, and economic differences across rural places-differences that have major implications for policy and research. Factors such as geographic scale and region also must be considered. Several useful rural taxonomies are discussed and compared in this article. Careful attention to the definition of "rural" is required for effectively targeting policy and research aimed at improving the health of rural Americans.
  • WWAMI Physician Workforce 2005
    Date: 05/2005
    This report responds to a request by the University of Washington School of Medicine Primary Care Steering Committee to examine the current supply and distribution of physicians in the WWAMI region.
  • Geographic Access to Health Care for Rural Medicare Beneficiaries
    Date: 04/2005
    This study looked at where Medicare beneficiaries from five states obtain their care, how far they travel for that care, and the mix of physician specialties from whom they obtain their ambulatory care.
  • Explaining Black-White Differences in Receipt of Recommended Colon Cancer Treatment
    Journal Article
    Date: 2005

    Black-white disparities exist in receipt of recommended medical care, including colorectal cancer treatment. This retrospective cohort study examines the degree to which health systems (e.g., physician, hospital) factors explain black-white disparities in colon cancer care. Black and white Medicare-insured colon cancer patients have an equal opportunity to learn about adjuvant chemotherapy from a medical oncologist but do not receive chemotherapy equally. Little disparity was explained by health systems; more was explained by illness severity, social support, and environment. Further qualitative research is needed to understand the factors that influence the lower receipt of chemotherapy by black patients.

  • The Flight of Physicians From West Africa: Views of African Physicians and Implications for Policy
    Journal Article
    Date: 2005
    West African-trained physicians have been migrating from the sub-continent to rich countries, primarily the US and the UK, since medical education began in Nigeria and Ghana in the 1960s. In 2003, we visited six medical schools in West Africa to investigate the magnitude, causes, and consequences of the migration.
  • A National Study of Obesity Prevalence and Trends by Type of Rural County
    Journal Article
    Date: 2005
    Analyzes data from the Behavioral Risk Factor Surveillance System for 1994-1996 and 2000-2001 to estimate the recent trends in obesity among U.S. adults residing in rural locations. In 2000-2001 the prevalence of obesity was 23.0% for rural adults and 20.5% for urban, representing increases of 4.8% and 5.5%, respectively, since 1994-1996.
  • Trends in Professional Advice to Lose Weight Among Obese Adults, 1994-2000
    Journal Article
    Date: 2005

    The authors studied whether rising obesity prevalence in the U.S. was accompanied by an increasing trend in professional advice to lose weight among obese adults, and found that disparities in professional advice to lose weight associated with income and educational attainment increased from 1994 to 2000. They concluded that there is a need for mechanisms that allow healthcare professionals to devote sufficient attention to weight control and to link with evidence-based weight loss interventions, especially those that target groups most at risk for obesity.


