Don’t Judge an RV by its Cover

Idaho State University (ISU) Class of 2023 graduate, Ruth Tretter, PhD, wrote a uniquely personal dissertation on the nomad lifestyle and how it can affect access to health care. Tretter’s research on the subject came from living in an RV herself and recording the experiences of other nomads from Oregon to Oklahoma to Texas to Arizona, learning about and documenting their experiences in accessing health care. The study described the experiences of RV-dwelling nomads and identified barriers as well as facilitators to health care access.

This dissertation ran closer to home for Tretter than most PhD students. She was a traveling nurse for 13 years in the US, Australia, and England. During her travels she would find herself skipping or delaying important health care visits such as check-ups and tests, because it was hard to organize.

Tretter learned she wasn’t alone in this and found other nomads experiencing the same concerns. However, as she began her PhD research, she couldn’t find any academic literature about traveler’s health care that wasn’t specific for snowbirds or tourists. So Tretter took it upon herself to start gathering the data on this unique community, fully immersing herself (and her loyal partner) into a fully“off the grid” experiment for several months.

There are thousands of nomads in America, coming from all economic backgrounds, and choosing this lifestyle for a variety of reasons, but it can also come with challenges, such as access to health care, stigma and even stereotyping from health care providers. 

Tretter's research explored the lifestyle of nomads who live in RVs, a choice that is becoming popular due to its flexibility and cost-effectiveness. However, she found, this lifestyle choice also presents unique challenges, particularly when it comes to accessing health care services.

Beginning in Oregon, Tretter and her partner traveled across the country in an RV, visiting states like Oregon, Idaho, Wyoming, Colorado, New Mexico, Texas, Oklahoma and ending in Arizona. The pair visited a variety of campgrounds to meet nomads with different socioeconomic circumstances. 

Tretter says, “About half the time (three months), we were ‘off the grid’ on public lands. The other half of the time, we camped in RV parks with connections to electricity and water. I met several dozen individuals and interviewed 25 of them, who shared their personal experiences of living a nomad lifestyle, and how that affected their health care interactions.”

Even with so many choosing this way of life, Tretter’s research also showed how common it is to experience a lot of barriers when you're not an established patient.

 “One participant claimed, “I spend more time explaining my lifestyle at the doctor’s office than I do talking about the condition I'm coming in for.”

Tretter spoke with several nomads that explained  that health care providers tended to assume that they were either homeless or on vacation. She says one woman who lived in a converted school bus explained, "I feel like they just don't get it. Like I feel like they go blank like they don't understand. Like it, totally short circuits and just doesn't compute." 

Nomads often had to explain multiple times to health care providers that they were at home while on the road and would not be returning to a "home base." Tretter says that understanding their lifestyle was essential to obtain a plan of care that would work within it.

“Once, I was relaxing by the campfire in a Colorado campground, when a young van-dweller visited to chat,” Tretter says. “Her voice broke with tears as she thanked me for my work. She stated that no one cared about RV dwellers. A nearby city ordinance had outlawed all camping. Her dream was to have a house with a garden. This illustrated that although many people prefer the nomadic lifestyle, for others, nomadism is an economic adaptation when property is unobtainable.”

Tretter also shared, “Some of the people I talked to had called around to multiple physicians offices, and they might have even called all the physicians offices in a given town and were told they weren't eligible to be seen.” 

Some of the common responses were that the offices were not accepting new patients, that they would not accept certain types of insurance, and that the individuals were deprioritized when limited visits were available and encouraged to get treatment "when you get home." 

Additionally, many had insurance that would not pay for visits out of the state of their legal address, or their primary providers did not provide telehealth because they were not licensed to treat people in other states.

"Now, some people did have very good telehealth options,” Tretter explained, “I had one gal who said she uses an app on her phone. Whenever she has an issue, she just goes there. And then, of course, if they needed hands-on care, sometimes you have a symptom that requires a physical exam, then their [online] provider would help them decide what was appropriate."

Overall, the research uncovered that many nomads are not understood by the health care providers they were seeing. They faced unique barriers when trying to access healthcare including seeking care in unfamiliar areas, misunderstandings about their lifestyle, and policies that prevented the portability of healthcare services across state lines.

Having just received her PhD in nursing, Tretter says, “As health care providers, it's important for us to ask patients and learn about what their values, preferences and resources are so that we can accommodate their lifestyle, the lifestyle that feels right for them, even though it might be different from others."

Dr. Mary Nies, Tretter’s dissertation chair, and tenured professor in the College of Health and School of Nursing at ISU, praised the approach to her research. Nies also notes that Tretter’s sample size was very robust and she gathered in-person data in the community, more than some PhD students do for their dissertations. 

“Ruth actually went out into the community and immersed herself with her participants there,” Nies explains. “Not all students go out and immerse themselves in such personal and vulnerable ways.” 

Tretter’s research is a testament to the importance of understanding different lifestyles and their impact on health care access and utilization. By shedding light on the unique needs and challenges of individuals living while traveling in RVs, she hopes to inform policies and practices that can improve health care access and utilization for all nomads in America.

To read the full dissertation, visit the ISU Oboler Library free access site.