Promoting Health Equity in Rural Communities
- The erasure of BIPOC rural communities has contributed to health disparities along racial lines, yet rural populations are not homogenous.
- The voices and strengths of communities that have been historically underrepresented need to be centered in policymaking.
- ChangeLab Solutions has a long track record of partnering with and serving rural communities through projects at national, state, and local levels.
- Our work in rural places focuses on addressing the fundamental drivers of health inequity through projects that range from broad national policy scans to tailored technical assistance for community and governmental partners.
Addressing the Health Needs of Rural Communities
When we picture rural America, we may imagine small Appalachian towns, post-industrial communities in the Midwest, or workers cultivating farmland in California’s Central Valley, but too often, implicit bias causes us to imagine the residents of rural communities as white. Narratives of whiteness are harmful to health equity work in rural America — which in reality consists of racially diverse areas that are home to one in five people in the United States and that make vital contributions to our economy, our culture, and our rich history.
Black residents and people of color have lived in rural places for generations, with histories dating back to colonization. Moreover, the majority of US states are historically and currently home to sovereign American Indian tribal nations with significant rural populations. Today, residents who are Black, Indigenous, and people of color (BIPOC) strengthen community resilience and build cultural richness through investments like small business endeavors and shared community goals. Although rural places have social strengths that aren’t always found in urban environments, erasure of BIPOC community members and a history of structural discrimination have caused inequities in access to health care and resources that contribute to complex and nuanced public health challenges. Rural localities face rising housing costs, lack of health care access, broadband deserts, and limited job opportunities; and these deepening health, social, and economic inequities have been exacerbated by the COVID-19 pandemic and resultant economic crisis on top of long-standing racial injustices.
Solutions to improve life in rural communities often fail to address the deep-rooted and unjust laws, policies, and practices that have shaped the physical, economic, and social conditions experienced by rural populations over many generations. Reframing assumptions about racial homogeneity is crucial to health equity work. And given the unique diversity and strengths of each rural community, policy solutions need to be tailored to the lived experiences of people in those diverse communities.
“Residents in the rural communities we partner with are key stakeholders in the development of policy solutions,” says Shauneequa Owusu, chief strategy officer at ChangeLab Solutions. “Residents experience firsthand the shortcomings in the communities where they live and are committed to improving their collective experience. It is imperative that BIPOC community members and others who’ve experienced marginalization have a seat at the policymaking table.”
Lessons Learned Through Our Work
ChangeLab Solutions has a long track record of working in rural places that dates back to our inception as a public health nonprofit focused on tobacco control and obesity prevention. We have worked to address upstream drivers of health inequity on policy initiatives that are nationwide, statewide, and local in scope.
Toward Better Rural Futures: A National Project
Our most recent project that serves rural communities is Toward Better Rural Futures, which is funded by the Robert Robert Wood Johnson Foundation and participates in the Aspen Institute’s Thrive Rural Initiative.
Toward Better Rural Futures aims to foster greater collaboration and alignment across local, regional, and state levels of government, equipping leaders with the tools and knowledge to fundamentally shift power, opportunity, and resources in order to create healthy rural places where everyone can thrive.
As the foundation of this work, we conducted a comprehensive policy scan with stakeholder interviews designed to identify high-impact, evidence-based state and local policies that advance racial equity and equitable economic development in BIPOC rural communities experiencing persistent poverty. Kimberly Libman, vice president of policy at ChangeLab Solutions, remarks, “There was broad agreement among the project partners and contributors that we should prioritize work on policies that advance both racial equity and equitable economic development. Our research recognizes that structural racism underpins disparities in wealth, income, and class mobility, so approaching these two drivers of inequity together is key to creating meaningful change.”
Through scoping interviews and cross-partner discussions, important themes surfaced that will continue to inform our work in rural places. First, acknowledging the long, fraught history of extractive and exclusionary policymaking is key to moving health equity forward. While local innovation is vital for equitable policy development, administrative barriers and capacity restraints remain a primary issue in rural communities. Capacity building for local government and community leaders can increase technical knowledge, develop shared resources, and encourage accountable, transparent investment.
Hollie Storie, senior policy analyst at ChangeLab Solutions, notes, “As our project has continued to demonstrate, stakeholders have an appetite for learning and desire meaningful conversations. As we seek to catalyze these conversations in communities, our approach should focus on people first. We continue to learn that shared dialogue with community members is an important anchor in centering rural policymaking directly on lived experience in rural America. We need to specifically involve people and communities whom state and local policies have a history of excluding.”
Integrating these key learnings into the next phase of the project, the partners will develop a suite of tools, resources, and convenings to help state and local decision makers craft policy solutions.
The Tobacco Settlement Endowment Trust: A State-Level Project
Working in rural areas requires partnerships rooted in the communities we serve. Collaborations diversify organizational strengths and can help steward projects through changing political climates and deepen engagement with stakeholders and community members. Our background in Oklahoma begins with a historic lawsuit in 1998, when 46 US states sued the big four tobacco companies, resulting in the Master Settlement Agreement. Oklahoma places 75% of their annual settlement payments from the tobacco industry into the Tobacco Settlement Endowment Trust (TSET), a state grantmaking agency focused on preventing cancer and cardiovascular disease. Our partnership with TSET is our longest-running project that consistently serves rural communities.
