Health Equity in Rural America, with Alana Knudson, Luciana Rocha, and Paula Swepson

Organizations and resources mentioned in this episode:

• NORC's Walsh Center for Rural Health Analysis
• Rural Health Equity Toolkit, Rural Health Information Hub
• What is Health Equity?, Robert Wood Johnson Foundation
• Health Equity, American Public Health Association
• Social Determinants of Health in Rural Communities Toolkit, Rural Health Information Hub
• Healthy Farms Program, Southeast Arizona Area Health Education Center (SEAHEC)
• Rhode Island's Health Equity Zone (HEZ) Initiative, State of Rhode Island Department of Health
• West Marion Community Forum Inc.

Transcript

Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. Today we're starting a two-part series about health equity, featuring conversations with people who have contributed to RHIhub's new Health Equity Toolkit. We'll start with Alana Knudson, Director of NORC's Walsh Center for Rural Health Analysis, and Luciana Rocha, Senior Research Scientist at the Walsh Center, as they provide us with an overview of this topic.

Luci, can you explain what the difference is between health equity and equality?

Luci Rocha: Yeah, absolutely. So first I think it's helpful to just think about how we define health equity. And in the Rural Health Equity Toolkit, we really emphasize that programs and communities in rural areas are using all kinds of different definitions of health equity. They're often really coming together, they're creating a vision of what health equity means for them. But we do have some commonly used definitions that I think are also really helpful to think about. So, for example, Robert Wood Johnson Foundation, they say that health equity means that everyone has a fair and just opportunity to be as healthy as possible. And that really requires removing obstacles to health, like poverty and discrimination and their consequences like powerlessness, lack of access to good jobs with fair pay and quality education and housing and safe environments. And when we look at that definition, I think we really start to see what could differentiate health equity from health equality.

So health equality means that everyone's given the same resources, the same opportunity is the same availability of healthcare services, but health equity recognizes that people have different starting positions in life, and it really acknowledges that people have different experiences and that can make it really hard to lead a healthy life. So, you know, discrimination, poverty, isolation. So when we think about health equity, we're thinking about the root causes for why people have different health outcomes and how we can provide opportunities that each person needs to thrive under their own circumstances. When we think about health equity in rural communities, we're thinking about multiple different layers that really apply to so many different people. So we know in rural communities that people are experiencing health inequities because of where they live and also because of their race and ethnicity and immigration status and gender and class and disability. And those identities are overlapping in rural communities. And we really have consistently heard that one thing that helps rural programs and organizations is really just finding that vision for health equity that really resonates for them and that they can work together to achieve.

Alana Knudson: I think the, the only other piece I would add is the American Public Health Association's definition sometimes is very simple. And I think when trying to explain some of these concepts, sometimes it's just helpful to state this definition, which is, everyone has the opportunity to attain their highest level of health. And I think that is a very straightforward way for us to be able to communicate with rural communities.

Luci Rocha: Yeah, absolutely. And in the toolkit we have examples of how different organizations and different communities have defined it themselves to which I think other people could really find helpful in terms of thinking of how they want to define it also.

Andrew Nelson: Yeah. Health inequities and health disparities can often get conflated. How are they different?

Luci Rocha: I think this is a great question. We really spend some time describing how important it is to frame health equity in a way that's easy to understand. I think that there's a lot of jargon in this space, and we wouldn't want that to preclude people from kind of getting involved in health equity work. So one way that we kind of came up with to differentiate these concepts is to think about health equity as our goal. So when we achieve health equity, that means that everyone has an opportunity to be healthy. We've removed the obstacles that cause inequity is like poverty and discrimination. And one other concept I want to introduce here is a social determinants of health. And that is how we can achieve health equity. That's how we can achieve our goal. And that talks about the conditions that affect health. So economic stability and education and healthcare access, the neighborhoods that we live in, and health disparities are how we can measure how we're doing. How close are we to achieving our goal? How close are we to achieving health equity? And those really refer to the preventable differences in health status between groups. So when we track health disparities, we can see, are we on the right track? How are we doing? What changes could we make to better achieve our goal of health equity?

