The health equity gap has long plagued rural areas due to a variety of factors that affect health and well-being. This video, from the National Rural Health Resource Center, that features Health Forward Foundation CEO Qiana Thomason paints a picture of the unique challenges rural communities experience in addressing health equity.
Thomason, vice chair of Grantmakers in Health’s board of directors, and a Resource Center board member, is a Kansas City native who has dedicated her career to improving health and wellness across Missouri and Kansas. Both her work and the work of Health Forward focus on equity-centered approaches to improve health outcomes for people of color and people in rural communities.
“As I engage with rural hospital and health leaders in our region, I constantly hear about the strength of their community bonds and how these relationships help the community face the most challenging conditions with ingenuity and resolve,” Thomason said. “This virtue, the strength of your community’s relationships and interdependence, is half the battle in addressing health equity in rural communities.”
The other half of the battle is addressing social determinants of health (SDOH), such as housing, insurance coverage, income, access to healthy food and transportation, education, and more, as these shape the health outcomes of both an individual and their community. However, lack of culturally-responsive care and social support, including a mindset of adversity to change, also keeps the rural health equity gap stagnant.
In the video, Thomason discusses how hospitals and their partners can advance health equity by making the issue a strategic priority. According to Thomason, “Health equity cannot only be one person’s accountability.” Instead, health equity must be at the center of a hospital’s systems, strategic plan, and budget, as well as championed by board members and staff at every level.
Rural health leaders and stakeholders across Missouri and Kansas are combatting the rural health equity gap by prioritizing community, collaboration, and diversity, all strategically conducted through an equity lens. Though the demographics they serve vary, they all share core rural values of building trust, following through, and looking out for one another. Community leaders in these areas unanimously agree that rural health equity means communities must have a seat at the table.
Building Community Trust
According to Thomason, a key step in making health equity a strategic priority is to develop structure and processes to support health equity work. Creating thoughtful processes to reach health equity goals that include culture of care training and assessment and quality improvement and measurement allows organizations to hold themselves and their staff accountable. Some of these processes may include deploying specific strategies to address determinants of health on which the organization can have a direct impact as well as a system for receiving feedback from patients and the surrounding community.
Rural residents have long experienced disparities due to a lack of funding and action, and simply being left out of conversations regarding what is truly needed to improve their communities. To combat this, community organizations like Thrive Allen County, REACH Healthcare Foundation, Missouri Ozarks Community Health (MOCH), and Migrant Farmworkers Assistance Fund speak directly with the communities they serve to build trust and tackle issues hands-on.
According to Thrive President and CEO Lisse Regehr, the organization visits every town and municipality in Allen County at least once a year to hold community conversations. During these meetings, residents are encouraged to speak up about issues affecting their community. As part of these conversations, Thrive asks what the communities are proud of, what they are excited about, what could be better, and what they are needing.
Once the top priorities are identified, Thrive works internally to decide how its staff will divide and tackle each issue. Then, a community engagement team visits and corresponds with the communities to work alongside them throughout the entire process.
“We always tell them, we can’t promise you that we can solve it, we can’t promise you that we can fix it, but we can promise you that we will work alongside you to do whatever we can to try and make it better,” Regehr said. “Because we’ve been doing this for 15 years, the community knows we’re not just going to show up, say we checked a box, and leave.”
REACH similarly communicates with its communities by going on “rural road trips” during which they meet with their rural grantees and other community leaders to catch up with how things are going, what everyone is working on, what’s needed, and how they can help. According to Vice President of Programs Carla Gibson, REACH considers its rural grantee partners from the onset and operates that way, rather than having a traditional grantee-funder relationship.
By making a point to visit, listen to, and communicate with their grantees, REACH has demonstrated that the communities they serve are treated as equal partners in identifying problems and finding solutions. “We don’t go in saying, ‘we’re going to affect change in this area.’ What we do is have that relationship with those communities where we’re able to plug in where we’re needed,” Gibson said. “Over time, they understand that we’re not going to prescribe fixes, we’re going to listen.”
Collaboration is Key
In an effort to close the health equity gap, rural health leaders are not only collaborating with their communities but with other organizations as well. By leaning on – rather than competing with – each other, they strengthen their ability to best serve and invest in their communities. “At Health Forward, we know there’s enough resources to go around when we come together across issues, sectors, and ideologies to work for thriving rural communities,” Thomason said.
