Tristan and Victor host a discussion with Dr. Alana Knudson, director and Senior Fellow at the NORC Walsh Center for Rural Health Analysis.

Plugged in to Public Health is produced and edited by the students in the University of Iowa College of Public Health, and views and opinions expressed in this podcast are solely those of the student hosts, guests, and contributors. They do not necessarily reflect the views or opinions of the University of Iowa or the College of Public Health.

Lauren Lavin: 

Welcome to Plugged in to Public Health, where we explore the pressing issues and innovative solutions shaping public health today. I’m Lauren Lavin and I’m the editor of this podcast. Today I’m excited to share that two new co-hosts are going to be hosting this podcast with Dr. Knudson today. Victor and Tristan are going to be leading you through this episode, where they get to speak with Dr. Alana Knudson, director and Senior Fellow at the NORC Walsh Center for Rural Health Analysis. With a deep-rooted passion for rural health, Dr. Knudson has dedicated her career to addressing disparities in health access, policy development, and capacity building in rural communities. From her early experiences in North Dakota to her leadership on the national stage, she brings a wealth of knowledge on how policy, research, and community engagement intersect to create meaningful change. Join us as we discuss the challenges and opportunities in rural health, the role of technology in improving healthcare access, and the power of community-driven solutions. Now let’s get Plugged Into Public Health. 

Tristan Milarch: 

Good afternoon, everyone. My name is Tristan Milarch. I’m joined here by Victor Fontanez. We are here today with Dr. Alana Knudson of the NORC Walsh Center for Rural Health Analysis, where she is a director as well as a Senior Fellow in public health. Thank you for joining us today. I greatly appreciate it. 

Alana Knudson: 

Thank you for inviting me. It’s a pleasure. 

Tristan Milarch: 

Thank you. First question we always like to start off with is what inspired your passion early on for rural health and for your research and capacity development? 

Alana Knudson: 

Well, I was born in a rural hospital, so that’s where it all began. In fact, the hospital that I was born in is in Rugby, North Dakota, and it is now a critical access hospital. It has not delivered babies for over 20 years, so you can do the math. 

I grew up in a rural area and I really felt a very kindred spirit growing up in that area, and also understanding the opportunities there were to be able to improve health and wellbeing for rural residents. It inspired me to continue to want to address different types of issues. I started out looking at health insurance coverage. I’d done a lot of work looking at chronic disease, looking at access to different types of health services and public health. As well as looking at some of the different policy levers that can be pulled to be able to ensure that rural communities have the same opportunities as urban communities to be able to achieve their highest level of health and wellbeing. 

Tristan Milarch: 

Of course. I guess that leads me perfectly into the next question. That really talks about can you share your experience specifically with the North Dakota Department of Health and how that has tied to your work with the ASTHO, and how that shaped your approach to rural health equity in general? 

Alana Knudson: 

Absolutely. Well, when I finished graduate school, I had this amazing opportunity to work for what was called the North Dakota Health Task Force. At that time, it was a task force that was funded by a Robert W. Johnson Foundation State Initiative Grant that provided opportunities for states to look at developing state-based solutions to improving access to health insurance. Trying to make sure that we lowered the uninsured rate in our states. Through that opportunity, I was able then to transition, after we were successful in passing legislation, to work for the North Dakota Department of Health. 

I think sometimes we don’t often appreciate the opportunities to connect with policymakers at the state level. That experience gave me opportunities to present to legislative committees, to present to the executive branch. I had a chance to speak directly with the governor and lieutenant governor on numerous occasions. I represented the state health official at different types of events. I was the only PhD in public health when I was working at the North Dakota Department of Health at that time. It really opened a lot of doors. 

I also had the good fortune of having a close relationship working with the congressional staff and the congressional members, because a lot of the things that we were doing and some of the issues that we were finding were also shared to be able to help address through a national policy. Having that type of synergy between working with the state and working with the national policy leadership was really important. 

But I think one of the most critical things that I learned was the importance of working with the communities. I went out to almost every single local health department in North Dakota and I helped them with their data. I helped them translate what we were seeing in trends to be able to have them look at different types of evidence-based practices that they could then implement to be able to support the improvement of health in those rural communities. For me, it just gave me a whole breadth of looking at the community, at the state, and at the national policy lever. 