Alana Knudson: I was just going to add, one fundamental way to track health disparities that we can look at across every single county in our country is to look at mortality differences. And sometimes that means we need to aggregate maybe three to five years of data, but that is a really important way that we can be able to look at what does it mean as an outcome when we're looking at differences, for example, in mortality. And that helps us then to be able to explain and track, as Lucy mentioned, how we are doing in advancing health equity. Are we seeing those differences dissipate over time? So it's a good way for us to be able to message to our communities as well as to provide a baseline about where we need to go to continue to advance, and hopefully achieve, health equity.

Andrew Nelson: Sure! You mentioned the importance of identifying social determinants of health. What are some steps that providers can take to identify those factors or improve upon them?

Luci Rocha: So we do also have a rural Social Determinants of Health Toolkit that really goes in depth to this. So there are lots of different kinds of tools that providers can use to actually identify for patients, what are social determinants of health that are affecting their health and their potential outcomes. So there's tools that, for example, they could integrate into their electronic health records. There's different kinds of tools that they could use an intake to really understand the circumstances of their patients and think about how to address those to achieve better outcomes. When we think about providers and their role in the community and public health practitioners, there's all kinds of different programs, all kinds of different strategies that rural practitioners, rural providers can engage in to really kind of move the needle on health disparities in rural communities. And the toolkits go really in depth into different areas, whether that's in education, in the healthcare settings with medical legal partnerships or school-based health centers, or in the environment, in the social and community context. There are really all kinds of different opportunities. And a lot of that will just depend on what the needs are in that particular community.

Alana Knudson: One of the underlying issues is really something that rural providers do pretty well, and that is meeting patients where they are. And part of meeting patients where they are is understanding the context in which they live. As Luci noted, there are a number of resources that are available to help providers track and understand what might be contributing to a person's health. And I'll give you one concrete example. We interviewed some folks in Iowa who were community health workers visiting a person living in the back of a machine shed, and that living environment with no running water and lack of toilet facilities contributed to that person's frequent visits to the emergency department. And so meeting that person where they lived gave them opportunity to identify what might be some resources in that community to help him. And he was eventually able to get into an apartment. He was able to engage in programs like Meals on Wheels, and become part of the senior center in that community. And surprisingly his trips to the ED diminished. Every single patient comes with different needs, but being able to have the time to understand the context in which they live helps to identify how providers can best meet those needs and work in partnership with that patient to advance their health.

Luci Rocha: Yeah. And I think that is a huge theme that we see is understanding truly what the priorities are. And like Alana said, meeting people where they are. And I think another great example we have of that in the toolkit is with the Southeast Arizona Area Health Education Center. And they were involved in a farm worker health initiative that was really community led, really community based. And when they worked with community health workers with promotores to do a community needs assessment, one of the things that they talked about is that, you know, a huge priority for the community was really just making the community safer. Like, for example, there were a lot of stray dogs in the area, and that made it hard for people to go outside and to do physical exercise and to kind of enjoy the community. And so once they kind of came together to address that issue, that really kind of created the foundation for additional opportunities to work together and to build capacity and to address additional priorities that came up. So just starting really small is another way that a lot of rural communities kind of embark in this kind of health equity work too.

Alana Knudson: I would say health equity is a cross-sector engagement opportunity. It is not solely with healthcare. It is not solely with public health. It is not solely with social services. It crosses everybody and has impacts for business education, the whole economic vitality of a community, a state, and frankly, our nation, is based on the ability for people to be as healthy as possible so they can live their best lives and have the kind of economic wherewithal to be able to support them. And so when you look at health equity issues, it is a cross-sector issue. It is not solely a health sector issue.

Luci Rocha: Yeah, I think that we can't emphasize that enough, the importance of really looking at how health affects every sector. And in the Social Determinants of Health Toolkit, we talk about health and all policies approaches. And in the Equity Toolkit, multi-sector collaborations are a really key theme in rural communities. And it's important too to think about resources and resource sharing and how to really maximize those to achieve equity.

Andrew Nelson: What are some measures that can be taken at federal or state levels to maximize people's health equity?

Alana Knudson: Well, if you look at the, the base of what contributes to health equity, it's really about economic opportunity and ensuring that everybody has an opportunity to have an economic resource to be able to live a healthy and productive life. And so different types of policies regarding education and that doesn't just pertain to K-12 or just through higher ed. We're also looking at lifelong learning opportunities. We know that people have many different careers, and in order to advance, we need additional education and training. So really looking at making investments so that people are in a place where they can actually get the kind of employment that provides a livable wage, which includes health insurance benefits and retirement benefits. You cannot spend your whole life stressed out, wondering if you are going to be able to put food on your table and keep a roof over your head. That type of stress really has a very negative impact on health outcomes long term. And so to really be able to identify and advance our work in health equity to achieve health equity, we really need to start with our economics. And that begins with education.