Nearly half of Oklahoma’s land falls under tribal sovereignty, and it has the third highest Native American population of any state. Oklahoma ranks sixteenth among US states in percentage of rural residents; more than 1.2 million Oklahomans, or 34% of the population, live in rural communities. Rural BIPOC communities in Oklahoma face significant inequities in health and opportunity; Oklahoma residents who are Black or Native American experience higher rates of obesity, heart disease, and smoking than non-Hispanic white Oklahoma residents.
“Oklahoma presents a unique and sometimes challenging political backdrop to our work,” says Chassidy Coffin, senior policy analyst at ChangeLab Solutions. “At times, our work toward health equity moves in great strides, and at other times, we are incrementally pushing forward to support the health of rural Oklahomans.” For instance, in 2015, ChangeLab Solutions created the Tobacco-Free Schools guide and model policy, which supported TSET grantees in helping schools comply with the new requirements of Oklahoma’s 24/7 Tobacco-Free Schools Act, which went into effect in August 2015. Since then, all public schools, including those on tribal lands, have implemented a 24/7 vape- and tobacco-free policy — a significant win for public health.
Over the past eight years, ChangeLab Solutions has worked closely with TSET and its Healthy Living Program and partners, including the Oklahoma State Department of Health. “In our partnership, we have delivered hundreds of hours of technical legal and policy assistance to TSET, conducted over a dozen trainings, and created more than 40 publications. All of these supports were provided with the express goal of advancing policy, systems, and environmental change in service of healthy eating, active living, and tobacco-free communities,” remarks Chassidy. “The projects we undertake have the greatest impact on communities that are experiencing health inequities and that have historically been overlooked, including Native American communities residing on tribal lands. We will continue to center community members as we work to advance health equity in this ongoing partnership.”
The BUILD Health Challenge in Sunflower County, Mississippi: A Local Project
In Sunflower County, Mississippi, located two hours north by car from Mississippi’s capital city of Jackson, a cross-sector partnership has been working to improve health outcomes for Black mothers and infants by reducing cultural and logistical barriers to breastfeeding. The project is one of 18 awardees of this year’s BUILD Health Challenge®. Since 2019, ChangeLab Solutions has been partnering with BUILD, an initiative of the de Beaumont Foundation, and offering technical assistance on a broad range of health-related issues to communities across the United States.
Cross-sector partnerships are the central pillar of the BUILD model. Each participating team consists of a community-based organization, a local health department, and a hospital or health care system. By strengthening local partnerships, BUILD cultivates a shared commitment to moving resources, attention, and action upstream to address systemic barriers to health. The partners on the Sunflower County BUILD team — Delta Health Alliance, Sunflower County Health Department, and South Sunflower County Hospital — work collaboratively to reduce racial disparities in breastfeeding. Research from the Centers for Disease Control and Prevention (CDC) shows that while breastfeeding has numerous health benefits for both mother and infant, Black infants are less likely to be breastfed than children in other racial and ethnic groups because Black mothers experience disproportionate barriers to breastfeeding. Barriers include insufficient peer support; workplace issues; and low implementation of evidence-based practices to support breastfeeding at maternity care facilities in neighborhoods with large Black populations.
“I learned from the Sunflower County team that Black mothers living in the Mississippi Delta face significant barriers to breastfeeding,” states Katie Hannon Michel, senior attorney at ChangeLab Solutions. “Through conversation with the team, it became clear that making a meaningful impact on this issue requires system-level interventions — namely, adoption and implementation of breastfeeding-supportive policies and practices in hospitals and workplaces — as well as effective framing and messaging to build support for such changes and to begin to address the stigma and bias that Black mothers face in relation to breastfeeding. Making meaningful change also requires direct, individual-level interventions — such as peer support networks for breastfeeding Black parents, to help build trust, community, and connections with resources.” Specific strategies the Sunflower County team has employed include connecting residents with a pre-existing “baby café” support group and developing a campaign to inform residents and employers about the health and economic benefits of breastfeeding and breastfeeding-supportive workplaces. In addition, the team created a breastfeeding-friendly business toolkit to disseminate to employers and hosted a conference that provided continuing education for breastfeeding providers.
“The work done by the Sunflower County team will improve health and support for mothers and young children,” says Katie. “The cross-sector collaborative that BUILD nurtured will have long-lasting impacts as the group continues their work — touching hundreds of families through their baby cafés, hosting ongoing continuing education events on breastfeeding, and building the power of breastfeeding Black mothers to become breastfeeding educators themselves.”
ChangeLab Solutions staff managed the initial review process for applications for the upcoming BUILD 4.0 cohort of awardees. A total of 155 applicants from 33 states applied for the next round of funding and support, which will commence in May 2023. Top areas of focus for this round of applicants include heath care access, healthy food, and housing.
ChangeLab Solutions will continue partnering with rural communities at national, state, and local levels to improve health outcomes and address the fundamental drivers of health inequities. Please stay tuned for updates as our Thrive Rural, TSET, and BUILD work continues in 2023. ChangeLab Solutions staff will be publishing a series of blog posts in 2023 on topics related to our Thrive Rural work.
By Spring Cutter & Patrick Glass
Top image: Michel Curi via Flickr