Obesity in Rural America, with Jennifer Conner and Jason Lofton

Organizations and resources mentioned in this episode:

• NYIT College of Osteopathic Medicine at Arkansas State University
• Lofton Family Clinic
• Walton Family Foundation
• International Mountain Bicycling Association
• Park Prescription
• Safe Routes to School
• National Interscholastic Cycling Association (NICA)

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. This an episode about obesity in rural America. Today we're talking to Dr. Jennifer Connor, who is an associate professor with the Delta Population Health Institute at the NYIT College of Osteopathic Medicine at Arkansas State University, as well as Dr. Jason Lofton. Dr. Lofton's a family doctor in De Queen, Arkansas at the Lofton Family Clinic. Thank you for joining us today.

Jason Lofton: Glad to be here.

Jennifer Conner: Yeah, pleasure.

Andrew Nelson: Yeah, absolutely. Dr. Connor, I guess I'll start with you and, and then Dr. Lofton, you can just chime in. First of all, we've seen that obesity rates have been growing across the United States for decades. Can you tell us about some of your concerns related to that growth in obesity in rural areas, especially, uh, both in terms of causes and also how it affects the health of rural residents?

Jennifer Conner: Yeah, as you stated, we know that obesity is on the rise, especially in our rural areas. And I think for a really long time we've talked about, food deserts and transportation and all how the social determinants of health are really, uh, are affecting our health outcomes, but specifically obesity. So while our, you know, clinical partners are super important in the biological piece of controlling obesity, we do have to think about our access to healthy foods, our access to park space. And so, grocery stores and park space are important, but I think more recently we've even talked about, if we do have a consumer, a patient that is relying on food assistance, for example, do we have healthy food pantries? You know, what are the commodities that we're giving out? And so we really have to think about this as a whole when we think about the causes of obesity, and take that really holistic lens of, what kind of conditions does that person work in?

Jason Lofton: And yeah, I agree with especially the access portion of that for, uh, rural communities. I just got back from a 50 mile bike ride in Little Rock, and there's trails. There's, you go to northwest Arkansas, one of the more populated areas in the state, and there's 30, 40 miles of paved trails. And so when, when I come back here to my community, we don't have bike lanes, we don't have safe roads to ride on. So it, it limits that, you go to big, bigger towns and there's 24 hour gyms. It, it's almost a, a afterthought for people. But you come here and, and that can be a problem. You know, access to different sport for your young children or limited on the amount of sports teams that they have access to indoor facilities.

Um, when you go to, you know, the larger populated areas, they're gonna have multiple gyms, racquetball courts, indoor swimming pools. We don't have that here. And so I think access is a big thing. And then how does that affect our community? I mean, when you look at workforce, we have a lot of people being limited by what they can do physically. And so, you know, we, we have a conversation there about what do we need to do?

And part of it is, it's also a mindset of, of, I don't need to lose weight. I like my weight. And, and having to educate on, well, this isn't healthy, and here's what can happen in 30 and 40 and 50 years down the road. And so access is a big deal especially to healthy foods. Even just having a food pantry in some of these smaller towns is a big deal, let, let alone a healthy food pantry.

Jennifer Conner: I'll just add from a, you know, from a systems perspective even, and some of our rural areas, in working with our food bank in the central part of the state, our rural areas may be the third or fourth week out in delivery. And so the commodities that come are what's left at that point. As Dr. Lofton said, it's a matter of systems thinking and looking at distribution available in our rural communities to access and to equity. And we know that just because there's an FQHC or Rural Health Clinic or a physician in the area doesn't necessarily mean that that's true access. So it's deep diving into what we mean by access, because again, as Dr. Lofton mentioned, you know, having food commodities or food distribution, having a food pantry, you know, even having a Critical Access Hospital doesn't mean that that facility or amenity is actually, um, accessible.

Andrew Nelson: When the facilities exist, do you find that people being able to afford care is an obstacle to accessing those services? Or is it awareness that the services even exist? What are some of the things that kind of stand between those people and that care?

Jason Lofton: I think when you say awareness, there's just, there's not even, there's nothing to be aware of because it doesn't exist in some of these smaller communities. There's not a dietitian. Well, we had a hospital that we lost. We're about to get another one, so they'll have a dietitian, but she's pretty busy just, just managing the patients there. And so we don't have necessarily a community dietitian that whose job is solely to help people in the community. At my clinic, I, I was a part of the comprehensive primary care program with Medicare, and, I have a care coordinator here who helps, we're calling patients, trying to get them patient assistance and helping them just sometimes help 'em fill out paperwork.