Luci Rocha: Yeah. And I, I couldn't agree more. And I also think that we are seeing states innovate in different ways too. And I think one state model that is really cool is in Rhode Island with the health equity zones, which takes a really community-based approach to advancing health equity. And that can be really important for rural communities because just because of that ability to really self-define and self-determine you know, what the initiative is going to focus on, it involves community assessments, it involves needs assessments, collaboration, action plans, really transformative approaches to entire neighborhoods, entire communities. And that is one initiative that has really achieved a lot of success, and that has been replicated in lots of different areas as well. So in Medicaid we see a lot of innovation too, with different opportunities to provide transportation, to increase access in different ways. So really at the federal level, at the state level, at the community level, there's so much important work going on in health equity, and we, we try to highlight some examples of that in the toolkit as well.

Alana Knudson: I would say the other piece that our state and federal partners can do to advance health equity is to support data — not only data collection, but data analysis — so that we are able to track health disparities and be able to identify where we need to target resources. So that data infrastructure is really important for us to be able to know where we are and where we're going.

Luci Rocha: Yeah. Data's huge for rural communities because of the small population sizes. It can be really difficult to obtain data sets that really show where the pattern also of health disparities, of where the highest need communities are, of who is experiencing inequities in terms of a breakdown by race or by ethnicity or by any other kind of demographic characteristic. Data is incredibly important for identifying priorities and just for forming different kinds of strategies. So the better the data, the more comprehensive the data, the more accessible the data, especially with community practitioners, the better the opportunities for advancing health equity.

Andrew Nelson: So with all of these efforts, eventually it comes down to helping people at individual people at a local level. And something that's really important when it comes to being able to provide help to those people is building rapport with communities and getting to the point where people actually trust you. What are some ways that local leaders and providers can kind of build that trust with their communities?

Luci Rocha: Fostering trust is incredibly important. I think part of that is an acknowledgement always of the different contexts that people are operating under, acknowledgement of any kind of historical oppression or historical exclusion that they've faced. You know, why they've been disenfranchised, why they haven't had a seat at the table. Those kinds of acknowledgements can be really important. I think one thing that the communities that we talk to always really emphasize is that there's usually already local leaders, community groups, advocacy groups or different kinds of structures that are already in place that are already working towards achieving some kind of goal. So really including them authentically engaging those people who have been kind of involved in that fight for a long time is really important.

So really understanding who's doing that kind of work in the community and how to engage them is really, really important. And, you know, supporting community-led solutions, promoting change, offering opportunities to be involved in decision making, those all can really help foster trust. And obviously time – that is something that we heard again and again. This is not quick work, it takes a long time to foster trust; it requires maintaining involvement, showing dedication, showing up over the long term. Those are all incredibly important constructs for really kind of creating change.

Alana Knudson: And in some ways, it can be boiled down to listening and acting. So really engaging the community, but listening to what they say and following through with action. And I think the example Luci shared about Arizona is case in point. You build trust by listening to what people's needs are and by acting to address them. And as she said, it takes time and it takes a commitment on community and community members to make that happen.

Luci Rocha: Yeah. Transparency, open, honest dialogue, like Alana said, listening, understanding that when we think for example, of tribes and tribal organizations, tribal communities, when we think about so much research has been performed on those communities — not necessarily for or by those communities — and the kind of distrust that that can cause. There's a lot of history that's important to understand when engaging different kinds of communities. And it's important to really acknowledge that and to understand how that could affect relationships.

Andrew Nelson: Can you talk about the role that broadband access plays in improving prospects for disadvantaged community members?

Alana Knudson: I might start with, community members need broadband access for a number of issues. And as we talked about, economic opportunity is linked to broadband. Advancing education is linked to broadband and health access is linked to broadband. And so if you are truly going to advance health equity in your community, you need to ensure that people have access to broadband, but it isn't just broadband connectivity. They also need access to the different types of technology that are supported through broadband, such as smartphones or tablets or computers. And the other piece that we also see is digital literacy. Making sure that when you need to access a telehealth visit, it often requires downloading software that is compliant with HIPAA to be able to have that private and secure connection. And so it is really important for all of us, as we're thinking about making sure people have access, that it goes beyond broadband. That that is our start, that is our beginning to have that broadband access, but also to make sure that the technology and the technology education and training is available so that people can adequately use that technology.

