Building Health Equity: Investing in Rural Health Equity and Prosperity
Podcast Transcript

- [Intro Narrator] Welcome to Share Public Health, the Midwestern Public Health Training Center’s podcast, connecting you to public health topics, issues, and colleagues throughout our region and the country, highlighting that we all share in public health. Thank you for tuning in to Building Health Equity, the Institute for Public Health Practice’s series highlighting health equity practice throughout Iowa. Over the course of the series, we will be inviting speakers to dive deeper into their experiences in health equity practice to serve as a learning enrichment opportunity for health department staff and anyone interested in building health equity. As a heads up, these podcasts have been reformatted from the original Building Health Equity Webinar Series recordings.  

- [Tricia Kitzmann] Welcome, everyone. My name is Tricia Kitzmann, I am the program coordinator with the Institute for Public Health Practice at the University of Iowa College of Public Health. I'd like to invite our guest speakers to introduce themselves. Once through panel discussion, panelists have introduced themselves, we will move into the discussion, the Q&A portion of the presentation today. So to kick it off, Cindy, I will start with you.

- [Cynthia Houlden] Perfect. Thank you so much, Tricia. My name is Cynthia Houlden. I'm a cooperative development specialist with the Nebraska Cooperative Development Center at the University of Nebraska-Lincoln. However, I am located in Kearney, Nebraska smack dab in the middle of the state. And what I'm gonna talk to you about a little bit is one of our newest co-op models. We were the fortunate beneficiary of a USDA Socially-Disadvantaged Groups Grant that allowed us to focus on rural home care. And we are partnering with Northwest Cooperative Development Center to create home care academies within Nebraska. Our impetus, of course: We're aging. I'm not quite at that 65 mark, but it's very close to me. Currently, one in five Americans will be over the age of 65 by 2030, and Nebraska's not far behind with 16.2%. Currently, people over the age of 65 actually outnumber children under the age of 65. And that statistic is getting close to Nebraska as well. 10,000 Americans are retiring every year. And in case you don't read the news in both Nebraska, Iowa, and most of our rural communities, rural long-term care facilities are closing, which means people don't have care close to home. And if they wanna stay at home, they need to have someone care for them. So this is why this topic was important to us and why we qualified for a USDA Socially-Disadvantaged Groups Grant. Believe it or not, personal care workers are the fastest-growing job in the country today. It is part of the healthcare industry, but its specific sector is very, very closely growing. The demand for these positions will increase by 70% in the next 20 years. Within the next eight years, we need to add 2 million direct care workers into this industry. It's difficult to recruit. Low wages, few benefits, these tend to be close to minimum wage jobs. And by minimum wage, we're talking wages at between 10 to $15 an hour. And most of these jobs do not offer health insurance. And just like the rest of our workforce, people that are in this industry are aging out. And because it's a really an industry that has a lot of demand on us as individuals, there's a lot of turnover. Currently, there are co-ops on both that provide home care on both coasts, as well as down into Texas. We're partnering with this group here in Washington because they have successfully started four that are working and one that is emerging in Washington State. So as I said, I work with Cooperative Development Center. A co-op is a member-owned, democratically controlled business. It operates in a manner that is mutually beneficial to all of its members. Co-ops tend to provide higher wages, as well as they meet the needs of their members. So if you think of it it's a private business that the people who own it are also the people that work for it, and they make all the business decisions. So unlike going to work for a home care industry business that's a private LLC, you don't have administration over you. You are the administration as the member. So member-owners set wages, benefits, policies. They say how the business is managed. They get to decide what type of care they provide and all profits go back to the employees. So this is why we selected a co-op model. This creates living way jobs, lower turnover, as well as democratic workplace influences within the entity. So if you want more information on our project for this discussion, as well as all of the work we do at the Nebraska Property Development Center, just visit our webpage.

- [Tricia] Wonderful. Thank you, Cindy. Devi, I will have you go next.

