S3 E10: Living in a Rural Community: Examining the Impact on Health

Episode 10: Living in a Rural Community: Examining the Impact on Health

Marena Works discusses important considerations for policy and services in order to promote health equity in rural communities. She shares barriers to health for citizens living in rural communities, and innovative strategies for overcoming these challenges. In addition, she highlights health disparities and what needs to be done in order to support citizens who live in rural areas.

Marena Works, MSN, MPH, RN

Marena Works is a Board-Certified Public Health Clinical Nurse Specialist and is currently working for UNR as a Public Health Policy and Planning Consultant and for Elko County as the Deputy Health Officer. Marena previously worked for Nevada Health Centers as Director of Clinical Services. Marena spent 10 years working for Carson City where she held positions as Director for Carson City Health and Human Services and Deputy City Manager. Prior to Carson City, Marena was the Chief School Nurse for the Carson City School District.

Marena earned her Master of Nursing, Master of Public Health, and Bachelor of Science in Nursing, all from the University of Nevada, Reno, and a certificate in Population Health Management from Johns Hopkins Bloomberg School of Public Health. She holds a certification in Public/Community Health Nursing from the American Nurses Credentialing Center. Marena also serves on the University of Nevada, Reno School of Public Health Advisory Board, Carson Tahoe Health Audit and Community Benefits Committee.

Marena has lived in northern Nevada since the early 1980’s and enjoys outside activities as well as spending time with her husband, four children and grandchildren.

Key terms: Rural health, healthspan, lifespan, mental health, chronic disease, cultural competency, community advocacy, public health, substance use, access to care, clinician shortage, telehealth

Episode Transcript

CASAT Podcast Network

Hello and welcome to season three of CASAT Conversations.

I am your host, Heather Haslem.

This season we will explore the weighty topic of health equity.

Within each conversation, we will discover insights from researchers, practitioners and experts on this complex and important topic.

We hope you enjoy today’s conversation on today’s episode.

We are joined by Marena Works.

Marena as a consultant with the University of Nevada, Reno School of Medicine.

Welcome Marena.

We’re happy to have you here today.

Thank you.

I’m happy to be here.

So please tell us a little bit about yourself and what inspires you to do the work that you’re doing in health equity.

Okay, great question.

I’m going to start a little bit back when I first moved to Carson city from Los Angeles and I really fell in love with smaller communities and I felt that even after I moved here that I could actually move to a smaller area.

So it just really struck me, I think living out in the rural, I was a young mother when I did go back to school and got my degree in nursing and I was very fortunate at that time to get a scholarship from the Sir Optimist of Reno and I really had a vision and part of that scholarship was to help underserved communities.

So I graduated from you and our School of Nursing and began my career in the community right away as I was hired as immunization nurse for Carson city Douglas and Lyon counties to immunize the two and under age group.

So after that job, I I did hospice care and in hospice care, especially in this area.

It’s Tends to be home visits and I had a 50 mile radius from Carson City where I live that gave me an opportunity to see areas especially in Lyon County that were more on the rural side and more having unmet needs if you will.

So it was a really good eye opening experience.

After that, I worked for the Carson City School district as a chief school nurse and that’s where I got another broad perspective on different challenges facing kids and families.

And then I worked after that for Carson city Health and human services as their director, that’s when I really fell in love with public health in a deeper way.

And then I worked for a few years with Nevada health centers as their director of operations and that brought me to do a lot of work in Elko county, Eureka County where they had clinics and a little bit into lander.

So I really became aware of the rural needs and even when I worked as director for Carson City Health and human services, they were always asking for calls of help out, especially in Elko because for whatever reason Elko has had on and off pertussis outbreaks and due to kind of lack of services, they always needed people to go out and help vaccinate.

Another thing is I had a daughter who did her first year of college out in Elko County and then ended up working out there for a while after her bachelor’s degree and she was applying for veterinary school.

So the first time she applied, she actually missed the deadline because of poor internet connection because she was out, not in the town of Elko, but she was out in a more rural area, really frontier area of Elko County.

So, again, it kind of opened my eyes to, we’ve got a lot of different issues in the rural areas certainly than we face in urban areas.

So that kind of brought me to the work I do today, working for you and our school of Medicine on a special project to help develop health departments in rural Nevada.