Luci Rocha: Yeah, and I think with broadband, we really saw a lot of those disparities highlighted during the COVID-19 pandemic, when we think about the ability to access education from home, the ability to access healthcare from home. What we just talked about in terms of like connecting and doing multi-sector partnerships and stuff, a lot of that work, you know, over long distances might have to happen electronically, might have to happen virtually. So what are the opportunities to engage in equitable work without broadband access, how does that make things more difficult? How does that pose additional challenges? And then also in connecting people to the resources that they need, broadband is an incredibly important determinant of health in rural communities.

Andrew Nelson: Yeah. What you said, Alana, kind of reminded me of something I've heard from some of the other folks I've talked to as part of putting together these health equity interviews. And that is that it's important to communicate with members of a community in terms of what they actually need. You're not necessarily going to get very good results if you just kind of come sweeping in with things you've decided they need. For example, broadband access can be a very important part of helping them achieve a better quality of life overall. It's important that folks also know how to use that technology. Availability is only part of what they need. There also needs to be education in some cases at least.

Alana Knudson: Well, and if you've ever raised elderly parents you may have had the experience of teaching them how to use a smartphone. It isn't as intuitive for an 85-year-old to use a smartphone as it is for a five-year-old who has been used to that technology since birth. I think it is really important as we think about what does it mean to measure broadband access? What does it also mean to have that technology literacy to be able to effectively use the connectivity that broadband brings?

Luci Rocha: Yeah. And I think one thing that sometimes we forget too is ability to participate in the social context of life too, and isolation and you know, the ability to connect at a very basic level too, and how that can differ across the lifespan and how people could have unique needs when it comes to broadband too. And we know social connectedness can be huge challenges for older adults in rural communities. So that's another example of why broadband access and literacy and accessibility can be so important also.

I think when it comes to framing health equity, we heard and really highlighted some different things. So one of them is just phrasing the concepts of health equity in a way that people will identify themselves in, that they'll identify as a common goal that they will understand as something that they want to achieve. And there are examples of messaging that people have found that work really well in rural communities. So finding common ground is really important. So we've talked about a lot of that today. You know, talking about concepts like access to broadband, access to healthcare, good jobs, reliable jobs, safe neighborhoods.

Those are really concepts that can reach wide varieties of audiences, different ages, different classes. These are all important concepts that people can really agree are important to have opportunities to achieve. It's important to also focus on solutions. I think that that is where people can potentially get a little bit lost in this conversation of health equity. It can seem so broad and it can seem really unattainable, but we can see that there are solutions and we can see that rural communities are working on this every day. We have examples of that in the toolkit. And really thinking in a solution-based frame can be super helpful for getting everyone on board, for creating a common vision. And being clear about how the, the solution will really help ultimately achieve what the community wants to achieve.

Alana Knudson: That whole issue of solutions and the advancement of health equity, this is something we are in for the long haul. This is not something we're going to complete next year. We are working toward a goal and we can measure our successes and continue to identify areas where we want to move the ball forward.

Luci Rocha: You can kind of think about what is possible this year, what is possible this month, what is possible in 10 years, and kind of think about the short term and the long term. How are you talking to decision makers? How is that different from talking to community members? How are you talking to leaders? How are you talking to representatives? How are you talking to different people in the community? And does that message need to be tailored based on their level of understanding, based on, on what they're also trying to achieve? There are lots of small ways to start kind of working on health equity and incorporating equitable practices into rural health work that, that don't have to you know, involve anything too complicated.

Musical bridge

Andrew Nelson: I'm talking to Paula Swepson, Executive Director of the West Marion Community Forum Inc. West Marion Inc. is a Black-led nonprofit working to create brave spaces for community members to share their stories, voice ideas, and build collective power to advance real and lasting changes related to food insecurity, childcare, mental health, affordable housing, youth engagement, immigrant justice, economic development, and health equity.

First of all, Paula, can you tell us about how West Marion Inc. came to be?