- [Devi Dwarabandam] Okay. Good afternoon, everyone. My name is Dr. Devi, currently a senior student in the Master Public Health in College of Public Health University of Nebraska Medical Center. So I've done my bachelor's in dental surgery for my graduate degree. And after that, during the COVID pandemic, I was really inspired and motivated to work more closely on the health equity in rural and remote areas so I got into the Master Public Health course. And my concentration is epidemiology, so, during this summer, as a part of my course curriculum, I've had an opportunity, amazing opportunity, to work in rural communities. I was approached by the University of Nebraska-Lincoln about their special initiative called Rural Fellowship, where I meet groups of people, go into small communities, and work on their culture and explore their opportunities in order to create a equity model. So it's called Rural Fellowship program. So I would just like to talk very briefly about whatever things that I did in the summer, and we could just take it from there. So what is health equity or anything? As a matter of fact, equity is having an equal opportunity in order to achieve their health potential, or if you say economic, economic potential. And basically, nobody is actually disadvantaged to reach their full potential irrespective of their cast, creed, or race, or social or economic conditions. So this is what everybody is trying to achieve, and this is what humanity is trying to achieve. And I guess that's why we are here right now. So during the fellowship, I have faced a lot of challenges and barriers, you could say. And I'm sure that everybody might get to see them if you go to rural areas in any kind of state in United States or in the world because small communities, they are lacking the awareness because of outreaches, because of availability of resources. That's what we are trying to do. So I would say getting to know about the community is kind of unique. Each and every community is unique. So that's the main challenge that everybody is gonna face. And also, their economic needs, their social status, their housing. You could easily see based on your hometown or where you grew up, or where you moved to, there are a lot of differences in social housings. And also their expectations on how their community should look like in the next few years, or what they're trying to see in their community. For example, grocery store, big malls, movie theaters, the list goes on. So, also, some towns have this kind of complex. This is what I've faced right now in the summer. Small town or big city, they have that kind of complex. We are a small town, nothing gets done. So bias is, of course, it's always there, but it's our job. If you are trying to go there and do something about it, or just trying to learn about it, it's our job to take that away. So, that's what I faced. And also, their needs are so unclear. I don't know if you guys have noticed, if you go to a small town, or if you are passing through town, they would say, "We would like to see that. We would like to see new jobs. We would like to see big buildings," but they're very broad. They're not focused. They're don't narrow down because they don't have much knowledge in their aspect. And most of them are in entry level jobs, their economic conditions, so. Also, their lack of community engagement. As a matter of fact, businesses, each and every business, they would feel that they're competitors, and they don't actually feel that they're part of one community and willing to work towards one goal. It's what they need to do. So, these are all the challenges that I've faced. So moving on to next thing, I am in the practice of public health. And I believe based on what evidence says, we believe that these are the three pillars of public health-community, health assessment, or any kind of assessment. So whatever their needs are, we need to start with an assessment. And again, using those results, we need to develop a planning for the improvement. And after that, using those results, we need to come up with a strategic plan in order to work on those. Like I said, broad to narrow mind work this is. So, this is the whole process of how health improvement planning takes place. These are the stuff that I've been working all these years. So they have come up with this. So first of all, we need to identify some stakeholders who would benefit from our health improvement planning, or health equity in a small town or a big city. We need to identify them. We need to define what kind of communities. Again, get to know about the community, their history, their values, their cultures, their population distribution. After that, we collect the data. On what you might ask, I'll get to that. So we need to collect the data and we need to, after that, using those results, we need to actually identify the needs and the problems. And after that, we need to plan some implementation strategies, some interventions. So, if they work out well, we need to know what, why, what and why worked out. And if they don't work out well, okay, what are we lacking? So I would just like to quote an example. So in the entire State of Nebraska, I am currently based out of Omaha, Nebraska, obesity has been growing like in triples since the last two or three decades. And it seems like none of the interventions, none of the public health interventions are working. So, what's the problem? Why isn't it working? Is it because of the health education methods, or health promotion methods are not working? What is lacking in those things? So evaluation gets us the facts about those where are we lacking? So based on that, we need to develop another strategy to work on it. So coming to the actual thing. How we actually proceed with this? First of all, before we actually get to the assessment, we need to look out for the stakeholders. Like I said, we need to get the team together. What kind of team would make an assessment for collecting the data, for analyzing the data, and also presentation of the data? So we need to put together a team, identify the resources. Funding is an important thing in small communities because of lack of resources because it may be a far, distant place, or it may be close to states. And so we need to look for the resources. And also, like I said, community engagement. This one is really important. So, again, I am kind of focusing on the community engagement. There's a reason why. I would like to tell you a story about it, just one minute. So I have been working in the summer with a lot of business partners. So I needed to actually reach out to the small community and I've had no idea about their culture, their values. So what I did was I kind of went into the community and started talking to random strangers in libraries and public places, and learned a lot about them in a span of like one or two hours, and made new friends out of them, and tried to include them in whatever activities that I did because the word gets out in small communities. Everybody knows each other. So, again, after we collect all the data, we can analyze it and present the data. So, I would like to end my brief thing with this, whatever I did. So it was a city called Wakefield. It's a small town in Nebraska. And again, I've had a very long brief meeting with my preceptor, with the organization there. And she has told me their existing needs from her perspective. And honestly, I wasn't convinced that I couldn't just take one person's forward for about every aspect of it. So I went into the community, and I started doing some focus group interviews, and I learned a lot. I noted it down. After that, I kind of started designing a needs assessment. It's a preliminary one, and it involves a lot of teams to do that, but I was just a one guy. So I could get to this sample. Done the sampling. I went into the community and did the sampling online and offline. I put out promotional posters, used all the media, whatever I could have in there, like we were talking about the equity. We were lacking in some resources so I have just used whatever we had in their existing strengths. So I've used the newspapers, and radios, and just word of mouth. Small communities work well with the word of mouth. So I've collected their demographics, their health conditions. Also, I was really impressed with their social conditions. And I just wanted to evaluate their current social or economic status or their conditions, so I put that on there. So all these demographics and health conditions, all of them, all the data that I wanted to collect in order to gauge them on the level of social or economic conditions.

