Barriers to College and Health Care Careers Among US Students From a Rural Community

Many rural communities face a shortage of health care workers.¹ Studies have consistently supported two health care educational interventions: selective admission of rural students, and rural clinical training opportunities, with longer exposure more strongly associated with rural practice.^2-7 Despite this evidence, rural students remain underepresented in health professional programs.^8-10 This is often due to educational and socioeconomic challenges for these rural students, rather than admission bias.^11-14 Rural students are less likely to graduate from high school, less likely to attend college, and much less likely to graduate from college than their peers from urban schools.^13,14 This results in a lower proportion of rural students applying to health professional programs, and consequently fewer rural health care workers than would be expected by population demographics.^8,9,15

Understanding the barriers rural high school students face may inform pipeline programs and help target interventions to bolster the rural health care workforce. A Canadian study showed that rural students are less likely than urban students to contemplate health care careers,¹⁶ with barriers postulated including distance to education, finances, and lack of role models.^17,18 An Australian qualitative study supported distance, cost, and insufficient information as barriers.¹⁹ However, no studies have explored this issue from the perspective of rural US high school students. The aim of this pilot study was to identify interest in and perceived barriers to higher education and health-related careers, as reported by high school students from an isolated rural community in Michigan.

This cross-sectional study explored rural students’ educational and career goals and perceived educational barriers.The survey included five demographic questions, seven questions about educational and career plans, and one question exploring students' perceptions of the impact of rural upbringing. Students also listed educational barriers using free text.

Alpena, Michigan (population 10,122)²⁰ is the largest population center of Alpena County, a rural county in Northern Michigan.²¹ Alpena is assigned a Rural Urban Continuum Code of 7 (Nonmetro-Urban population of 2,500 to 19,999, not adjacent to a metro area),²² a Frontier and Remote Area Level 2 (areas where the majority of the population lives 60 minutes or more from urbanized areas,²³ and is a medically underserved population.²⁴ A survey was administered anonymously via Google Forms to all students attending Alpena High School from February 3-12, 2017, who did not opt out of participation via a parental consent form. Students had an additional opt-out option on the survey itself.

Data was analyzed using IBM SPSS Statistics, version 24. Responses were compared using χ² and logistic regression, with significance set at P<0.05. Two researchers separately coded free-text quotes and grouped them into themes using immersion and crystallization. Codes and themes were cross checked, and any discrepancies were discussed until consensus was reached. Frequency of quotes was compared within each theme through counts of individuals.

The Munson Medical Center Institutional Review Board determined the project was exempt.

Survey response rate was 97.1% (506/521); 274 respondents (54.2%) identified as female, 209 (41.3%) male, and the remaining 23 (4.5%) did not identify as either gender; 459 (90.7%) were Caucasian. The majority planned on attending college (80.2%). See Table 1 for student demographic information and educational/career plans.

Table 2 delineates student interest in a health care career as related to gender, socioeconomic status (as measured by eligibility for free or reduced lunch), and parental education. High school females in our study pool were more likely to plan on attending college and to contemplate a health care career. Students of lower SES and those who would be first-generation college students were less likely to plan on college, although they were equally likely as other students to be considering a health care career. Multivariate logistic regression models were constructed for college plans and health care interest using gender, SES, and parental education as independent variables. Gender and parental education were significant independent predictors of plans for college (female gender odds ratio [OR] 2.0, P<0.01; parental college OR 2.6, P<0.01; full model χ² [3, N=444]=20.9, P<0.01). With regression modeling of the impact of these three variables on health care interest, gender was the only significant independent predictor (female OR 4.9, P<0.01; full model χ² [3,N=434]=65.1, P<0.01).

Education/work plans and perception of rural impact were also compared by student class level. There were no significant differences by class level in any education or work plans or in the perception of rural impact, with one exception. Of the four classes, freshman were most likely to respond “yes” or “maybe” to plans for a master’s or doctorate degree (130/145, 89.6%) and seniors were the least likely (64/72, 71.9%; P=0.01).

Short-answer responses describing barriers were grouped thematically (Table 3). The most frequently reported perceived barriers to college were financial (Figure 1), while the most frequently reported barriers to pursuing health care careers were academic concerns (Figure 2).

This study of educational goals, health care-related career plans, and barriers as perceived by high school students from a rural county in Michigan shows that although many rural students contemplate college and health care careers, these students anticipate significant barriers including financial, academic, and social concerns. Understanding and addressing these perceived barriers early in rural students’ education may help to alleviate concerns²⁵ and increase the likelihood of college attendance and success.

This study supports previous work demonstrating a relationship between parental education and likelihood of considering college, although SES did not remain a significant predictor—a difference from previous work.^14,26 Providing rural high schoolers with mentorship and encouragement—especially for those without family experience with higher education—may be an effective community-based educational strategy to address this initial barrier.

Many rural students’ concerns about college success and health care career training were centered around financial issues, with some eliminating options early because financial concerns were so high. Counseling rural students early in their high school years about need-based educational scholarships and grants, loan repayment opportunities for rural health professionals, and programs such as the National Health Service Corps could potentially address financial concerns.

Students were concerned about their readiness for college studies. Academic concerns could be addressed through guidance counselors and career mentors, who could provide information about academic requirements for various programs. Rural high schools could invite alumni who are successfully attending college, recent college graduates, and those enrolled in health professional programs to speak about their experience to current high school students. Seeing graduates from their own high schools successfully navigating these educational paths may help rural students better visualize their own success.

This study had several limitations, the most important being that only one rural Michigan county was surveyed, limiting generalizability. The survey combined health-related careers when inquiring about interest, limiting information about specific health care paths. The survey also did not provide a definition of “health care career,” which may have affected responses.

Understanding the financial and academic concerns of high school students from high-need rural communities may help inform targeted strategies to address these concerns, and potentially increase medical practitioners in rural communities in the future.