As CEO of MOCH, Tim Shryack models the “civic mindset to take care of each other” that is prominent in rural areas. In his eyes, the work goes beyond health care and is truly about serving people. As a federally qualified health center, he recognizes MOCH doesn’t always have the resources a patient may need and that strong partnerships can help cover the gaps.
“We have to have good partnerships with all the other providers of health care in our area so that we don’t just duplicate services and look at each other as competition, but we actually build upon the strength of each other to be able to do the most we can for our communities,” Shryack said.
Out of this mindset came the creation of the Missouri Ozarks Rural Health Network, in which various community providers can meet and discuss collaboration efforts. Building these relationships allows them to skip the referral process, share costs, and send patients to each other for services they don’t offer. This collaborative process takes the burden of finding referrals off patients and keeps them in the area rather than sending them to urban hospitals which may be too far for them to travel to.
These partnerships proved especially crucial throughout the COVID-19 pandemic when many rural areas were devastated by staffing shortages, lack of resources, and widespread fear and uncertainty. MOCH partnered with other organizations in a variety of ways, including using larger providers’ parking lots to host mass COVID-19 testing and sending nurses to other hospitals to help with staffing shortages and vaccine events. Shryack believes that coming together to improve the community’s health and keep people safe also contributed to building community trust.
Populations in rural areas are predominantly white, leading many to incorrectly believe that health equity may be a moot point and worse, develop adversity to diversity. However, diverse populations do exist in rural areas everywhere, and unfortunately face discrimination not only from neighbors but health care providers as well. As a result, people of color in rural areas receive lower-quality health care and higher rates of negative health outcomes.
Since the release of Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, which Thomason calls a landmark publication, the Centers for Disease Control and Prevention and all other medical associations have declared racism as a public health crisis.
“While these acknowledgments are necessary and incremental first steps, lauding ourselves for incrementalism is just short of complicit as Black and Brown lives literally lay in the balance,” Thomason said. “The time to address health trauma and health injustice and their impact on the well-being and life expectancy of people of color is now.”
According to Thomason, one of the most critical and achievable solutions is to diversify the health care workforce and pipeline. Suzanne Gladney, immigration attorney and director of the Migrant Farmworkers Assistance Fund, believes this process begins with the children of vulnerable populations. Through her work helping integrate seasonal and migratory farm workers into communities within Lafayette County, she has witnessed firsthand how limited the scope of farmworkers and their families is. Migrant children spend the majority of their time either at school or in the orchards with their parents, with little knowledge of the opportunities that exist for them beyond their current world.
Gladney believes health care providers can find a way to introduce children of vulnerable populations, such as the migrant farmworkers she works with, to the health care facilities and learn about what options are available to them. She recalled speaking to a young girl, who detested the idea of giving shots, about the possibility of her working in a local clinic; she had only known the clinic as a place where she received vaccines, and was not aware of the plethora of other roles providers within the clinic played.
Another migrant child, Gladney recalled, dreamt of working as a tractor driver as this was the highest paying job he knew of at the orchard. Gladney and others in the organization pointed out that with his skills running track, it was likely he would receive college offers, and encouraged him to pursue dreams outside of farmwork. Now, 25 years later and having attended college on track scholarships, he is completing a Ph.D. program.
Introducing children of vulnerable populations not only expands their horizon of possibilities for their futures, but also helps combat the “brain drain” phenomenon of young, emerging rural minds leaving the area for education and work opportunities – and never returning back to their rural roots. By creating and showing them a path of success in the areas in which they grew up, they are more likely to want to stay, creating a rural workforce that is as diverse and ever-changing as the population.
Gladney recommends health care facilities offer internships or job shadowing days for adolescents in the community, especially from vulnerable populations, to see future opportunities that may interest them. As a result, communities can diversify their health care workforce, allowing patients to have access to providers who understand their cultural background and speak multiple languages.
For Gladney, health equity in rural areas is defined by the ability to not only have the same opportunities as everyone else, but to be aware of them from a young age and know a different life is possible. “It’s to be sure that everyone you’re serving – no matter what their age, education, birthplace, nationality, language – is treated in the same way and has the same possibility of success with their health,” she said.