Paula Swepson: In 2016, the McDowell County Health Coalition had hired a facilitator just to run a meeting in our community and see what the issues we have. It was just a new model that they were thinking about doing. And so when I went to the meeting, it was, what is your vision for your community? The facilitator asked, and I thought, well, I didn't even know we had the choice. I didn't know how things happened. I was just like, well, I went to my 9-to-5 and came home and didn't really worry about much else. But when it was brought to me, something just like a light bulb went off and I was like, wow, we have a choice.

And then I was just looking around the room thinking, do y'all hear what they're saying? We can have a choice about what goes on in our community. Funding is always the issue, but the momentum in those meetings was so great. We realized we could do this with or without the money. If we all just come together like they did in the old days and just barter and trade the things that we have and just look out for our community members, then that's the change that we wanted to see. The community has come together to just voice what they want to see here. And so that has been the most amazing thing in our community to see residents talking to the institutional partners about what they want, what they need, instead of someone telling them, here, we can go over here in this community. This is what we can do for them. Now let's go into this community and ask what the community needs and see how we can connect it with the resources that they need.

Andrew Nelson: In preparation for our second episode on health equity, I was talking with some folks that were involved with the Two Georgias Initiative, and that was something they also said that I thought was interesting; a lot of the outreach that they do involves having a conversation with the community, and finding out from them what they need and what they want, rather than just having well-intentioned people who decide what they think is best, and just say, “well, this is what we're going to do.” But it sounds like it's really important that there's more of a dialogue, more of a conversation.

Paula Swepson: That was one of the things that program officer told us, how they went into this community and put tennis courts – low-income community, didn't think about, they didn't have tennis rackets, they didn't have balls, and then did you ask them if they wanted tennis courts? You know? You can sit around a boardroom and say, yes, this is what we gonna do. Let's go ahead and save these people, and give them some things that they never had without asking them about the things they never had. One of the initiatives we do is with the youth, and we've been able to take them on a civil rights tour to Montgomery and Birmingham.

And then we went to New Orleans to have a couple days of fun, but to just get them out to try some different foods, see some truth that you don't see taught in your school, and then just learn to work together, build the relationships with one another so you're supporting one another whenever you know you're going through some issues. They did a Photovoice project and it was supposed to be focused on obesity, but what came out of it was racism and bullying in the school. And we got the chance to, for them to present their Photovoice project to the institutional leaders of the county.

And the school superintendent was like, wow, I've never heard that. They went to the school board and all the school principals, and just told them, you know, what they were experiencing. So now they have a brave space at the high. We only have one high school where they're able to go in there and have someone to talk to whenever they're going through a issue. But it's not just for kids of color, anyone who's having issues, welcome to go in that room and start talking it out. That's what we tried to do.

Andrew Nelson: Can you tell us a little bit about the community you live in, and how its people are affected by health inequities?

Paula Swepson: Growing up in rural West North Carolina, we were raised to eat what was on your plate… “Clean your plate, there's people over in Africa starving.” That was a lot of things that they would say to us. The way the culture has been is we use a lot of lard and butter, and so that creates being unhealthy. And so as we think about going to the doctor, a lot of people are usually scared to go to the doctor, but when they go, they don't go with their true self. You need to tell your doctor exactly what you're doing.

You can tell a doctor what's going on with your body, and that's a better way to make sure that you get the prescriptions or the help or anything that you need, the treatment that you need to be healthier yourself.

One other thing; I was thinking about the inequities. We have a Latinx population here, and some of them are undocumented, and we had one case that was a baby that died because they were scared to call the EMS. Just the fear that, how when you go to the hospital that they're in charge or you go to the emergency room, they're going to call the police on you if you're not documented. So what we have done is, you know, start having conversations with the hospital system, with the police and the sheriff's office, to say, this is what's going on in our community as far as the undocumented immigrants. So how can we make sure they're taken care of?

Andrew Nelson: Yeah. Yeah, absolutely. You definitely want people to feel like they're going be safe going to the doctor and, and getting the getting care they need. What are some ways in which you'd say that living in a rural environment can make it more difficult to advance or improve health equity?

Paula Swepson: Not knowing the resources available is a big thing. A lot of hospitals have charity care and what we find out is a lot of older people who want to pay their bills. So when they get this big hospital bill, they go without medication to pay a hospital bill. So if they have the knowledge that that program is there, then they will be able to go to the doctor with some facts.

