How Access Shapes Trust in Rural Health Systems

In southeastern North Carolina, residents in Columbus County face some of the steepest challenges to living a healthy life. They consistently have the lowest health outcomes in the state. 

Like in many rural communities, people have to put in more time and effort to access public services and healthcare systems. And a lack of access and familiarity informs how much people trust the systems meant to serve them. 

In this episode, we look at what builds trust in the systems people rely on to stay healthy — and what gets in the way. 

Guests: 

Jason Elleby, mayor of the Town of Brunswick, NC

Helen Holden, owner of Penn’s Grill in Whiteville, NC

Read more about how to talk about health, trust, and rural communities:

Talking about Health Disparities in Rural Contexts by the FrameWorks Institute explores how access, systems design, and community conditions shape health—and how to communicate these issues in ways that build understanding and support for solutions.

Transcript

LAYNA HONG: Most of the systems that shape our health are mundane.

Think of the annual check ups at the doctor’s office. The seasonal flu shot. Using food stamps to buy groceries for Sunday dinner. 

Ideally, people feel as though they can rely on these systems without thinking about it too much.

But when care becomes harder to reach, people have less faith in the systems meant to serve them. 

In places like rural North Carolina, systems are more spread out and information can be hard to get. Building trust in public systems then becomes an uphill battle.  

I’m Layna Hong. Welcome to Rural Narratives.

This week, we’re looking at what builds trust in the systems people rely on to stay healthy — and what gets in the way. 

In Columbus County, in southeastern North Carolina, residents face some of the steepest challenges to healthcare in the state. 

County health rankings are produced annually by the University of Wisconsin. The data shows that people in Columbus County have less healthcare providers and are less likely to have health insurance compared to North Carolinians as a whole. 

All these factors impact how people get care. In Columbus County, many health care and public services are centered in Whiteville. It’s the county seat and largest city. 

When getting help takes more time and effort, people have fewer chances to experience those systems as responsive and trustworthy.

And even when people trust their doctors, they still rely on people like friends, family members and neighbors for information that they use to make decisions about their health.

I spoke with Helen Holden, the owner of Penn’s Grill. She’s Whiteville born and raised. She sees health as something shaped long before anyone enters an exam room. We talked about how she’s trying to play her part in trying to make Whiteville a healthier place. 

Then, we’ll hear from Jason Elleby, the mayor of a town just down the road from Whiteville called Brunswick. He’ll tell us about what he’s doing to build trust in public systems. 

Helen Holden says the first moment she really understood public health as something bigger  than just doctors and exam rooms was during the COVID-19 pandemic. 

HELEN HOLDEN: Families were separated in ways none of us were prepared for.  Grandparents quarantined for safety, children afraid to bring something harmful to their homes. Some didn't have extra money, some didn't have transportation. Some had to choose between paying bills and getting food to someone who couldn't leave the house. 

HONG: Helen’s reading from an essay she wrote connecting public health with communication, access, and trust. At the time, she was running Penn’s Grill, a beloved institution in Whiteville.

HOLDEN: The restaurant has been there since 1945. It was built on hamburgers and hot dogs and fried steak sandwiches.

HONG: During the pandemic, she says she fed people out of her own pockets. 

HOLDEN: I believe that people should at least be able to eat. Their struggles, and you don't know what kind of struggles, but I believe that the least I could do is I can cook, so I feed people. 

HONG: Helen’s 49, and is Whiteville born and raised. 

HOLDEN: I grew up here, moved away after high school, went to college and I moved back 13 years ago. I brought my daughter home to be raised in the area. I love Whiteville. 

HONG: And Penn’s isn’t just a place to get a hot meal. Helen also sees it as a community hub and that it’s her responsibility to educate her customers about what she knows best: food.  

HOLDEN: My family is a long list of educators. I cook, but they were teachers and principals and phenomenal at that. I try to educate customers in different types of foods, healthier foods.

HONG: She started cooking in the restaurant eight years ago, and wanted to give people more menu options. 

HOLDEN: So eight years ago, when I first opened, people were doing low carb and diabetics were looking for better healthy options.

HONG: And as more get into dieting and healthy eating, Helen says a lot of people hear words like gluten-free without really knowing what they mean. 

HOLDEN: I've got husbands calling in for a chef salad gluten free. Well, all the ingredients are gluten free to start with, but it just makes me question…How come they don't know that? 

HONG: In her experience, people are not always getting the kind of explanation they need from the health care system.

HOLDEN: The doctors and the healthcare systems don't explain, like these are the foods you need to stay away from. There's miscommunication or lack of it.

HONG: And that isn’t how things should work. 

HOLDEN: But if you get diagnosed with something, you should know what you should be able to eat and not eat, and there shouldn't be a question about it. You shouldn't have to rely on a restaurant to go ‘Oh, gluten free, that’s fine.’

HONG: When people don’t have all the information, it’s harder to ask for what they need.

And for Helen, that goes far beyond food.

HOLDEN: For instance, all roads aren't state roads. Some roads are county roads, and some roads are city roads. 

HONG: So when you're complaining or asking questions, you might be calling the wrong person you know, because they're not maintained by the city. They're made by the NCDOT. It’s just trying to get information out there for people to read and hopefully use to benefit them.