According to Regehr, Thrive openly welcomes diversity, ensuring that their values as well as their built environments encourage people of all races, ethnicities, and backgrounds to have equal opportunity to live well. Thrive recognizes that the organization was founded in response to a century-long decline in the area’s health, and that embracing diversity was necessary to grow.
“The only rural communities that are growing are the ones that have embraced different cultures, different races, different ethnicities to come into those communities and be a part of them,” Regehr said. “We are adverse to change. For so long, the only thing we’ve known about change is that it’s bad. What we have to do is create a culture shift and a mind shift saying that tomorrow can be better than today.”
Regehr believes that to see more diversity in a community, that community must first provide the resources those populations need. Thrive has made it a priority to find bilingual care coordinators who can serve non-English-speaking families both through their services and through contracts with other community organizations. Their economic development department is also looking at how to recruit migrant workers to address workforce shortages in the area.
“These are people who want to work, they want to find safe housing, they want to feel included, they want to be safe and provide for their families,” she said. “So how do we become a community that welcomes that?”
In one example of building an equitable environment, Regehr recalled an all-hands-on-deck effort to place a grocery store in the heart of a food desert and low-income area. In addition to providing nutritious food and job opportunities to a historically underserved population, they also added affordable apartments, benches, and picnic tables, making the area a center of the community. Because many area residents didn’t own vehicles, they also added bike racks and ensured sidewalks were walkable and bikeable.
Access for All
At the heart of the conversation surrounding health equity is the matter of access. Without access – to education, healthy food, stable housing, a livable income, health insurance, transportation, etc. – one cannot achieve positive health outcomes. Rural health leaders agree that accessibility is a starting point in the conversation to identify what SDOH may be impacting a population.
For Shryack, asking a patient about their insurance status has a “trickle-down effect” in identifying SDOH. If they don’t have insurance, they are asked about their income, which leads to a conversation that paints a picture of their lived experience and highlights where they may need support. MOCH’s new patient intake process inquires about insurance coverage as well as whether someone is struggling with transportation, substance use, cultural attitudes about going to the hospital, and more, allowing providers to identify both health and social needs that need to be addressed.
“We know all of those factors play a part in the person’s ability to achieve that health equity, to achieve their highest potential for living a healthy life,” Shryack said. “Trying to have a patient achieve their highest level of health, to me, is what health equity is all about.”
In Missouri, expanded Medicaid coverage is helping bring affordable insurance to more people who were previously ineligible. In Kansas, however, the decision not to expand has left rural residents avoiding care until it’s far too late, creating high rates of chronic illness and mortality.
Regehr recalls when Thrive’s board chair was working as a provider at a clinic when he noticed his patients were no longer able to afford visits, let alone medications or procedures. By the time he joined a community health clinic that was more accessible, it was too late for many of his patients.
“There were body parts that had to be amputated, there was cancer that had spread too much and was inoperable at that point, diabetes that had spread beyond repair – all these diseases that had they been able to be seen years before and gotten that preventative care, our population would be much healthier,” Regehr said.
“I believe that if Medicaid were expanded we would continue to see those positive ripple effects,” she continued. “We’d see more people in the workforce, we would see a healthier workforce, we’d see a healthier community, our hospital would be fiscally healthier – all around it’s a better deal.”
According to Gibson, funders play just as much of a role in accessibility as community-based organizations and health centers like Thrive and MOCH. “You can’t be a health funder and not go beyond traditional health care in your investments,” Gibson said. “You can’t address health equity if you aren’t addressing those things or investing in those things that prevent people from receiving health care.”
Instead, funders must take initiative to build trust and relationships with the communities they are a part of, listen to what is needed, and bring their residents in as part of the solution. The health equity gap in rural areas has demonstrated that traditional health care and standalone health facilities are not enough to improve the health and wellness of rural communities.
“To address deep, long-standing health inequities, we need to recognize the systems and practices that stifle health and health care, as well as the power and duty each of us has to take action,” Thomason said. “No one is better suited to inform the solutions needed in our health care systems than the people who have experienced firsthand the harmful discrimination in those systems.”
Learn more about how leaders can strategically advance health equity in rural areas.