Andrew Nelson: What are some ways that you and other community members have been able to come together to address some of those problems?

Paula Swepson: Well, we hosted pre-COVID monthly community forums, and we invite the institutional partners from the hospital to come and just listen to what the people have to say. We have a group now that is collecting stories from people's experience with the healthcare system – good, bad, and indifferent. You know, we're not trying to bash the hospital, we just wanna get the truths out there. So we're close to maybe 200 surveys right now where people are talking about their experiences. And so we're going back to the head of the hospital and say, what's going on in your hospital? How can we work together to solve this so people don't have these horror stories whenever they're coming to the hospital or the doctor's office.

Andrew Nelson: Yeah. And as I mentioned before, you're the executive director of West Marion Incorporated. In our Rural Health Equity Toolkit, you talked about some of your experiences with that organization. How did you go about coming up with a common vision or sort of identifying the ways in which you could make the biggest changes?

Paula Swepson: Well, we listen to community. That is the biggest thing, because a lot of times if people just have the opportunity to speak their truths, they'll be able to talk out how it's gonna work out better for them.

Andrew Nelson: Yeah. It sounds like a really important part of the process was kind of being able to develop sort of a dialogue where everybody's talking on the same level, instead of some people assuming that nobody wants to hear what they have to say and, and other people maybe assuming that they're going to be in charge and everyone else is just going to have to listen.

Paula Swepson: Yes.

Andrew Nelson: You mentioned a local hospital. What are some other local or regional partners that West Marion Incorporated has worked with to help community members and their access to healthcare?

Paula Swepson: Well, we're working with a local pediatric clinic, and food insecurity is a big issue in our community. And childhood obesity is also, so we've been working with the local pediatric clinic and we provide fresh produce that whenever they go to the doctor's visit, the kids will go out and kind of like do shopping like the grocery store shopping, and it's all free. We have grant funds that pays for the produce, and it is encouraging them to try different produce, like eggplant and squash, something they normally wouldn't eat, and also give them recipes. So the kids are more excited when they come into the doctor now they want to hurry up, get through with their examination so they can go out there and pick out some fresh produce.

We buy from local farmers, so we're boosting the economy too. Then we have a community garden that we give our community residents and the low-income residents, we give the produce with them in the, in the seasons that we grow there. We have another garden of produce that specifically everything goes to that doctor's office. The local food advisory council, they have relationships with local farmers through cooperative extension. So that's the connection that we made when we were able to buy the produce from them.

So we don't have an actual storefront. So because we don't provide a service, we do more of a resource connector, but our community gardens give it to the residents. It's a youth-led community garden that they decide what they going to plant for the seasons, and they distribute it out into the community.

Andrew Nelson: Over the last few years, what kind of impacts have you seen the COVID-19 pandemic have on health equity in your community?

Paula Swepson: We had built a foundation with the community forums so that our institutional partners — the EMS, the police, the health department — they knew about us and they knew we could bring people together. So one of the first COVID testing sites in the community, other than at the hospital or the health department, was actually in our community. So people were able to come do a drive-through and get tested. The EMS director was telling me that 40% of the cases in McDowell County was the Latinx community, and they didn't know what to do. And we had some Latinx girls that work with us that were able to start going to all the test sites and dispel the myths about what's going on there.

So when the Latinx people come up, they see someone that looks like them, that talks like them. So they were more apt to come and get tested. And then when the vaccines come in, they prioritize the people of color so that we had that connection there, so they were able to come and be the first ones to get the vaccine too. So I think if we hadn't had that foundation in the beginning to have the relationship to talk with the EMS director, and they shared what was actually going on with the COVID-19, then it would've been a lot worse in McDowell County. So we got the rates of Latinx positive cases down just by having those people at the test site and vaccine sites.

Andrew Nelson: Oh, yeah. And it's really great that you already had that infrastructure kind of set up before the pandemic. That made everything so crazy. It was nice that you already kind of had those connections with different parts of the community. So like you said earlier, there was already that kind of trust.

Paula Swepson: Mm-hmm.

Andrew Nelson: It's also my understanding that you recently co-authored a book called Shift Happens in Community: A Toolkit to Build Power and Ignite Change. Can you tell us a little bit about that?