- [Tricia] Thank you so much. I'm gonna go ahead - I'm gonna cut you off 'cause what you're sharing, we're gonna cover in some of our other questions. So I wanna make sure we give enough time for introductions, but then also go into our presentation.

- [Devi] Got it. Yes, just one last one. So all of this was to establish, narrow it down all the needs in order to put together a plan. So we'll come back to it again. So thank you so much.

- [Tricia] Keith, I would like to turn it over to you. Thank you.

- [Keith Mueller] Okay. Well, it's probably appropriate that I'm going third. My own personal academic career threads through the three institutions. I started out at the University of Nebraska-Lincoln and Political Science in 1979. I moved to University of Nebraska Medical Center in the late 1980s, early 1990s, and was actually part of the founding of the College of Public Health at UNMC. I was at one point the interim dean during the first year and a half of that college. And now, I'm at the College of Public Health at the University of Iowa, where I am the director of the Rural Policy Research Institute or RUPRI, R-U-P-R-I. I've been associated with RUPRI since 1993, so almost 30 years. RUPRI itself is about 32 years old. Our mission is to do two things. One, bring a lot of the knowledge that you've heard about from the field through and in research into policy discussions, primarily at the national level, but we also work in various states; and two, to help raise the voice of rural America in policy development. We're broadly based across different sectors. Health is the most prominent one because we've had my activity running the rural health portfolio for RUPRI since '93, we now have a research center, the RUPRI Center for Rural Health Policy Analysis. We have an expert panel in health that I chair, and we also do technical assistance in the field for the last three years, predominantly through our website. And now, we'll be getting back out into the field. The field for us is hospitals, and communities, healthcare systems, health providers around the country. RUPRI written large as I refer to it, which I'm the director includes community development activity run by our center for local and state policy, which is based at Ball State University. The important contribution to a lot of the discussion we'll have this afternoon that RUPRI brings is we have developed over the years a couple of frameworks to use. One in community development that we call the Rural Comprehensive Wealth Framework, which lays out eight different capitals that are interrelated, of course, and we've developed through CLASP-- that's the state and local center that we have-- a way of using that to help communities in their development. We're in the early phases of bringing that model to Iowa. There are places in Iowa that use it now. I think there's one or two in Nebraska, as well. In the health sector, we have a framework called the High-performing Rural Health System, which uses four pillars-- access, affordability, community-based, and quality-- with a foundation of equity. And that drives a lot of our analytical work that we do as a health panel. It drives a lot of the research we do out of our research center. Both of those frameworks are easily accessible through a website that I've put into chat, the www.rupri.org website, which also includes, if you go to focus areas and health, you can see everything the health panel does. And I also included the website for our center, which is again fairly easy one, it's www.ruprihealth.org. It's actually based out of the University of Iowa's website. And that includes all of our publications and presentations. I wanna stop there because I'm anxious to get to those questions, Tricia, so I'm gonna turn it back over to you.