  • Characterizing the General Surgery Workforce in Rural America
    Date: 05/2004
    General surgeons form a crucial component of the medical workforce in rural areas of the United States. Analysis of the data suggests that the general surgical workforce has not kept pace with the rising population, and that the number of general surgeons in most rural areas of the United States will decline further.
  • An Analysis of Medicare's Incentive Payment Program for Physicians in Health Professional Shortage Areas
    Journal Article
    Date: 03/2004
    The Medicare Incentive Payment program provides a 10 percent bonus payment to physicians who treat patients in Health Professional Shortage Areas (HPSAs). Results show that physicians eligible for the bonus payments often did not claim them, and physicians who likely did not work in approved HPSA sites, claimed the bonus payments and received them.
  • American Indians and Alaska Natives: How Do They Find Their Path to Medical School?
    Date: 01/2004
    This paper describes the findings of a study to understand the paths of American Indian and Alaska Native students who successfully entered medical school.
  • Obesity Prevalence in Rural Counties: A National Study
    Date: 01/2004
    Using a telephone survey of adults ages 18 and older residing in states participating in the Behavioral Risk Factor Surveillance System in 1994-96 and 2000-01, researchers found that the prevalence of obesity was 23% for rural adults and 20.5% for urban adults.
  • The Migration of Physicians From Sub-Saharan Africa to the United States of America: Measures of the African Brain Drain
    Journal Article
    Date: 2004
    The objective of this paper is to describe the numbers, characteristics, and trends in the migration to the United States of physicians trained in sub-Saharan Africa.
    Methods: We used the American Medical Association 2002 Masterfile to identify and describe physicians who received their medical training in sub-Saharan Africa and are currently practicing in the USA.
    Results: More than 23% of America's 771 491 physicians received their medical training outside the USA, the majority (64%) in low-income or lower middle-income countries. A total of 5334 physicians from sub-Saharan Africa are in that group, a number that represents more than 6% of the physicians practicing in sub-Saharan Africa now. Nearly 86% of these Africans practicing in the USA originate from only three countries: Nigeria, South Africa and Ghana. Furthermore, 79% were trained at only 10 medical schools.
    Conclusions: Physician migration from poor countries to rich ones contributes to worldwide health workforce imbalances that may be detrimental to the health systems of source countries. The migration of over 5000 doctors from sub-Saharan Africa to the USA has had a significantly negative effect on the doctor-to-population ratio of Africa. The finding that the bulk of migration occurs from only a few countries and medical schools suggests policy interventions in only a few locations could be effective in stemming the brain drain.
  • The Productivity of Washington State's Obstetrician-Gynecologist Workforce: Does Gender Make a Difference?
    Journal Article
    Date: 2004
    Objective: To compare the practice productivity of female and male obstetrician-gynecologists in Washington State.
    Methods: The primary data collection tool was a practice survey that accompanied each licensed practitioner's license renewal in 1998-1999. Washington State birth certificate data were linked with the licensure data to obtain objective information regarding obstetric births.
    Results: Of the 541 obstetrician-gynecologists identified, two thirds were men and one third were women. Women were significantly younger than men (mean age 43.3 years versus 51.7 years). Ten practice variables were evaluated: total weeks worked per year, total professional hours per week, direct patient care hours per week, nondirect patient care hours per week, outpatient visits per week, inpatient visits per week, percent practicing obstetrics, number of obstetrical deliveries per year, percentage working less than 32 hours per week, and percentage working 60 or more hours per week. Of these, only 2 variables showed significant differences: inpatient visits per week (women 10.1 per week, men 12.8 per week, P <= .01) and working 60 or more hours per week (women 22.1% versus men 31.5%, P <= .05). After controlling for age, analysis of covariance and multiple logistic regression confirmed these findings and in addition showed that women worked 4.1 fewer hours per week than men (P < .01). When examining the ratio of female-to-male practice productivity in 10-year age increments from the 30-39 through the 50-59 age groups, a pattern emerged suggesting lower productivity in many variables in the women in the 40-49 age group.
    Conclusion: Only small differences in practice productivity between men and women were demonstrated in a survey of nearly all obstetrician-gynecologists in Washington State. Changing demographics and behaviors of the obstetrician-gynecologist workforce will require ongoing longitudinal studies to confirm these findings and determine whether they are generalizable to the rest of the United States.
  • Quality of Care for Acute Myocardial Infarction in Rural and Urban U.S. Hospitals
    Journal Article
    Date: 2004
    Acute myocardial infarction (AMI) is a common and important cause of admission to rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care. This study examines the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers.



  • Accounting for Graduate Medical Education Funding in Family Practice Training
    Journal Article
    Date: 10/2002
    Medicare provides the majority of funding to support graduate medical education (GME). Following the flow of these funds from hospitals to training programs is an important step in accounting for GME funding.
  • Family Medicine Training in Rural Areas
    Journal Article
    Date: 09/2002

    Letter to the Editor: The discipline of family medicine was created in the 1970s, in part, as a way to address the chronic shortage of US rural physicians. It was predicted that the new discipline would augment the supply of rural clinicians because family physicians are much more likely than other physicians to settle in rural areas.

    There is also empirical evidence that training family physicians in rural areas increases the likelihood that residency graduates will choose to settle in rural places. However, the exact proportion of family medicine residency programs located in truly rural parts of the United States remains unknown, as does the extent to which training rural physicians is a priority of existing family medicine residency programs.

  • Perinatal and Infant Health Among Rural and Urban American Indians/Alaska Natives
    Journal Article
    Date: 09/2002
    Provides a national profile of rural and urban American Indian/Alaska Native (AI/AN) maternal and infant health.
  • Rural-Urban Differences in the Public Health Workforce: Findings From Local Health Departments in Three Rural Western States
    Journal Article
    Date: 07/2002

    Most local health departments or districts are small and rural; two thirds of the nation's 2832 local health departments serve populations smaller than 50,000 people. Rural local health departments have small staffs and slender budgets, yet they are expected to provide a wide array of services during a period when the healthcare system of which they are a part is undergoing change.

    This study provided quantitative, population-based data on the supply and composition of the rural public health workforce in 3 extremely rural states: Alaska, Montana, and Wyoming. The study focused on the relative supply of personnel in the principal public health occupational categories, differences across states in staffing levels, and difficulties experienced in recruiting and retaining personnel.

  • Rural Research Focus: Rural Physician Shortages
    Date: 05/2002
    This paper discusses a model for understanding how many physicians a rural community can support, based on research at the WWAMI Rural Health Research Center.
  • Family Medicine Residency Training in Rural Areas: How Much Is Taking Place, and Is It Enough to Prepare a Future Generation of Rural Family Physicians?
    Date: 03/2002
    This paper examines how much rural family practice training is taking place in the United States. The report concludes that to the extent that there is a link between the place of training and future practice, the lack of rural training contributes to the shortage of rural physicians.