Paula Swepson: Yeah. So we were talking about the foundation that we had laid. Once we started having these meetings in West Marion, we were like, well, we need to go to other communities in our county. It was like, we really need a pamphlet that discusses our process. But as we started writing this pamphlet, it turned into a book. It was just like, so many lessons learned… how to work with institutional partners, but more importantly, how institutional partners can work with grassroots communities. And the best thing about it is, it doesn't have to be community work. You can do it at your workplace because you're asking the people, what is your vision for this organization? Where do you want to see it go? And get the buy-in, so they'll be more apt to be harder workers for you.

And we had wrote a recommendations to the policy makers. So every, like the county commissioner, city council, school system, healthcare system, we went and looked at what the community said the issues were, and made recommendations on how they could solve some of these problems from what we taught with community. That was the first thing we wrote.

A lot of people don't know how to talk in community or talk to people for that fact. We're doing some DEI [diversity, equity, and inclusion] training for one of our local organizations. I hate to say the buzz word for funders now is equity, uh, diversity, inclusion, and then racial equity. So how is it showing up in your everyday organization? So that has always been at the forefront of our work is equity, not equality it, some people get it confused equity. So, and helping people to understand what that means.

When we started this work, there's no way we could see it being anything like it is now. Even my growth had to come because I was so institutionalized. I was like, there's only one way to be right. And I don't know why people don't understand that. So as my growing has come, I've been able to share with my communities members and say, you know, think about it a little bit different. It doesn't have to be so black and white. We can all get to this common goal. All we need is to work together. And one of the sayings we have is just about collaboration, not competition. We're looking to see how we can work together and collaborate with anybody that's trying to do anything better for their community.

We say we're the learners and the experts at the same time, and we treat everybody that way. A lot of times, if you give into space and the opportunity, you can figure out some of the things that's going on in your community or your organization and have it work out. It's just giving people the space to, to be the best that they can be without shame, stigma, any of that, pushing people back and, you know, cause a lot of people, they don't like talking in front of people, but once they see that, it was not a scary thing where somebody was going to look down upon them for speaking out. You know, they're more vocal.

Andrew Nelson: Yeah. You have this really powerful network existing in your community. Are there any things in particular that going forward you'd like to work on next or you'd like to improve?

Paula Swepson: Well, always, trying to get people healthier. That is the biggest thing. Our whole organization now, everything is equity. We just recently hired a director of equity, so we'll make sure that we are walking the walk that we're talking, we want to make sure that we're correct because we can't go out there and advise somebody on how to do something if we're not doing it ourself.

We have called all the institutional partners together, and we've been trying to do a racial equity statement for the county. So we got the hospital system, county, city government. We met back in October, we had like 60 people come. So we're trying to build a relationship, and so we all have this common goal of we would write this racial equity statement for the county, and then seeing how we can continue to work together. Because a lot of people don't think racism exists. It's a rough subject, you know. One of our other government leaders said, “I don't have a racist bone in my body.”

So I told my team, I was like, well, when people say something like that, invite them to the meeting and say, yeah, you're just the person. We're looking for those who are not racist to come in here and help those people, for white people who are racist to have a better understanding. So if we get them in the room who have that attitude, then they'll be able to understand better what that actually means. So we have like definitions up around the room on boards, and we just having the conversation. And so hopefully in the next six months we'll have a countywide racial equity statement.

Andrew Nelson: A lot of people can just kind of stay in their little bubble, and not realize that they might kind of be missing the boat on some kind of important things.

Paula Swepson: We want to work, like I say, work with people. We're not trying to push people away. We all gonna live in this community. I'm not going anywhere. And the majority of people are not either. So why, how can we make a better, healthier county? Because if, if you make people feel comfortable, they can shop in your stores, they can come to your hospitals, they can come to your doctor's office and feel like, you know, they're welcome. They can come into the YMCA, and feel welcome. So all these things are going to make people healthier. And if you can get that vision to everybody to see how much it, how much better it would be if you just make people feel valued.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. Today we spoke with Alana Knudson and Luciana Rocha from NORC's Walsh Center for Rural Health Analysis, as well as Paula Swepson from West Marion Inc. Look in our show notes for more information about their work, and visit ruralhealthinfo.org for all things pertaining to rural health. Join us next time for out second episode about health equity, here on Exploring Rural Health.