- [Tricia] Wonderful. Thank you, Keith. All right, so you guys have shared quite a bit about kind of your history, where you've come from, what work you've done. So, tell me what brought you to this area of work, and describe your work as it relates to rural health or the economic prosperity. What's the driving force for you? Why do you do this work? What's the importance? Why should we care about what you're doing?

- [Keith] (laughs) Well, I can start since I'm still unmuted. What drives me is a real strong passion to be of help to rural people. I'm not of rural origin myself. I grew up in the areas of Milwaukee and Kansas City, but I married into a rural family from the Panhandle of Nebraska, Chadron and Alliance - that part of the state. And I've just come to really love rural people, rural culture, want to do whatever I can to help with it. During the years, I've been heavily involved in advocacy as president of the National Rural Health Association, president of the Iowa Rural Health Association. So my passion carries me far beyond research. But, in research, I started out ironically in urban politics in public budgeting. I moved into health policy and then into rural in part to capture an opportunity. Being at UNL in Lincoln, Nebraska, I was identified in my field of health services research as rural. And when I started my career, there were set asides for rural research because of its paucity overall. Now, we're a pretty vibrant sort of subset, if you will, of health services research. But that was an opportunity captured that matched up with, as I say, really strong passion on behalf of rural people and places.

- [Cindy] I'm a native Nebraskan kind of sort of. I was an army brat. I was born in Massachusetts, but my parents are both from Nebraska, so this is where we ended up when my dad got out of the army. I love the ruralness. I live in Kearney, which by definition is a small town. We're just under 40,000. But I do what I do... two words - oh, actually, three words or four words: jobs and quality of life. Those of us that live in rural communities or in rural states or rural counties, we like where we live, but we need certain services available to us. A lot of the work we do through Co-op Development Nebraska, we're known for our grocery store work. But moving into the home care field, into healthcare, it's not unheard of obviously within the co-op sector, but it's unheard of in the central part of the US. And I look at these, these are quality jobs. They pay good salaries for people that live in these communities. So, they have an opportunity to earn a living, but it also provides a service that's necessary for people to have to live in these communities. So it's twofold. It goes back to quality of life, as well as job. And that's everything we do within the Cooperative Development Center is we look at rural quality of life, growing rural economy, making rural communities somewhere that not only do you want to live, but you can live and live with a good quality of life with all the services that are necessary to you. I choose to live here. And I'm glad that I get to spread outside of it through the university and through our work.

- [Devi] So, I was a healthcare professional. I studied dentistry. I practiced dentistry for about two years, and the COVID pandemic started. I was really frustrated as you could actually guess because we were treating one patient at a time, and the people just kept on coming, and they would never run. So I've had a little bit of basic fundamentals about public health. In India, I've done my studying in India, did my bachelor's in India and public health is offered very differently in India. They call it social and preventive medicine. They just termed as that. So yeah, I was back there in India doing my residency and doing also my clinical practice. And I just got very curious about their preventive strategies. If we could have prevented the COVID altogether, we didn't need to stay back home. And also, you would also agree the fact that treating one patient at a time is terribly inefficient when we could actually prevent the disease altogether. That was my main motto even now and that's what drives me actually. I don't know why I cannot explain it, but I started working on some research, like doing some research articles. And I've been getting into small towns. Back in India - I was born in a small town in India, and I moved to Omaha. It's been a year. And I got into this program, and I was really impressed. It was so attractive public health. United States spends about $3 trillion on healthcare system and still we rank the last, last high-income countries in terms of overall health. So, simply said, that's what drives me. I just want to take it up this far. So that's it.

- [Tricia] Thank you. So, with your guys' expertise, what are some of the most pressing health equity and prosperity issues you know and have seen in rural communities?