There's, I've got patients who cannot read or write, and we just have to help fill out the paperwork for them. I did a home visit just before this podcast, you know, went out to saw a patient. This gentleman was, is in his eighties. I have a fitness center and talked him into trying to start visiting the fitness center just to get out of his house. And, so sometimes people are willing, they just need that little bit of encouragement to say, you know, actually, you're not too old or you're not too big, and, and then that's something I think, you know, that that's a big deal is that stigma of nobody wants me, or people are gonna make fun of me. There's stuff like that that, that we definitely, I think, have to have to address with patients.

Jennifer Conner: Yeah. Echo. I work with the agricultural community a lot. Or shift workers. I work with a lot of work sites, so, to Dr. Lofton's point, if we do have a food pantry, if it's opened on Tuesdays and Thursdays from nine to noon, that's not equitable or accessible for some of the populations that I work with.

So we do have some system barriers there. And then, yeah, we do have the awareness piece. We get a grant, we start a program, the grant goes away, the program goes away. And so sometimes we do more harm than good in rural communities of trying to bring services if we don't have that plan of sustainability in mind.

Andrew Nelson: Dr. Lofton mentioned earlier how some people feel fine about their weight when maybe there is a health issue there, but also the, the stigma and shame that some people can feel, and that can obviously create some barriers for people who want to make positive changes in their health. What are some ways that communities and clinicians, providers can help address those factors when they're trying to create programs to address obesity or to treat patients in a clinical setting?

Jason Lofton: You know, one thing I try to start with my patient. I think one is just that taking time to address obesity. I mean, we have so many patients that are obese that it can almost be an afterthought. The payment for obesity education inside the clinics is not worth most doctor's time doing it. I do it because I enjoy it, but if I did it full time, I would go broke. Medicare's intensive weight loss counseling that they pay for, it pays about $25 for a 16 minute visit. I have to sparingly do them because I can't sustain a business on that model. And so that has to change. Medicare, Medicaid have to pay for preventative services if they're gonna get the providers, because it's a business, we have to keep the doors open.

So I'll suggest to them to maybe go to the gym at a time when it's kind of the dead hour, so to speak, that kind of 10:30, 11 in the morning, your morning people have been there, your lunch people aren't there yet, and you don't have the after work, after school crowd. When they first go into the gym, everybody thinks everybody's looking at them. Letting 'em know that's a normal thought and that you're not abnormal thinking that, and trying to create those opportunities for them to go and possibly get with somebody that's maybe close to their size and, and see somebody that's exercising, that's overweight.

And I talk to people. It's not so much about how you look, but how you feel and that we exercise so that we, we can feel better and eventually you're gonna lose some weight and you're gonna get stronger. And kind of a focus on being fit and, and not worry about our size so much as just trying to get fit, because say my bike ride this past weekend, there were people that were overweight that were doing that 50 mile bike ride, and if you just looked at 'em and judged them based off of their looks, you said there's no way. But they're out there doing it really well. And I've seen cyclists that, that look like they couldn't do it, who are way more fit than I. And so trying to just talk to people about that and talking them through that.

Jennifer Conner: Yeah. And I would add, nomenclature, right? So, I, I use a lot of quality of place, quality of space, quality of life, , and try to stay away from obesity. And in my past work, I've literally been called the obese police, and that's not my role. What we're trying to say is, what can be the healthiest you, right? And then there's the paradox of obesity. You can be obese and be malnourished, right? Based on high caloric foods that you're intaking. And so we really have to have this narrative around obesity that's not about weight, but is more about the healthiest you. I do a lot of motivational interviewing and I'm like, What is it that you want to, you know, achieve five years from now?

And we take that and sometimes it's, I wanna be able to play with my grandkids. So this is about quality of life with your grandkids. This isn't about losing 50 pounds. And I think that if we started having those conversations, we started using that language, and we got away from the word obesity, I think some of that stigma would be reduced. Because again, we're all trying to just achieve the best us. And that's where I know over my course of career in working in obesity, I've, you know, I've really worked with communities, you know, to say healthy lifestyle, not obesity reduction, to say quality of place, not obesity reduction facilities. And so, it's just a little tweak and, and change in the way that we approach it.

But I think it welcomes more people to the table and it reduces some of that stigma when we use that language. And so I have mayors, for example, that have the mayor's mile walk. And it, this is an opportunity, you know, for the community just to engage, but we're increasing physical activity as a part of that. So, you know, there are definitely low cost and no cost strategies that we can implement, and programs that we can implement that are more welcoming and less about stigma in the long run on the community side.