Then when I went to ASTHO, I had an opportunity then to work with different types of national leaders. I routinely worked with CDC leadership, including the director of science. I had a chance to work with the HRSA administrator, as well as USDA leadership with regard to some of the programs, such was WIC and SNAP at that time. I also had an opportunity to be able to expand my network in that regard. I think as public health practitioners, the most important thing we can do is be connected. Connected at the community, connected at the state, and connected at the national levels. For me, it has really given me a foundation that I am very grateful for, and also that I want to pay forward so that future rural health leaders can have that opportunity by opening the door to those leaders in other sectors. 

Victor Fontanez: 

Yeah, you sound very passionate about these rural health experiences, and obviously you sound very accomplished as well. You’ve worked in both academic and public health settings. How have these experiences maybe influenced your research and leadership at the NORC Walsh Center? 

Alana Knudson: 

Great question. Well, I think for me, it has helped me to be very grounded because I want to ask research questions that we can answer through our analysis and be able to use that information to help inform policy. For me, the motivation is to be actionable. I really want to make sure that the work that I do, as well as the work that I support for the rest of our team, really has an opportunity to make a difference. That’s what motivates me every day. 

Tristan Milarch: 

That makes perfect sense. Also, too, that moves into talking about being actionable and how us as young public health professionals can be actionable. What are some of the most pressing health challenges facing rural communities today? 

Alana Knudson: 

Well, this may be a surprise to you, but I really see poverty and the challenge of not having livable wages. When I mean livable wages, I mean the full compensation package. Not only what people get in salaries, but also that benefit. Are they getting health insurance benefits? Is there a retirement benefit that goes along with it? Are people able to take sick days and not lose pay so that they can be their best health when they’re working? 

I think for me, that is my most pressing concern because, as we look at issues that are affecting health literacy, it has a lot to do with education and our economic viability in rural communities. It also affects housing, transportation, our tax base. It affects how much we can invest in education. And of course, what we can invest in public health. 

Victor Fontanez: 

Yeah, definitely. It seems like the approaches that we’re looking at are very holistic and not just the treatments maybe that we could give to rural health communities, but more like you said, the financial packages, and housing, and all that’s really important in making sure these communities are healthy. 

Next question. How do state and federal policies impact rural healthcare delivery? And where do you see opportunities for improvement? 

Alana Knudson: 

Well, I think one of the primary drivers is finance. What we often talk about, and I think all of your professors also share with you, is that finance drives function. If that finance piece is not aligned to address the unique settings of rural providers. For example, in the hospital setting, we have some that have very low volumes. But you know what? We count on being able to use those important services at our community. What kind of policy can we have at the state or the federal level that recognizes those low volumes and provides enough financial support to address those standby costs? Because if you’re in a car accident driving through a small town, you are going to hope that you are going to have access to emergency medical services that can take you to a hospital to address your needs immediately. Without having policy that is really focused on ensuring that people have access to those services, that is the most critical piece that I think our state and federal funding really affect when it comes to health. 

Tristan Milarch: 

That makes great sense. Really, that goes into, when you talk about finances equals functionality. In terms of emerging technologies that we see in the public health world, how is that playing into addressing rural health disparities and how we can improve them moving forward? 

Alana Knudson: 

Well, I got the chance to do some really cool formative evaluation work for a project that was looking at remote patient monitoring. One of the things that this particular project was doing was trying to extend the services of a wound care nurse. If you know about a lot of people who are at home getting home health, many of them end up needing to have wounds addressed. Either as a result of post-surgery, or as issues from lack of mobility as well. I got a chance to observe a technology that supports a home health nurse that goes in and uses his or her cellphone to take a picture with this technology. That beams it back to a central place where a specialist in wound care is available. They are then able to provide guidance about how to treat that particular wound. 

What was really neat about it, it was also trying to look at how to be most impactful with the resources that we have. If that person needed that wound care specialist to go to the home, then they knew that that was the right resource to send. Whereas if the nurse that was providing the home health service was in consultation with that wound care, they could be able to extend that workforce. I think looking at how we can leverage technology to be able to support people healing in their homes, as well as being supportive, because we’ve got a lot of people with multiple chronic conditions that really need that support in homes. 