- [Cindy] Can we just simply say money? I think, Devi, you just alluded into it, the US healthcare system, the disparity. If I need care in my home, I'm speaking my specific industry, and I don't have insurance that covers it, which most insurances don't, then I pay out of pocket. And to pay out of pocket, if I don't have means, then I may qualify for Medicaid or Medicare. But if I don't qualify, and I pay cash. It's hard to pay for the care we deserve. And it's not just in home care, it's everything within the rural, which is part of the reason the wages are so low is in order to charge a rate and make a profit, you don't pay your people what they deserve, so it creates a huge disparity. And I can't access care because I can't afford it. I either qualify for benefits or I can't afford it, or you can't access care because no one can work for the wages that are paid. So it's simple, it's money.

- [Devi] And I don't know if, you guys might have seen it in the news, but do you guys have any idea what's the top most in terms of rural health and peace of mind? A small country in Europe, I think it's Norway. In terms of health, it is at the top most. You know why? From what I could see from my research, they have a universal healthcare system, health insurance system, and it covers everyone at an affordable price. I think about in terms of USD, 80 or a hundred bucks for every month or so. And the health insurance, it's a really big deal. I would just like to relate to some experience that I had in this last summer. During my needs assessment survey, the study, I found out that majority, almost 75% of Hispanics in Wakefield, which is 50/50 Hispanic and whites, so they were not having health insurance. You might even wonder why. I mean, they don't know about it or why not? Like, is it not reaching to out to them? They don't just care about it. I mean, from what they told me, either they pay out of their cash and they don't get the medical attention at all. So there are disparities in terms of their economic status or their awareness, their perspective of it. So I think there are disparities even in their immigration status and yeah, their jobs. So overall, yes, that is really true, actually.

- [Keith] When I pondered the question, I thought about what my colleagues at the University of South Carolina, where there's another one of these research centers like us. They have really written a lot about in places like health affairs in the general rural health and that's the dual disparity that occurs. And one disparity is rural populations are classified by the federal agencies as a population that has disparities compared to urban. And then that gets compounded for subpopulations within rural. And I reflect on some data that we've published out of our center on death rates from COVID-19. And since the second most recent surge back in January, the death rates are higher in non-metropolitan counties than they are in metropolitan counties. And within those counties, that are higher, if the population is 20% or more Hispanic, if the population is 20% or more American Indian, Alaska native, if it's 20% or more Black, and in particular for the Black population, a lot of disparities that show up in the states that have not expanded their Medicaid programs and what that means for those populations. So I think about that, I think about what are the leading causes of mortality in rural, and one of those is what we call deaths of despair. Those are suicides and other deaths that are related back to things like substance use. And again, if you tease out the data, you see the inequities there-- that they're higher among those subpopulations within rural. So it's because of our work in COVID that this came to my attention and one of our colleagues here, Whitney Zahnd, recently published a paper through publication that's available at www.ruralhealthinformationhub.org on death rates being higher overall in rural than they are in urban.

- [Tricia] Thank you. So, with that, what promising practices, tools, or resources have you found to be the most useful and beneficial in working to promote rural health equity and prosperity?

- [Devi] So, again, if I could go back to the Rural Fellowship experience. So on my very first day, I was really not aware about the community. I mean, we are talking about the rural health equity, right? So for our community, you head in to Iowa or any state, for example, we are concerned with Iowa right now, I believe so? So it's a new one, and we really not know about the community. So I was really blind in terms of that. So first, I started learning about their culture, just get to know about the community, first of all. And like I said, I'm actually a student in senior year right now. I'm still learning. I was really impressed by the social determinants of health model and ecology lens aspect of it. So I try to apply that model in the existing community. And it's like a framework in fact, as a matter of fact. I am trying to develop a protocol, like a checklist, for every community that could apply to any community in the entire United States where we go off and take off their housing, their economic conditions, their healthcare access, their everything related to the social determinants of health, their environment. So using that, we could predict their overall health. So, Mr. Keith was talking about their Blacks and Hispanics having disparities in terms of their mobility or mortality. So I would like to point out a fact about the availability of mental health services because I'm a strong believer if we don't have a peace of mind, also today, or with our family at work, just being happy is the most important thing. I mean, I am sure you guys would also agree. All of it comes down to one thing: being actually happy and being content with your life. So whether it's Blacks or Hispanics, or Americans or whites, being just physically healthy is important, just as important as mentally healthy. So I think because of their availability of resources to healthcare and mental health services, their health insurance, so the tools that I could say that worked well for me were using the social determinants of health aspect of it. I'm still trying to develop a protocol for it, a framework where we could run into any community in any state, even in Iowa, and try to assess and evaluate their needs. And based on that, we try to focus on priorities and try to work on them using a team. So that's what worked for me.