Jason Lofton: With Medicare, when they pay for that, it's called intensive weight loss counseling. It's the focus is weight, and we gotta change that focus to being fit or being healthy. Everybody's initial thought is weight, but it, it goes beyond that. And , trying to get people to move more and to eat a little healthier and get where they can walk that mile or bike 10 miles or swim and play with their grandkids.

Jennifer Conner: Food is medicine, right? And then we have those conversations and dialogue that, you know, food is just as important as another prescription. It's what kind of medicine are you putting in your body, that is fueling and being the food that you need to be the healthiest you. So that's just another tidbit of, again, changing that language ever so slightly to say, food is medicine.

Andrew Nelson: Yeah. I can see how reframing it to think of food as medicine… you're not foregoing something that's maybe less healthy that's kind of more satisfying, on an immediate level, you're taking medicine that's helping you achieve a better you. That's improving your quality of life., I can see how that would be very helpful. And also, the idea of just kind of starting that process of, of going to the gym. It's not going to change your life the first time you go, but you're focusing on improving your quality of life and not really worrying about what other people are thinking about you.

Jason Lofton: Yeah.

Andrew Nelson: We've talked a little bit about the clinical aspect of achieving, the best version of ourselves or higher quality of life. You mentioned the Mayor's Mile and some things like that. Are there any other examples you have of collaborating with public health or other partners in the community?

Jason Lofton: I'm a part of a local community development nonprofit, and we started in 2016 seeking funding to get a trail. We have public lands around our lake, it's Corps of Engineer property, and so it's public land, but there were no trails. And so we approached the Corps of Engineers and asked them if we could put trails around the lake and multi-use hiking and biking trails. Uh, took a couple years to get that initial approval. And then we got a seed grant, you could say, with the Walton Family Foundation and IMBA, which is the International Mountain Bicycling Association. So we have trails started. They're still in the process, but there's funding out there for communities to look for. There's community garden programs out there that's for schools as well.

There's grant funding for that. And then funding for trails. There's a lot of federal programs and, even private foundations. So, it gets people out in, the environment, out in the, you know, natural environment. There's benefits to just that. And then giving people access to some maybe community gardens or healthy food options like that. So funding is out there and, and sometimes a public private partnership to help make that work so it is sustainable and doesn't just go by the wayside with that one grant that went by.

Jennifer Conner: Yeah, and I would just add, you know, we've got some great clinical community linkage examples. Like we've got physicians that are willing to do the Veggies RX program, so literally prescribing veggies, you know, we've got the Park Prescription program where we have docs that are prescribed, or providers that are prescribing parks. And so I think that there's great, like I said, ideas of the clinical community linkages where we're absolutely making sure that our community resources are tied as a referral source for our clinicians, but also as Dr. Lofton mentioned, we've done programs like Safe Routes to School. So, how do we get kids to walk and bike to school again? So I think that there's just a variety of, you know, low-cost to no-cost programs all the way up to the, the really big built environment like Dr. Lofton was talking about, you know, the million dollar trails. And I think it's just incremental. A lot of the community work that I do, communities often get overwhelmed and don't know where to start or don't have that grant writer or economic development commission that can really help in the, the development process. But I think that, I just, you know, try to encourage communities, start somewhere and do the SNAP program, you know, where you have a farmer's market that can do the double up food bucks, um, you know, engage in the existing resources and then work incrementally, um, to start on the bigger, uh, dollar sign projects, if you will. And so those are just a couple of examples.

We have a lot of work site wellness, you know, and a lot of our small communities, we may have 125-employee factory, that doesn't have the capacity to have a, a wellness program. But we can pull our resources together in a community and support them and keep the factory in business. I have an example down in southeast Arkansas where, you know, about 20% of the employee base was diabetic and they were really at risk for shutting the factory down just because the interest premiums, and the cost of the employee was too much. And so, you know, I worked with the local health department, the local cooperative extension, the local AHEC [Area Health Education Center], and we really just said, you know what, to lose 125 jobs in a 1,200 resident town is very significant, and we've just gotta do what we can do with our existing resources.

Andrew Nelson: Yeah. Before we move on, were there any other things you've seen that schools have done or possibly the schools could do in the future to help students stay healthy or get healthy?