So that’s kind of a quick synopsis of how I got to where I’m at today, wow, you’ve had quite the varied career and really have worked across the lifespan um, from immunizations to hospice work.

So, something that comes to mind, really, is that when we think about health equity, rural health might not always be at the forefront of what people think about when it comes to health equity.

Can you tell us a little bit more about how rural health and health equity are connected?

I’m sure.

So, you know, I’ve looked at a lot of different sources on the rural areas, especially with the job that I’m doing now and so I have delved into some of the health problems out in the rural and, you know, even though if you look across the state of Nevada, you’re going to see similarities without a doubt.

So heart disease is going to rise to the top and cancer is going to rise to the top.

But when you look at the rural areas, in fact one of the counties I’m working with has the absolute highest rates in the entire state and not by a little bit, but by a lot and, and another one of the counties is a close second.

So it makes you wonder, well, they’re, they’re not getting something’s happening.

Is that care, is it the availability of what they have?

There’s a lot there that it really deserves a deeper dive into what what is happening.

I think the other thing that I see is when you’re in the urban areas, whether you have, you certainly have more people, maybe you have more advocates.

But some of the things that we’ve instituted, if you look at Reno Carson City Las Vegas area, you see for example, that there’s a push to have walkable areas, There’s a push to have a lot of different things that when you go to the rural ALS just doesn’t happen.

And so there’s multiple things that I think it really leads to an equity in the rural, It’s very hard to get workforce you want.

You know, you’re asking people to go live out in an area that maybe doesn’t have many offerings, Nevada is not known for its best schools as an example.

And so if you’re in the urban areas you have an opportunity to choose a private school.

If you can do so or a charter school, they’re in the rural, we don’t have that.

So you’re confined to this.

So then you’re trying to recruit providers out there and so you’ve got a lot of things against you you’ve got or you think it would be a low cost of living.

Sometimes it’s actually kind of high.

In fact, Elko County is quite a bit higher than the rest of the state in fact for its cost of living.

So you bring pete, you’re trying to recruit people to these areas and it’s very very difficult.

So I think there’s multiple things that layer and add to inequity that we see in the rural.

Yeah, that makes a lot of sense to me.

Um it sounds like lack of choice um lack of access and from a public health perspective right?

Like being able to have those walkable spaces access to fresh fruits and vegetables which um I’ve been in many rural grocery stores where they may look a little sad and they’re incredibly expensive.


Even just lack of access to food.

Exactly, yep.

So I’d love for you to share with us some more data that you think would be helpful for listeners to know.

So maybe starting with any specific data related to mental health needs in the rules.


Uh, so there’s a yearly report, there’s a couple of areas I know that I go to for data.

So Back in, I believe the first year was 2010, there was a large grant put out by the Robert Wood Johnson Foundation to do what’s called the county health rankings.

And so when they started to do that, it was the first time that we got to see county by county data in not only Nevada, but all of the US.

Because what happens again with data in Nevada is it was very traditional to gather statistics for Washoe County, Clark County, and Carson City and then they would lump together the rest of the state.

So it was really hard to know because, you know, even though they’re okay, there are rural counties, but they can still be a little bit different.

So the county health rankings started to divide things up by county and that was super helpful.

And then additionally, when the Affordable Care Act came into play, nonprofit hospitals were required to do community health assessments every three years.

So those are some data sources that I look at.

And then with public health, there was, there’s a move has been now for several years to health departments to become accredited and that’s not only a local health department, but also state health department as part of that accreditation.

They also have to do a community needs assessment.

So these are the main sources that I have looked at and especially in regards to behavioral health, what rises to the top is we have some of the highest rates in these counties.

One of the questions, for example, in the community health rankings goes something like this, that how many, um, like poor mental health days to use self report.

And so that is very high.

In fact, one of the counties, again that I’m working with in trying to develop a new health district has the highest rate by far in the state.

So that’s one thing the depression tends to really rise up and not surprising, I think especially coming out of two years of covid lockdown.

So you already have in isolation if you will in these rural areas.

But some of the things that you do have is, you might be isolated in crescent valley if, if you’re familiar with where that is, it’s, it’s a ways from services, but they do have a senior center, they do have senior lunches.

So there’s some socialization that is available to those who lived there.