For Helen, health starts with knowing what’s here and how to use it. So I asked her to describe her vision for a healthier Whiteville.

HOLDEN: Hopefully eating more locally produced foods, utilizing the resources that we have in our county, our local farmers, working together, being more transparent, appreciating the resources we have, and making a plan for tomorrow and next year and five years.

HONG: And as for what stands in the way of her dream? 

HOLDEN: That one, it is a dream. Two, people in general don't like change. Everybody’s stubborn everywhere, it's not just, it's just not the county. You get set in your ways, you get your routines, you know? And I understand that. I mean, I drive the same way to work every day, like I go down this road and I come back this way, and I get weird if I do it backwards.

HONG: But Helen says change becomes more possible when new options feel familiar enough for people to try them. When Helen first introduced healthier options to Penn’s grill, she says it was a big transition for people. 

HOLDEN: Eight years ago, people looked at me like I had eight heads. They're like, what's this? I'm like, It's quinoa or it's a little carb bowl..

HONG: And having the option to order quinoa didn’t mean that your country classics like meatloafs and gravys go away. Helen says it’s important to keep things people are used to when introducing change. 

HOLDEN: We have worked really hard to incorporate healthier options and local source foods. And I think after eight years, the people in the community are appreciating it and are feeling better.

HONG: And even though Helen says people can be stubborn…

HOLDEN: People show up in Whiteville, which is a blessing in Columbus County. They see a car beside the road with a flat tire, people stop and ask,’Can I help you?’ 

HONG: Outside Whiteville, access to public services can be even more limited. I spoke with Jason Elleby, the mayor of Brunswick, a town of a little more than 900 people.

JASON ELLEBY: I wouldn’t say I know everybody. I’ll say I know about 75 percent of everyone. 75 to 80 percent. 

HONG: He primarily works with a team of five, including himself. 

ELLEBY: I do a little bit of everything here, from helping with the planning and zoning to HR stuff to community engagement.

HONG: Elleby has been mayor for close to two years now. He says one of his priorities is improving access to social services.

ELLEBY: We have to go to Whiteville before our health needs, which is not a bad thing, but it would be nice if we could have something like a doctor's office for our elderly people in Brunswick who have a hard time getting transportation. 

HONG: While Columbus County is still ranked near the bottom for health outcomes in the state, it’s an improvement from a decade ago. They used to be ranked last for five years in a row.

Elleby is 36 and has lived in Columbus County his whole life. He says that he’s seen an improvement in healthcare providers in the county. 

ELLEBY: They got better doctors. They are opening up another hospital. They're very involved with the community. They always be at health fairs like they have stepped up above and beyond to get their things done.

HONG: But he says that trust was not always there.

ELLEBY: One point in time I didn't trust ‘em at all.

HONG: In a small community, stories travel fast. And they last. 

ELLEBY: Just the horror stories you hear from other people. There were stories that you hear where one parent went in for a minor surgery and didn't make it out of surgery, or there was somebody that got some kind of staph infection just from being in the hospital on the surgical table.

HONG: These experiences and stories travel throughout the community. They shape how people feel about public health systems long before they walk through the door.

ELLEBY: If you start hearing stuff like that in the community, it's going to scare you.

HONG: One way Elleby has resolved to increase public trust is to bring the Department of Social Services down to Brunswick every couple of months to set up a satellite office. Before, folks would have to go up to Whiteville to apply for programs like Medicaid and food stamps. 

ELLEBY: There was people who said that they were scared to go to the Department of Social Service because they just felt intimidated down there. 

HONG: Those feelings then can outweigh any benefit that social services can provide to the community. 

ELLEBY: I'm not knocking on my Department of Social Services. I love those people. I worked with them for years out there. Sometimes when you go out there, and if you get a certain caseworker, these people do treat you badly there, some of them, not all of them, but you can get treated badly there.

HONG: Nearly half of Columbus County is enrolled in state Medicaid. And about 1 in 8 people under 65 years old still don’t have insurance. But since Elleby and his office started partnering with social services, he says he’s seen a change. 

ELLEBY: But now they come down here, when the Department of Social Services here, they feel more relaxed. And there was one girl who sent us a thank you note because she got approved for her food stamps. 

HONG: And Elleby says even impacting one community member makes him feel good about what he’s doing as mayor. 

ELLEBY: So I mean, of course, I can't save the world, but I can start somewhere. If I help one person at a time, I’m happy with that. 

HONG: And like Helen, he accepts his community for all their complexities and nuances. 

ELLEBY: Oh, we got some characters in Brunswick. Now, you got some characters here, but you know what? I wouldn't give up my citizens for nothing.

HONG: At the beginning of this episode, I said trust might help explain why public systems don’t work the same for everyone. 

In Columbus County, trust begins when institutions meet people where they are. When they understand all their options and feel like their experiences are respected. That kind of trust has to move in both directions.

And as Helen sees it, trust may be one of the most important forms of preparedness a community can have.

HELEN: When I look back at COVID-19, hurricanes and the flooding, I don't see separate events. I see one message: access, communication and trust. Because the next crisis will come and that what carries the community through isn't only supplies and generators, it's trust.

HONG: I’m Layna Hong. Thanks for listening to Rural Narratives.