Jason Lofton: You know, a lot of schools are trying to offer healthier options at lunch. Maybe you're removing the soda machine from campus, offering the salad bar. And that depends on your school, the, you know, the resources you have. And also I think another thing is trying to offer some type of physical activity outside of your kind of main sports. You know, in Arkansas at least, there's a big push for something called NICA. It's a National Interscholastic Cycling Association. It's a, it's a kinda like a club cycling team. And, and they're just trying to get kids on bikes. It starts in sixth grade and goes to 12th grade, and there's, there's programs out there to get kids just moving. I've seen grants for walking programs after school for kids.

And so it doesn't have to be a big push or, you know, an expensive push. We need a consistent message and a reminder of, Hey, let's keep moving. Let's keep doing this and build a healthy community. And if we can build it in the kids, then they're gonna ideally be healthy adults. And so I think that's probably an area that could be worked on more and more emphasis. But it's hard when you have a provider like myself who's in the office all day, not necessarily at the school. And so I think that's where the community can come together and say, how do we, how do we, you know, can you work with the mayor and the principal or the superintendent and the hospital and the doctors all coming together, with the local health department and what, what can we do to get this community healthier?

Andrew Nelson: Yeah. Sort of integrating that into the structure of the community is, it's something that every, everybody's going to benefit from. I definitely think it's great when that's something that just becomes part of the fabric of a community.

Jennifer Conner: Yeah, we have the let's move salad bars to schools. You know, in some of our rural areas we've been able to institute, um, salad bars, which just wasn't an option. Um, we've got the, as Dr. Lofton mentioned, the school garden programs. But I, I wanna, um, just give a shout out to some of the school districts that I've worked with that you talked about that fabric. We've been able to establish like the Mayor's Youth Health Council, where specifically there has been as much as the clinical community linkage, there's been this school community linkage where, you know, we've really worked on, you know, how do we engage our youth in community and economic development and local civic engagement. And so, you know, I've got examples where our students at the high school were able to use CAD design to propose a soccer field because we didn't have a soccer facility.

And so, you know, they went through the whole planning process of, you know, what does it take to, to get on a city council agenda to what does it take to get a grant with parks and recs to the actual implementation of that. We had students who did walk audits, and so if we need more sidewalks, around the school or if we have sidewalks, but they're not safe. So I think there's definite examples of youth engagement, not only at the programmatic level and what we needed to do at the school, but, you know, how do we use the creativity and the perspective of our youth to drive what we're doing at the community level to make it what I said earlier, that healthy and quality space of living.

And you wanna retain 'em in rural areas. That's a big thing is we wanna retain our youth. So engaging them not only in, you know, not only in offering the salad bars, but saying, Hey, if you want park space, you know, here's, here's how we can make this happen. Here's how you even start the dialogue with your community leaders, you know, about this amenity that you really feel is important. So I just wanted to, you know, shout out the policy system and environment changes we've been able to do by engaging our school districts and the teachers that are on board who've integrated healthy nutrition into their science curriculum or, you know, macronutrients into their math curriculum. So I definitely think that there are ways and we just have to be innovative, um, and have those linkages that we talked about both at the school level, but at the clinician level.

Andrew Nelson: Certainly. Moving to a little bit of a bigger picture, what are some things you've seen or things that you would like to see regarding policy initiatives that can incentivize lifestyle changes, like physical activity or better nutrition?

Jason Lofton: You know, I guess when I think about that the incentive would be probably coming more from the insurance industry, but maybe the lawmakers could help make that easier for the insurance industry. But cuz you know, I look at my patients and I feel like some of them, they just need a little bit of incentive. If you give 'em a discount on their copay or their deductible just enough to help get them, you know, if they'll exercise so many days, um, you know, a week or if they, and lose a certain amount of weight. There's different ideas I've, that I've thought of that I think definitely needs to come from a higher up level, even in small towns, if having a consistent message from a mayor can have impact and whether it be keeping your yard clean or Hey, let's go walk once a week on a Monday. Those types of consistent things from people who are in leadership positions can definitely make a difference. But, I would love to see some sort of incentivization for patients to, to stay fit. Again, it's not just about losing weight, it's about, staying fit and, and being healthy. But those high level changes take time and, take a lot of people agreeing on things, which can be hard to do at this day and age.

Jennifer Conner: Yeah, and I would just say I, I think Arkansas has been pretty progressive in their obesity efforts. You know, we were one of the first states that did a comprehensive childhood obesity legislation, Act 1220 of 2003. But as I mentioned earlier, there's “Little p” policy that we can do here, as in principals and school of superintendents, the mayors and those kinds of things. But I think, you know, some incentives, for example, if you've got a health coalition at a local level, what we call the local health policy board, and we do have a couple of those here in the state of Arkansas, you know, maybe that gives you priority points for the state recreational trails, grant funding. So I do think that there are both appropriation and policy and legislations that we can do.