I think technology is going to be able to continue to push those boundaries so that we are able to heal at home, but yet still have world-class care to be able to support that healing. 

Victor Fontanez: 

Definitely. That’s so cool to see how emerging technologies are improving our communities. Can you share success stories from rural communities that may have benefited from evidence-based interventions like the ones you’ve mentioned previously? 

Alana Knudson: 

Absolutely. Well, I have to tell you, one of my favorite ones is about community health workers. I’ve had the pleasure of evaluating a number of community health worker programs. It has been really rewarding to see how those community health worker programs have really been able to make a difference. It affects people in very sparsely populated areas being able to have that connector, as well as a little bit more densely populated rural areas where maybe people need to also have somebody who is able to support that coordination of care. 

I’ve also heard from different family members how much they value the community health worker because it has helped the caregiver step out of some of those roles and become more supportive, rather than directive. If you’ve ever raised any older parents or older grandparents, you may well understand how important it is to also have somebody else be able to support that direction for care. 

Tristan Milarch: 

Of course. That makes sense. Speaking of support, in the many programs and projects you’ve supported throughout your career, what is one that you feel particularly proud of, or that you love telling people about and that you yourself really pat yourself on the back for? 

Alana Knudson: 

I have to say, one of the things that I am most proud of is the development of toolkits that our team has produced. These toolkits are available on the Rural Health Information Hub. I have to give kudos to our team. My incredible colleague Alicia Bane was the original architect of the modular format. It was the Federal Office of Rural Health Policies’ intention to be able to try to scale more promising practices because what we know about rural communities is we’re very resourceful people. We are innovative, and creative, and we find solutions to address the issues that are before us. But what we’re not good it, and in part because we don’t usually have the funding to do so, we’re not good at disseminating those. 

I feel exceptionally proud that we have been able to showcase some of the greatest innovations that are in rural communities that other rural communities can then learn from, and be able to implement and share with their community members. For me, when you’re thinking of over 15 million pages views, to me that is a sign of success. But even more importantly, it’s fun to go to a meeting and somebody comes up to me and say, “You know, I learned something really cool. Your preparedness toolkit had a really great idea about connecting with libraries, and we had never done that before until we saw that on your toolkit.” That just really brings a lot of job, and just personal reward, to know that we can make a difference in rural communities. 

Victor Fontanez: 

Yeah, definitely. What advice do you have for researchers and public health professionals looking to make a meaningful impact in rural communities? 

Alana Knudson: 

My biggest advice is to listen. I really believe that we need to listen to communities to find out what are their concerns, what are their issues. I don’t have the answers. 

I often tell a story of a colleague of mine who had MPH students. They went to a rural community and that rural community actually had a very high prevalence of diabetes, type II diabetes. The students thought when they went to the community that they were going to do something with diabetes prevention. The very wise faculty person said, “You know what, I just want you to go to a community meeting and listen. Ask them what are their concerns.” Guess what? Their concerns had nothing to do with diabetes. Their concerns were about having adequate lighting because they did not feel safe to walk at night. 

The students came back and said, “Wow, this is not what we had on our radar.” The response was, “Well, how are you going to support them? How are you going to listen to them to make sure that you are able to address their needs? Because there is no way you are going to be able to move forward in even talking about their diabetes or their health condition until you meet that basic need of safety.” They were able to come together and support that community in getting some grants in getting some lighting. Guess what? When they came back to the table again, they started talking about health needs because they were now safe and they also felt heard. To me, that is the most important thing we can do as researchers is to meet people where they are and listen. 

Tristan Milarch: 

That’s a great point. I guess this delves into a question I wanted to ask you as well. Related to how can rural communities, and especially those who maybe have limited accessibility to healthcare, how can they best advocate for themselves and their community? In terms of we’re a rural population whose very self-dependent, independent, and is very prideful of that. But at the same time, really wants to get the most out of the healthcare accessibility they do have nearest them. What’s your best advice? 

Alana Knudson: 

The power of rural is coming together. I really believe it’s important for our rural communities to come together as a collective voice. I grew up in rural North Dakota. Sometimes the biggest separation between communities was our football team. To give you an idea of how small my community was, we had nine-man football. We didn’t even have the regular 11-man football. We had small football teams from small communities, but we were fiercely competitive. 