But when you took that away with lockdowns, then even that little bit of socialization they had went away.

So depression tended to really rise to the top.

And then I think it’s hard to mention any kind of behavioral health without, you know, unfortunately there’s oftentimes a mix with substance abuse.

So I think the rules see a little bit difference in that in that, um, their rates, you know, you’re not going to see as much heroin at least.

That’s what the numbers I’ve looked at.

I haven’t seen that.

However, there is a lot of meth, so there’s, there can be some um, little bit of differences but but very similar.

The problem is though you get out in these areas and what’s their access.

So we have, um, so the data book that the office of statewide initiatives put out every year, the rural and frontier data book, they will track how many mental health professionals, they track every professional that being one of them in every county.

And so there’s two things number one, you look at that and the number of professionals is very low in these counties coupled with that is the way the data is collected.

It’s where that professional might live and collect their mail, not where they practice necessarily.

So for example, you could have five mental health professionals in Fallon but they practice in Reno so it doesn’t necessarily give a really good picture.

And we, so we intuitively know that the chances are we even have less in these counties than even our data is going to show.


Yeah, those are some major challenges that the rural space and I’m curious also what are some of the physical health needs of people living in the rural.

Yeah, that’s great.

So one of the counties I work with is highest in the state for diabetes prevalence and another one is the second highest in the state for obesity.

They also have these counties have some of the highest smoking rates in the state.

And then I mentioned earlier about heart disease is tends to be higher in the rural areas than we see in our urban areas.

And so they’re, they’re fighting again a lot of the same problems, but they don’t have good avenues for care to help manage and maintain them.

So what we also see then is a lower life expectancy.

And again, one of the counties I don’t even want to mention because I don’t want to point them out, I feel bad for them already, but they have the lowest life expectancy in the state and it’s by several years, by quite a few years.

So, you know, when you look at life expectancy is such a good barometer, if you will of the health of communities.

So when you look at that, you know, you have a problem.

And one of the issues we’ve had in Nevada is the rural czar overseen on a public health platform by the state and the state be in headquartered in Carson city doesn’t have too many boots on the ground in the rural.

So they try, it’s just, it’s a very difficult thing to manage and in some counties, they don’t have really much of a presence at all.

So could this be something that’s leading to some of these causes.

I don’t really know, but I think that there needs to be a way to drill down better and find out why we’re seeing such a disparity in the rural compared to our urban areas.


I also wonder about health expectancy.

Um and just based on the chronic disease rates, I would imagine their health expectancy is lower than those in urban areas too.



Super interesting.

Um so I know that you’ve been doing focus groups across the state of Nevada to understand the needs better within the rural counties and what are some of the themes that you’ve been seeing?

I’m sure.

So what does rise to the top or mental health concerns and substance abuse and those were from the citizens that attended felt that that was some of their biggest problems.

The other thing that rose up was home visits for seniors.


They felt that there’s a lot of shut ins, a lot of people that just somebody needs to kind of get a pulse on what it’s their home situation, like that type of thing.

one of the things we tend to do in the medical field is, let’s say somebody comes into one of these rural hospitals and gets discharged and they need to be on oxygen.

So you set up the oxygen.

The trouble is some of these homes may not even have the electrical power outlets that will run because we tend to put home oxygen on what we call an oxygen concentrator.

So it’s a machine that has to run and so that doesn’t always work and sometimes we forget to even ask people where they live.

I talked to one man who and this was actually by choice.

He actually had money but he lived in his van and this is exactly what happened to him.

He was sent home on oxygen but he had no way to plug anything in so he just didn’t do it.

And so home visits came up as the as a high priority.

The lack of providers was a concern coupled with unreliable or no internet.

So some of these people are willing for example to do telehealth visits but they either don’t have internet or they may not have a computer and they may not know how to use it.

Especially when you’re talking about the platforms that we might be used to such as zoom, that type of thing.

They’re not really sure how to hook up.

The other thing that came up was they felt that there was a tremendous lack of transportation so they might go again to one of these rural hospitals which have a lot of them don’t have have minimal services.

So if somebody needs specialty care they need to go to one of the urban areas and transportation was a big deal for them.

We have no bus service.

Certainly that goes out, some of the areas don’t have taxis or certainly the people can’t really afford them.