- [Cindy] I really like what you were saying. And when you put this question to us, Tricia, my first answer was Zoom because it's allowed me to work with nationwide without having to travel. But along with that, models that work. This model was actually brought to us by a person who relocated from Washington State into Lincoln, Nebraska. And they had worked for a home care cooperative. And they said, "Is there anything like that in Nebraska?" And we're like, "No, but let's investigate." And so we connected with the group in Washington State, and we said, "We could do this in Nebraska." And our whole goal is to provide a service in a rural community. And I like what Keith said, you know, disparities, rural communities. I live in Kearney. We have the services that are necessary. Some of them are a bit limited, but we have things available. But you get not too far away. And you're basically told if the care facility closes in your community. Well, I guess you're just gonna have to go to the closest facility, which is 30 miles, which 30 miles traveling in a Midwestern winter can be an issue for family members. So you're forcing people out of their communities. And so we're looking at, you know, and that goes back to that mental health. And are you happy? Do you have what you need? Do you feel safe? Do you feel secure? And these models prove that you can provide this service anywhere that makes people happy and you satisfy both sides of the equation, the person receiving the care, as well as the person providing the care. So both people can now provide care because one of the comments that was brought up when we started researching was the care providers. the facilities closed. They don't have a job in their community now. So not only are the patients moving 30 miles away, so are the care providers. So it's this circle of the model works, delivering the model into rural Nebraska. Again, thanks to Zoom and finding the partners that can help us connect all the pieces together. And because going back to mental health and happiness, that is the key to surviving in a rural community and delivering rural healthcare. It's a huge part of it. I think COVID taught us a lot about why we need that mental aspect in healthcare.

- [Keith] Well, you might expect this from somebody who runs a research institute in a research center: I think data are really important. It's really important in the policy world, especially, to be able to make the case. And making the case requires two elements, one being strong data analysis, and the other being really effective powerful stories that you can tell, which from multidisciplinary research, the former takes people like health economists, the latter takes people like anthropologists, and we have all of that in our mix. Right now, I think there is a great opportunity to use data and stories to inform policy implementation, particularly at the national level. As you may know, President Biden, in his first day in office, inauguration day, issued an executive order related to equity across all federal agencies to implement programs, emphasize equity. They are doing that. They're doing that through proposed rules and regulations that appear on their websites and in the federal register. One of the things that we do in our health panel is we write comment letters every time those proposed rules come out to try to inform the development of policy. And I know that those are read and used by the agencies. So we have more opportunity now than we've had in a long time. And this goes back more than just one presidential administration with that emphasis in all of the agencies engaged in that activity. And similar things are happening at the state level, as well. And I think the best way of presenting a lot of that is to go back to things like the frameworks that I offered earlier. And I think particularly about the comprehensive wealth framework 'cause your question was rural health equity and prosperity. And you cannot address those by staying within the lane of a single sector like health. You need to move beyond that. And that's where that comprehensive framing becomes so intriguing and important for rural communities to use and for our policymakers to understand.

- [Tricia] Thank you. We had a question come in through the question and answer box. And so I am going to read that out loud and have you guys work or answer that for me if that's okay. In what ways have each of you capitalized on the many strengths in the respective rural communities you engage your work? Could you offer one specific strategy as an example?

- [Cindy] We always say through our center, you know your community better than we do. I don't live there. And that's so important to remember that. So when we go into the community that the people we're working with and throughout this home care academy, I'm working in three separate communities, specifically. We've engaged in eight, but I've got three that I'm working with currently to form the first co-op. They know their communities, they know the movers and shakers, they know their resources, they know the needs. And so they bring their expertise into the conversation, and then I can help almost coach the conversation. I don't make this happen. They make that happen. And so the strategy is just recognizing that they know what they need. And my role is more of a coach or facilitator to help bring that together to help meet the need they've identified in their community. And that's why, like I just said, eight different groups and we're with three of them currently. One of the groups that we pulled out is an Hispanic group. And so how they're going to develop their specific entity will look different than in another rural community. And so we recognize that the communities are different.