And you know, there's been some food councils established in, you know, certain states that have really examined this and had state legislation that supported, you know, nonprofits or others around, you know, food security. So definitely, there's “big P” and “little p” strategies that have been proven all across the US, to address obesity. And I think it just takes both constituent understanding, right? So if you're, you're gonna implement a program that money has to come from somewhere. If you're gonna allocate it as a mayor, that money has to come from somewhere. But, you know, on our side, as practitioners doing that return on investment and making the community see what a park space can mean, you know, not only in terms of, you know, our own personal health, but as I mentioned earlier, you know, reducing premiums at the local factory.

Andrew Nelson: Dr. Lofton, my understanding is that recently you helped to develop gym facilities for patients in your community. Can you tell us a little bit about that?

Jason Lofton: Yeah, so, I moved here 2007 and rented space for my clinic for the first couple years. And then we bought an old downtown building and rehabbed it. And I, I was an exercise science major in college. And I've always been of a kind of a preventative mindset and encouraging people to be active. And so we started looking at, what are we gonna do with this extra space? And after talking to patients, really they were, they were saying we needed a different gym space than what they currently had, or more space. And so we basically built a fitness center with the extra space through our back door of our gym, it was all the same building.

You know, you literally stepped through the back door of the clinic and you were in the gym. But I could talk to a patient and say, Hey, here's a one month free membership kind of, it's a, it's a prescription. You could say it's a, , it's a prescribing exercise, but I give it to 'em for free. I've had a few patients that I've just let 'em work free with our, our personal trainer, cuz I just knew they just needed something to help get the ball rolling.

So we just moved our fitness center across the street. We bought another old building and renovated it and, and enlarged our facilities. We put a sauna in just because I know there's some therapeutic, you know, impacts for saunas for people. And so we're, um, trying to give people more opportunity. You know, I have, uh, I have my trainer, he's gotten his certification in working with people over 65.

I just tell people, never stop moving. That's kind of my mantra. But that's something that I wish more clinicians had the, had the ability to do is just to write that prescription, here's a free month. And cuz that's, that's all some people need is just that, just that little push to get them in a facility to see that, hey, there's other people like me in here, or people older than me in here, and it, it's worked well. I think it could work better just because I'm so busy. Sometimes it, it's harder for me to engage with my patients as much as I'd like in, in that arena, but it, it's, it's been a good approach.

Andrew Nelson: Yeah, that's really neat, that's something you're able to, you're able to pull together. I'm sure that's very, very beneficial to your patients to have that kind of integration.

Jason Lofton: You know, and if people go to the gym and have questions about diet or, or even even just health problems, then they can step through the door and we'll work 'em in and talk, talk to 'em about their health problems. And I tell patients, I say, I don't care where you're working out. It's, it's free to work out outside, you know, go outside and, and, uh, walk or get on a trail or ride a bike. It's not about getting in a gym necessarily, it's just about being active. And so that gym is just one of the tools that, that we can use to help get people active.

You know, there's grant funding… it is expensive, but trails, you know, you don't have to have, uh, funding though to do a trail. You can get a group of volunteers. Our, our trails so far, other than the funding to design our trail, it is all hand built so far. We've got three and a half miles of handbuilt trail. And, it brings people together in a way that it, there's nowhere else in the community I've ever seen people brought together for a common purpose.

And it's really neat to see what, what's been done. And it opens people's eyes to our, we have a beautiful lake and nobody had ever seen the lake on foot essentially outside of a campground or a boat ramp. And so we're seeing more and more people get out there just because they have access now.

Jennifer Conner: Yeah, I would just echo and say, so for example, we have in, in one of my communities, rural communities that I work with. We have a free gym. However, childcare being sometimes a limitation, right outside of the free gym, we put an outdoor fitness cluster that had some of the same machines as we had inside. And it was then became like a, you know, a family ordeal. If there were only adult classes or only maybe youth classes offered and they wanted to, you know, participate as a family. Another great example is we have yoga in the park, we have fitness in the park. Um, and so, you know, you can use a baseball field for that. And then most small towns, we actually had to do that. The only green space we had was a baseball field.

And so how do we think about converting some of the spaces we have? And that goes back to that asset mapping is that, you know, it may be for one purpose, but how do we think outside of the traditional purpose, and maximize the resources that we have.