  • U.S. Medical Schools and the Rural Family Physician Gender Gap
    Journal Article
    Date: 05/2000
    Women comprise increasing proportions of med school graduates. They tend to choose primary care but are less likely than men to choose rural practice. This study identified the U.S. medical schools most successful at producing rural family physicians and general practitioners of both genders.
  • The Effect of the Doctor-Patient Relationship on Emergency Department Use Among the Elderly
    Journal Article
    Date: 01/2000
    OBJECTIVES: This study sought to determine the rate of emergency department use among the elderly and examined whether that use is reduced if the patient has a principal-care physician.
    METHODS: The Health Care Financing Administration's National Claims History File was used to study emergency department use by Medicare patients older than 65 years in Washington State during 1994. RESULTS: A total of 18.1% of patients had 1 or more emergency department visits during the study year; the rate increased with age and illness severity. Patients with principal-care physicians were much less likely to use the emergency department for every category of disease severity. After case mix, Medicaid eligibility, and rural/urban residence were controlled for, the odds ratio for having any emergency department visit was 0.47 for patients with a generalist principal-care physician and 0.58 for patients with a specialist principal-care physician.
    CONCLUSIONS: The rate of emergency department use among the elderly is substantial, and most visits are for serious medical problems. The presence of a continuous relationship with a physician--regardless of specialty--may reduce emergency department use.
  • The Distribution of Rural Female Generalist Physicians in the United States
    Journal Article
    Date: 2000
    Female physicians are underrepresented in rural areas. What impact might the increasing proportion of women in medicine have on the rural physician shortage? To begin addressing this question, we present data describing the geographic distribution of female physicians in the United States.
  • Educating Generalist Physicians for Rural Practice: How Are We Doing?
    Journal Article
    Date: 2000
    About 20 percent of Americans live in rural areas, 9 percent of physicians practice there. Physicians consistently settle in metropolitan, suburban, and other nonrural areas. This report summarizes the successes/failures of medical education and government initiatives intended to prepare and place more generalist physicians in rural practice.
  • Emergency Department Use by the Rural Elderly
    Journal Article
    Date: 2000
    This study uses Medicare data to compare emergency department (ED) use by rural and urban elderly beneficiaries. Given the similarity of diagnostic conditions associated with ED visits, rural EDs must be capable of dealing with the same range of emergency conditions as urban EDs.


  • The Production of Rural Female Generalists by U.S. Medical Schools
    Date: 05/1999
    This paper compares the production of rural female generalists among medical schools. Data from the AMA Physician Masterfile for the 1988-1996 graduate cohort were used to compare the production of rural female generalists by medical school. Outcome measures included total number and percentage of rural female generalist graduates of each school.
  • Dimensions of Retention: A National Study of the Locational Histories of Physician Assistants
    Journal Article
    Date: 1999
    This study describes the locational histories of a representative national sample of physician assistants and considers the implications of observed locational behavior for recruitment and retention of physician assistants in rural practice.
  • Metropolitan, Urban and Rural Commuting Areas: Toward a Better Depiction of the U.S. Settlement System
    Journal Article
    Date: 1999
    Analyzes 1990 census-defined urbanized areas and tract-to-tract commuter flows. Results include a modest shift of population from metropolitan to nonmetropolitan, as well as a significant reduction in the areal size of metropolitan areas, disaggregation of many areas, and frequent reconfiguration to a more realistic settlement form.
  • Rural and Urban Physicians: Does the Content of Their Medicare Practices Differ?
    Journal Article
    Date: 1999
    Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas.


  • Availability of Anesthesia Personnel in Rural Washington and Montana
    Journal Article
    Date: 03/1998
    Anesthesia has historically been an undersupplied specialty. Health personnel issues used to be dominated by the findings of the 1980 Graduate Medical Education National Advisory Committee study, which suggested that anesthesia would be a balanced specialty for the rest of the century. Recent studies, however, have demonstrated that there is an oversupply of all specialists, including anesthesiology. These studies take a "top down" view of health personnel through analysis of national statistics and exploration of subsets of the data by hospital size and rurality. This approach assumes that the databases of the American Hospital Association and the American Medical Association are accurate and do not take into account the presence of certified registered nurse anesthetists (CRNAs), who are the predominant providers of anesthesia care in the smallest and most remote hospitals in the United States. We compared the 1994 master file of the American Medical Association with our local knowledge of the practitioners in the rural areas of Washington state and found numerous small errors. These errors of one or two practitioners made no difference to the analysis of practitioner groups with more than approximately five people, but in the most rural communities the erroneous presence or absence of a single practitioner made a significant difference.


  • The National Health Service Corps: Rural Physician Service and Retention
    Journal Article
    Date: 07/1997
    The National Health Service Corps (NHSC) scholarship program is the most ambitious program in the US designed to supply physicians to underserved areas, in addition the NHSC promotes long-term retention of physicians in the areas to which they were initially assigned. This study explores some of the issues involved in retention in rural areas.