The things that again the urban’s might be used to such as right share there’s that’s not available.

We do have a service R.S.V.P. that provides transportation but it can be spotty or they may not have because it’s run off volunteers.

They may not have an available volunteer.

So that came up as an issue.

And and the other thing I understand that it’s kind of the reality is uh in one of the areas they were saying well even if we get R.S.V.P. for transportation they’re as old as we are.

And I and I’m thinking yeah unfortunately I mean as people that are older that tend to have time to volunteer and will volunteer for these services.

That’s not really a bad thing.

I didn’t see it as a bad thing but there was a little bit of a complaint about that.

The other thing that came up is prescriptions.

So to get a prescription in one of the counties for example that the hospital did run a clinic and that was good even though they felt the clinic wasn’t open enough hours.

But then the pharmacy was only open one day a week.

So in order to get to a pharmacy the closest one was over 70 miles away.

So that was that came up as a problem and um that was I think the gist of of all the counties kind of they they had many of the same thing, really, really high on the list.

So we’re definitely home visits that came up very, very high.

So that, that’s in a nutshell what we got out of those community meetings.

Those are major barriers and challenges to promoting health, that the rural space, I’ve worked some in the worlds and um, sometimes there’s a lack of trust, um, with people coming in.

I’m curious if you experience that and how, how do you overcome that as you’re working with?

Um, the rural counties?

That’s a really good question.

I definitely have come across that one county, which is not part of the forum currently working with, I was doing some work in and I still do, they were very, I guess I could use kind of a strong word, vicious.

They, and I think it’s just the unknown.

And so when you come in and you want to offer services, they take that as a negative that you’re trying to somehow take away their control, bring in things that they don’t want anything to do with.

And so it’s very hard to build the trust.

I think the trust comes slowly and it comes piece by piece.

It’s just not going to happen fast.

And I think you have to have the patience and the ability to not get confrontational and not get defensive and it takes a lot of understanding of where they’re at and the fears that they have in one of the four counties that I’m particularly working with that’s actually, I’m not seeing as much of that except in one of the county’s, there’s a little bit of it that there’s a fear, there’s a fear that, you know, it’s kind of this thing where they really want services, but how that comes in is important to them.

And so I think we try really hard to make sure that we get residents that our, our advocates as well, that can help talk to other residents kind of that peer counseling sort of thing.

If you will, that you could, you get their peers that understand that can then go talk to the communities, but it’s a challenge and it’s things that you want to have happen quickly or just going to take a little more time?


And it also really makes me think about cultural competency and that each of these rural counties is their own culture and when an outsider comes in, they need to learn how to speak the language and that takes time.

Exactly see.

And sometimes the consistency part, right.

If there’s just a rolling new face coming from the state, um, on an annual basis, that’s not building that trust or rapport either.

So I could see that being a challenge.

Yeah, Yeah.

So as you’ve been doing this work, what are some of the innovative strategies that you’ve been working on to address some of these challenges.

So the first step is really to develop local health districts.

So one of the things I’m working on is trying to establish what we’re terming the central Nevada health district and you know, the health district.

And this is where I think there’s misunderstanding is a public health department really becomes a hub of community services.

So it starts to really bring together the entities that are doing some things because we do have stuff going on in the rural, We have the coalition’s do a lot of work and they do some really good work.

There are some other local groups, nonprofits that are working.

So I think that bringing it together because what happens is still Sometimes one entity doesn’t know what another is doing.

So I think really closing those gaps in care.

I think a health department is very, very important in one of the rural counties, not the four that we’re working with to really get this health district going, but in another one, um, I was told that one of their issues for recruiting people in especially any kind of of health care provider was that, believe it or not, which kind of surprised me pleasantly surprised me maybe, but was asking if there was a health department and when they found out there was not a local health department that was like a no go for them and maybe that is a sign, which I didn’t think about before as a bigger problem for an area.

and so as you’re recruiting people in, there’s just certain things they really do want to see, but I also think that a health department can really help them.

Another thing that came out in the community meetings was really a lack of education as far as health education, if you will, and whether that dealt with mental health or physical health, it didn’t matter.

And so again, I think that a health department can start to fill those gaps and that’s like a perfect role is some of that teaching area is a great role for a health department.