I think we’ve got to step back and say, “You know what, we may be competitive on the football field or on the basketball court, but guess what? When it comes to ensuring that we have access to essential services, we really need to band together.” We need to come together as a collective to remind people. This is what I tell everybody, and you’re going to hear this tomorrow as well. I remind people rural America is the source of your food, most of your drinking water. Your energy, your recreation. We have a disproportionate number of people in the military serving from rural America. It is absolutely vital to our country that we have a strong and vibrant rural America because the only way our country can be strong and vibrant is to have that foundation from the rural communities. 

Tristan Milarch: 

Yeah. I had one more personal anecdotal question as well. I grew up in Northern Michigan, rural Northern Michigan. One thing I really attached to when I came out here to Iowa, you see all these ANF or America Needs Farmers T-shirts, logos, and everything else. What does ANF mean to you? 

Alana Knudson: 

Well, I grew up on a wheat farm. We also grew sunflowers. You know what? We wouldn’t be here if we didn’t have farmers. I also remind people that our farming and our agriculture, it’s foundational to our national security. It isn’t just about feeding the people in our country, it’s about having an important leverage to ensure that we are continuing to be the breadbasket for the world. For me, farmers are absolutely vital to ensure that our rural communities continue. 

Farming looks different in different parts of the country. I grew up similar probably to you, where we have a lot more grain. In my home county, there were more cows than people. It just depends where you grow up. In Iowa, we have some counties that probably have more hogs than people, correct? 

Tristan Milarch: 

That’s correct. 

Victor Fontanez: 

All right. Here’s a fun question to end us off. What are you reading or watching right now? 

Alana Knudson: 

I’m so glad you asked that because I love to read. For fun, I just finished … I wrote it down to make sure I’d get this correct. 

Victor Fontanez: 

Yeah. 

Alana Knudson: 

Ina Gartner, Be Ready When Luck Happens. I love Barefoot Contessa, and that book is very inspirational, but nothing just happens. There is a lot of hard work that goes into everything we do. I think it’s a great reminder for those of us in public health that you don’t just flip a switch and everything magically changes. It takes a lot of hard work, a lot of dedication, and a lot of perseverance. I love that book. 

The other book that I’m reading is Nicholas Kristof and Sheryl WuDunn called Tightrope. It’s America Reaching for Hope. I really resonated because I did my graduate work in Oregon and he tell a story of him and his family going back to live in rural Oregon. I just it just also provides a context because I think there’s a lot of consternation right now about what is ahead for all of us. I think the most important thing we can do is to keep calm and carry on, and inspire. And make sure that we support our communities and that they have hope for the future. That is where I would leave you. 

Victor Fontanez: 

Awesome. I’ll be sure to grab a copy of those. 

Alana Knudson: 

Excellent. I can even send you mine. 

Victor Fontanez: 

Awesome. Yeah. 

Tristan Milarch: 

Well, thank you so much, Dr. Knudson, for your time today and everything. Victor and I cannot thank you enough for taking the time to be here in the studio with us. And taking the time to not only inform the students here at the University of Iowa, but also rural populations across the entire nation. Once again, thank you for your time today. 

Alana Knudson: 

Thank you. It’s been a pleasure. 

Lauren Lavin: 

That brings us to the end of today’s conversation with Dr. Alana Knudson. They covered a lot, from the importance of financial sustainability in rural healthcare to how emerging technologies and community-driven initiatives are shaping the future of public health. 

My one key takeaway after listening is actually the power of listening. As Dr. Knudson reminded us, real change starts with understanding the needs of the communities we serve. Whether you’re a public health professional, a researcher, or someone passionate about rural health equity, we all have our role to play in creating solutions that make a difference. Thank you Dr. Knudson for sharing your insights with us today, and thank you to our listeners for tuning in. 

This episode was hosted and written by Victor Fontanez and Tristan Milarch, and edited and produced by Lauren Lavin. 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, friends, or anyone interested in public health. Have a suggestion for our team? You can reach us at cph-gradambassador@uiowa.edu. This episode is brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.