Jason Lofton: We've gotta get, uh, parents to try to limit kids access to social media and iPads and TVs. So we really have to be a partnership between the school, the city, the, the clinic and the home to have kind of common goals and recognize, yeah, I know my kid likes this, but I gotta get 'em outside and I've gotta encourage them to walk or play soccer or to do a marathon. I mean, anything like that is what we've got to do.

Andrew Nelson: Yeah. Are there any things you've learned over, over the years, when it comes to treating people with obesity or, or people that could increase their health, improve their quality of life, that you'd like to be able to share with other primary care providers?

Jason Lofton: Yeah, I, I think one is just not being afraid to approach, ask the question. People are sometimes embarrassed to talk about it, but as are providers it can be a little bit of a stigma bringing it up. But one is most people do want to change. Most people recognize that there's a need for change and we just wanna be a facilitator to that. There's no magic button, there's no magic formula that it's not one size fits all. But we want to try to just help facilitate.

You know what, one of the things I think that has helped my, especially my elderly patients that I've helped lose weight and get fit is it's just accountability. Having them come in once a week for so many weeks and then every other week for so many weeks and we, we kind of celebrate with them. We'll have patients when they get below a certain a goal weight, we give 'em a, that's a graduation certificates and hey, you've graduated. We make it fun in our clinic. But, the accountability is, is real key. And I think getting people in a community setting, maybe some people exercising together because that, that in itself becomes accountability. Cuz if, if, you know, if Sherry doesn't show up for her workout that day or that walk, then her friends are gonna text her or call her and say, Hey, we missed you today.

And so I think just having those, trying to create more groups of people that are inter engaging with each other and, and kind of letting those things take a life of their own and I think is primary care providers, just being that that initial kind of a, an encouragement or, or asking that question and just asking patients, what is a fitness goal of yours? Cause maybe they have one and nobody's ever asked them and we just need to say, Okay, well here's a goal. How do we help you navigate that to get there?

Jennifer Conner: I'd be remiss if we didn't say there's also space here for, you know, public health and wraparound services. So for example, Dr. Lofton and I worked a lot on health literacy and I always shared this story, but you know, when we're talking about medication adherence, I literally had a patient that I was working with and it said take one tablet twice a day. So we were working, working, working with this patient and then realized that he was taking one tablet, cutting it in half because it said one tablet a day. And so there's just this understanding that we have to have a meeting patients where they are. And I think oftentimes we don't think about, you know, the literacy or again, those social determinants pieces. So this is where, you know, we've had creative models with community health workers where, you know, if the clinic can't do it or there's not a case manager, we've been able to tap community health workers. So it's somebody that's their peer, you know, that's been educated and trained on effective motivational interviewing or health behavior change.

I would just say, you know, obesity is, is very complex. Community and economic development is very complex. And again, the more that we can change this narrative about how all of these interplay, I think the better that we'll be situated to tackle, um, some of the complex issues that our rural communities face.

Jason Lofton: Sometimes I think primary care providers tend to carry a lot of, of burden on their shoulders to be the only one involved sometimes. Cause that's kind of how we were trained is that you prescribe a medicine, maybe you send 'em to somebody else, but trying to have a more of a collaborative approach with your community health worker. You know, the schools, the mayor, the public health, you know, and how do we, I think from a primary care perspective that I'm from, that's if we can engage them where that kind of takes the weight off of my shoulders and allows me to, to get the help that really my patients need and I need cuz I can't do it by myself.

Andrew Nelson: Yeah. Something that kind of stood out to me during this interview is how it's all kind of interconnected, how engagement in, in any sector can kind of, can kind of have like a complimentary effect to all the other, all the other pieces too. I think that's really neat.

Jennifer Conner: Yeah. We call it the ripple effect. The one investment that Dr. Lofton does can have this ripple effect, you know, to that person's employer, to that community's tax base, to that, you know, And so we just show, um, how much we are connected and how the ripple along the way of, you know, one community health worker, one clinician and one mayor can make a broader and bigger, um, impact than any one of them alone.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. Today, we spoke with Dr. Jennifer Conner, who is an associate professor with the Delta Population Health Institute at the NYIT College of Osteopathic Medicine at Arkansas State University, as well as Jason Lofton, MD, who is a family doctor in De Queen, Arkansas, at the Lofton Family Clinic. Look in our show notes for more information about their work, and visit ruralhealthinfo.org for all things pertaining to rural health.