- [Keith] I think that was incredibly well said, Cindy. And very little that I could add to that. The one thing I would add is sometimes if you can, if you're coming new into a community, if you can try to identify the two or three key leaders in the community that can help you, then network beyond that into the other organizations. For us in healthcare, that is often entering through the local hospital, but not always. One thing that we've learned is a hospital is not always in the best position 'cause they're not necessarily the most trusted organization in the community. And one example of that, some work that RUPRI did years ago in Humboldt County, California. The entry there was through a local foundation that was trusted and they were able to bring people together as a neutral entity within the community.

- [Devi] Both of you are very well said, I completely agree with you. And as a matter of fact, my fellowship may have ended, but I decided to volunteer. I'm still associated with that small community. So one thing to the question, the very first advantage that I had and I still have was having good relations with the community leaders, Mr. Keith and Ms. Cindy was telling about. And also, I have currently about, for each and every group, for each and every different sections in the small town, Wakefield. For the Hispanics, I have a contact for the small communities. For the kids, I have a contact. So make good relations and identify some key stakeholders or community partners so that you could always reach out to them. And as they were talking about, I really didn't know about that town. And I just went there and been there for 10 weeks. Quite literally, not possible to learn each and everything about the community. I may never could actually to the full extent. So it's their community and they know it better. I completely agree. So in order to do something, in order to actually make an impact and see an impact, it's better, whatever we come up with, make it visible, make it work through the community partners, to your relations, your professional contacts, and always have good relations, make the community engagement a good thing, and just keep it going. That's what I would suggest and that's what I did for my community.

- [Tricia] Wonderful. So we have another question in the question and answer box. How do you identify the communities themselves?

- [Cindy] For us, it's word of mouth. Sometimes we hear that there's something going on and we'll reach out. Other times, other partners within the university will hear and will forward names. Sometimes they call us for this project specifically. We communicated through Area Agency on Aging, through providers, through every possible potential partner we could think of, and it turned out the Omaha World Herald was who connected us with two of our partners. There was a newspaper story. I sent an email to the reporter and said, "This may sound weird, but could you get me contact information for your sources?" which, of course, she can't. However, she forwarded my message to them. They contacted me back and that's kind of how we connected with three of our partners was a newspaper story. So it's - How do you identify them? It's good, old fashioned research. That's kind of keeping your ear to the ground and knowing what's out there.

- [Devi] My case was different because I was given an opportunity. I was approached by the team of University of Nebraska-Lincoln because I had to do it as part of my curriculum. But, if I have to do it again and I will do it again as soon as I graduate, so I just used my variations, my contacts. I've had amazing contacts with the University of Nebraska and that's what I used. And I would just like to point out one more thing Mr. Keith said, health is not just health, not just one thing. These days, health and economy go hand-in-hand. Let's support everyone in their small community. That's just narrow down everyone. Like 100% of them are healthy. Top to bottom. And could this arrive with just one thing, but just help without any job, without any money? We know health and economy go hand-in-hand. So, in order to do that, we worked on bringing people together by putting up some events, like street markets or for... Just inviting the local vendors, local people to put up their food, their clothing, their jewelry, just to get the people together and give that little economy boost to the community, to the individual people, not just businesses. And yeah, economy and health, that's a really good point, Mr. Keith. So I just wanted to point that out.

- [Keith] And my answer is again the researcher answer of, if it's a particular research question, we will actually construct a sampling frame of communities based on community characteristics, like size, demographics, including the racial ethnic mix in the community, and then go from there. Other times, we are invited in as researchers with the expertise we can bring to what the community's already doing, similar to what Cindy talked about. And we don't select those. They select us. And sometimes when we're doing technical assistance, we know we've got something that works well in a certain type of healthcare system. So we put out an invitation and then those go out nationally, actually, for people that think they might benefit from that TA and then we take that off to the community.

- [Tricia] Okay. We have couple more questions in the question and answer. We are down to approximately six minutes, so I'm going to say we'll try to get through as many as we can. I also do wanna make sure we cover one last question that I have. So first question, how do you evaluate success of your efforts?

- [Cindy] For our project, we formed the cooperative, and we are able to deliver the services. That's our goal. We, of course, have a matrix because we're grant-funded and that is the matrix that's part of our grant is that we will form a cooperative with this many members that will reach this geographic area. So we have a matrix. But from the feel-good side of me, knowing that we succeeded, that we did the best we could, and we've created a model that can be replicated outside of Nebraska.