I think it also helps to get there get a better pulse on the community and it gives the community a better sounding board and keeping these, these concerns of theirs in the forefront so that they had, they, there is at least somebody, some entity working on trying to solve it problems in the world aren’t going to be solved quickly, they’re not going to be solved easily.

There needs to be something at the hub that really helps to pull it together.

So that, that’s what I’m working on and that’s what my vision is for rural Nevada, I think if we can get some district health departments, I think it would be a really good first step and even just thinking about like logistically in Nevada, um, how many of those health departments do you think are needed?

I think probably three ISH, something like that.

So, for example, you know, you got to have some kind of leverage with people in order to make it financially feasible.

So I don’t think that’s why I think it’s not feasible, for example, maybe to have a county by county.

Health Department wouldn’t be the worst thing, but it does make it difficult, difficult to fund and you know, and then, but you can leverage resources better if you’re dealing with a little bit bigger area.

So I think, you know, probably somewhere around three would divide up the rural is in a good way that would help give the coverage that a health department could really then be valuable.

Well, and as you’ve been doing this work, are there any health disparities in rural Nevada that you’ve seen maybe in addition to what you’ve shared?

Um I’m not sure there’s anything any different.

I think it’s just the the big disparity comes into.

How do we get these people care and how do we keep them on a better path so that they can live longer healthier lives.

So that that’s really that just really is the disparity is that we’ve got to somehow figure out how to wrap them into the services that we do have in the state.

I mean, we’re not necessarily the best in Nevada.

I think we’re short, for example, providers, especially mental health providers alter the state, even if you’re in the urban areas, but they’re still just has to be a better way that we can incorporate those rural residents to get the care they need so that we can see their numbers go up.

I mean there’s, we want to see the people that live in, you know, Lander County or Mineral County or Persian County all have the same life expectancy if they live in reno or Carson city or las Vegas.

So, um, but I think it’s just really around what’s been mentioned I think is where we need to focus.

Yeah, that makes sense.

I’m really aware of, you know, the big five when it comes to chronic disease, smoking and activity, alcohol use physical and activity and stress and um, how that’s highlighted in some of the challenges that you’ve discussed people facing in the world or the incidents being higher of some of these health behaviors.

And so when you think about the education piece, I would imagine that’s a big piece of it as well.

It is.

And when that came out at the community group, I was um I was kind of happy it came out because sometimes you think we just over educate everybody and now we just need to, I mean because education as we know isn’t the whole thing, right?

And so sometimes I feel like maybe we’ve educated too much and haven’t done other things too much, but, but they were really feeling just that lack of education.

So I think that really showed me that.

So maybe we’re doing a pretty good job of that and have been in the, in the urban areas, but we really haven’t in the rural Yeah, that was surprising to me too when you share and then you mentioned also the importance of peer support and I could see how peer support specifically in rural counties could be so beneficial if you have a few people advocates are ambassadors really of health in rural that are supporting piers how powerful that could be in a community.


So I really have a vision for utilizing community health workers throughout the worlds and I envision those people as doing some of these home visits, really taking a big lead in the education piece.

So that’s what we’re trying to set up as we do this.

And then one of the other challenges that you identified was internet access and really people wanting telehealth services, some people wanting telehealth services, the internet access, even the example you shared about your daughter um still being a challenge.

So I’m curious if you’re aware of any innovative ways to um getting people access to internet in some of these areas.


You know, I don’t know, I know that statewide for years now there’s been a lot of effort going into getting capabilities out throughout the whole state.

Certainly that needs to continue because we’re still really spotty and I’m not exactly sure where the state is at this point on working on that.

Um, so the access piece of it, I’m not really sure, but the flip side of it with the individuals that need to learn how to use technology that I think we can really make an impact on.

For example, um I have been aware of grants on a national level that you can get that for example would supply maybe ipads or some kind of tablet and then again using community health workers that we could actually teach people how to do that.

There was actually a really good pilot program that was done.

I think it was done in Maryland in the rural areas on how they well, you know, they’re not quite real like we are, you know what I mean?

And they did um they were able to get these devices, they had small group teachings and then they had individual one on one and really made a huge impact and got people over that some have a fear of using technology, some just don’t feel like they can ever learn it.