- [Keith] I like that feel-good answer, that works for us, as well. But again, as researchers, we do some measurement and then we use the county health indicators, which most people participating in this website, I'm sure, are familiar with, to see if there's any difference in those, we use other health indicators. And when we're dealing with healthcare systems, we use some of the financial indicators. And there are now a series of quality measures and I am actually part of a national group that helps develop quality measurements. And we'll use those to see if there's any difference in quality of care.

- [Devi] And it actually depends for the evaluation process. And being an epidemiology or biostatistics student, so we kind of use data as well in the long term. And if it's an economical prosperity project, we kind of go ahead, whoever was involved in that project, we go ahead and try to measure their income turnout if it's an economical one. But if it's a health intervention for a long time, we actually rely on post feedback surveys and again, a study, as well. But, like Mr. Keith was telling, we use indicators to measure, but it's gonna take some time to evaluate, as well. So, also, I think the very best thing that we could do or anybody could do in short time is to reach out to people and just ask them, just get some feedback through word of mouth. So that's the, I think, simplest thing that we could do randomly if it's a small community.

- [Tricia] So I'm gonna wrap up with combining these two questions. So my last question and then the question that's in the Q&A. So my question is, what advice would you give health departments and other organizations looking into initiating equity in their rural communities? And I think that ducktails into the question that's also in the Q&A of: Any recommendations for continuing to expand their messages and their initiatives? So, with our last three minutes, I will let you guys take over.

- [Cindy] Find partners. Don't be afraid to learn new things. Don't be afraid to reach outside your comfort zone. Look at models. You know, find the need, find what you can do. We always say teamwork makes the dream work, and it really does in all aspects of our work, but especially in any time when you're looking at equity. When you bring a group of people together, we can achieve amazing things. And don't be afraid of it. This is not my area of expertise. My degree is economics, but I can do this work with a little bit of research.

- [Keith] I heard some great advice yesterday in a symposium I participated in on the human services side, which is closely related to health, and it was all around equity and how to move upstream, which is one piece of the advice, get closer to what is causing the actual issues that you're confronting. A lot of our conversation yesterday was: we've gotta get to poverty. That's the root cause. And how do we get to that point? So, child tax credit, for example, became a major topic item. But one of the quotes I wrote in my notes from that discussion was: ask people what they want and give it to them. And boy, that's powerful. And I intend to use that a lot. Another one was: let people with lived experience lead, experiences as profound as lots of schooling. Another one was: not taking the emergency room approach. And bandaids are not effective, which is kind of like getting upstream. All of which resonates well with everybody in this webinar because we're all in public health and that's really where we need to be headed.

- [Devi] I would just like to close it with whatever I could add to Mr. Keith. So, talk to the community more often, talk to people more often as in from a health department aspect, and try to do a lot of promotions. That's all I could say on top of what both of them said. Whatever you do, just make it known and do a lot of promotion and use all the tools necessary. And just get that to people, and they would understand. Otherwise, they feel like nothing's getting done. They're not even giving them attention. So, just talk to them, listen to their needs, and just give them assurance, and just start working on it so that it gets done sometime in the long run. But just make it known whatever you do, so.

- [Tricia] Well, I cannot thank the three of you enough for taking time out of your busy schedules to spend an hour with us answering our questions. I wanna remind our participants to subscribe to the Building Health Equity site. Go there. You can register for more webinars or upcoming webinars that we will be hosting. The next webinar will be "Food Access Equity: Giving Everyone a Seat at the Table." Again, Devi, Keith, Cindy-- thank you so much for your time. I appreciate it. Have a wonderful day.

- [Outro Narrator] Thank you for joining us today. Special thanks to Tricia Kitzmann, Cynthia Maharani, Natalie Peters, Melissa Richlen, and the speakers who have shared their expertise with us. Theme music for the Building Health Equity podcast series was composed and produced by Dave Hoing and Roger Hileman. Funding for the Building Health Equity initiative is provided by the Iowa Department of Health and Human Services. Please see the podcast notes for an evaluation link and transcript. For additional resources and information, or to view the video webinar recordings, be sure to visit www.buildinghealthequity.com