And I think when going through this, they learned that it wasn’t as bad as they thought it was going to be.

So they actually learned how to use these devices and learn them very well and that and the main goal of that was to connect them to some kind of provider that they needed.

So I, I think that that’s I think our rural areas are really ripe for that type of a program and so I can’t do much about the actual infrastructure, but certainly we could do something about making sure people have devices and know how to use them.

Yeah, that makes a lot of sense.

And then one of the other I would say, I don’t know what stands out is like one of the biggest pieces of this puzzle is lack of providers in these rural communities.

Um and so are there examples from other states or different ideas that you’ve heard or that you have on how to address the lack of providers in the rural counties?

The thing that I have been made aware of really comes down to telehealth because the capacity is better, you can tap in in some instances even out of state if needed.

But I think as an immediate fix that is probably one of the better solutions right now.

You know, I think you know telehealth only goes so far, I think you still need people, I mean people need that touch right and that interaction, but I think telehealth is a good place to start because we just have nothing the other.

But the other thing is we’ve got to figure out better transportation that we have good and consistent transportation for these people to get into care.

And so again, I think that’s something that can be solved.

We you know, we do we have some kind of courier that can transport people, we, I think we can solve this, but we gotta, you know, get some heads together and see what would be the best solution and how we can get people into care because they’re going to have to until we can get more providers in all areas of the state than we’re really looking at getting into an urban area.

But I think again, I think these are all doable.

We just need to figure out what the best route of solving that problem is.

But we can do it well.

And in that vein, I can see the value of these health districts because they know the community, they know the needs and they’re the ones who are putting their heads together to think about these problems.

Whereas if you don’t live in that community, you don’t really understand what’s going on.

So that really strikes me as, you know, one of the big values of having these centralist health districts.

Yeah, I totally agree with you.

So as we um wrap up here, is there anything else that you feel is important for our listeners to know about rural health?

I think we’ve covered it pretty well, but I would just say the residents know they have problems not only with mental health and substance abuse, but in general access to health care and health education.

They just don’t really know how to move that needle.

So the more we can come together and offer what what we may take for granted and ensure that there are some of these things happening all over the state.

I think it’s really going to help and, you know, Nevada, I don’t know if you know this, but Our public health funding, depending on what reference you look at is 49th or 50th in the United States.

So we’re really bad.

So there we need to have a better commitment on a state level to service the rules.

And, you know, when you look at what public health funding, so that that that I’m talking about is being more state general fund.

And then, in additionally, with our grants are federal grants that we get into the state has really been focused on the their urban areas.

And so we’re going to need to have a little better equity on how we’re distributing grant funds.

And I think that’s going to be really helpful.

And then I think, and again, kind of, mental health rises to the top for the residents.

But I think at the moment it’s really going to be telehealth visits and but I do see that great opportunity to utilize community health workers.

So, a lot of really a lot of opportunity, and I think we can grab this opportunity and really make a difference in our state.


Yeah, I can see the movement and really, you talked about that ability to move the needle and so, so glad there’s people like you out there, really advocating for the people’s health in rural counties.

Well, thank you so much for your time and for sharing all the great work that you’re doing across the state today.

We really appreciate it.


Thank you for having me.

Thank you for listening to CASAT Conversations, your resource for exploring behavioral health topics.

We hope you found today’s conversation timely and meaningful.

Please share this podcast with your friends and colleagues.

If you want to learn more, visit us at our blog at CASATondemand.org

CASAT Podcast Network.

This podcast has been brought to you by the CASAT Podcast Network, located within the Center for the Application of Substance Abuse Technologies at the University of Nevada, Reno.

For more podcasts, information and resources visit CASAT.org.

This episode features the song “My Tribe” by Ketsa, available under a Creative Commons Attribution-Noncommercial license.

Disclaimer: This podcast is for educational purposes only. Any advice offered on the podcast is an educational context and is not intended as direct medical advice, nor as a replacement for it. If you are experiencing a medical or life emergency, please call 911. If you are experiencing a crisis, please contact the National Suicide Prevention Lifeline at (800) 273 – 8255.  If you are experiencing stress, and would like professional help please contact your insurance company to identify a therapist in your area or contact the organization you work for and ask about an employee assistance program.

jose l. melendrez, mswclaudia