Sometimes, even local just isn’t enough.
Planned Parenthood Great Northwest, Hawaii, Alaska, Indiana, Kentucky (PPGNHAIK) has two brick-and-mortar health clinics in Kentucky – one in Louisville and one in Lexington – “but we know this isn’t sufficient,” said Steven Conrad, PPGNHAIK’s institutional giving officer. Many patients lack the transportation needed to easily travel a long distance to a clinic, don’t have time, or don’t have the child care needed to make it to an appointment.
Conrad reported that 76 of Kentucky’s 120 counties have no OB/GYNs.
For people who need birth control, getting to a local clinic may not even be a desirable option. Their parents or a friend’s parents may work there, or they may just feel concerned about whom they might encounter in the waiting room.
“Sometimes folks in rural areas only have access to one county health clinic, and they may not feel comfortable going to that clinic for birth control,” Conrad said. “We sometimes hear from patients that they forego reproductive health services due to fear of judgment.”
PPGNHAIK decided to think outside the box, with an increased focus on providing virtual appointments to Kentucky patients with a clinician through their Planned Parenthood Direct app.
In many states, the Planned Parenthood Direct app, which launched in 2017 and has more than 320,000 enrolled users, can provide birth control, emergency contraception, and UTI treatments. In Kentucky, the only service currently available is birth control, although PPGNHAIK is working to change that.
Through Direct Relief’s Community Health Awards, funded by Bayer, PPGNHAIK is working to expand awareness and access to patients seeking birth control in Kentucky, with the goal of doubling the number of Kentuckians receiving contraceptive care through the Planned Parenthood Direct app. The organization is one of three that received $50,000 to expand creative programs that remove barriers to reproductive health care in underserved communities. The Community Health Awards are currently in their second year; first-year awardees are profiled here.
“This generous grant from Direct Relief will support PPGNHAIK’s efforts to increase awareness of and access to telehealth services, which is critical to providing sexual and reproductive health care in communities facing the most barriers to care,” said Rebecca Gibron, CEO of PPGNHAIK, in a statement.
According to the Guttmacher Institute, 47% of Kentucky’s pregnancies are unintended. Conrad explained that teen birth – Kentucky has the fourth-highest rate in the country – and unintended pregnancies increase the rate of childhood poverty and can perpetuate poverty over generations.
That’s particularly problematic in Kentucky, which is among the poorest states in the U.S., with a poverty rate of 16.3%. Poverty rates for women are even higher, and the country has the fourth-highest teen birth rate in the country.
“Through the Planned Parenthood Direct app, we can…provide the same quality care that [patients] would receive at a health center visit. We want every patient – no matter where they are – to be able to stay healthy and reach their life goals,” Conrad said.
In particular, he explained, the pandemic has shown the importance of providing virtual access to contraception in rural areas.
The app isn’t intended to replace in-person exams, and clinicians still counsel patients on the importance of getting preventative care. “This can be a challenge with some patients who like the comfort of telehealth services, getting them in the clinic for preventative care and continuing to follow up with those services needed,” said nurse practitioner Deborah Dlik, who provides virtual care in Kentucky through Planned Parenthood Direct.
Still, Conrad said, it’s an effective part of the picture: “PP Direct can help countless Kentuckians take control of their reproductive lives.”
Learning from local sources
Dr. Caroline Weinberg has learned a lot from launching a mobile reproductive health clinic in rural Mississippi.
“If someone had given me $1 million the day I had the idea…it wouldn’t have been a good program that was a part of the community,” she said. “You do really need that time to get to know the community.”
Weinberg was drawn to Mississippi because of its maternal health outcomes – for example, the state has approximately 33 maternal deaths per 1,000 live births, nearly twice the national average – but quickly found that providing sexual, reproductive, and primary care in a rural setting wasn’t going to be a straightforward enterprise.
“The fact that I was not from Mississippi was a barrier, and a totally legitimate one,” she said, citing a long history of “people shoving local perspectives to the side to think that they could solve every problem.”
Through conversations – often over meals – with members of local communities, she learned some indispensable lessons: Hire local, but not too local, because no one wants to run into a reproductive health provider at the supermarket. Confidentiality is everything, because sometimes clinic workers will talk – even though doing so is in violation of federal confidentiality requirements. Trusted local programs often don’t have an Internet presence. Don’t advertise that you’re offering birth control – instead, focus on whole-person wellness and primary care – “because if you do, everyone will know your business when you walk into the clinic.”
Today, the clinic provides sexual and reproductive health care, along with primary care, to people throughout rural Mississippi, often traveling to towns with populations as small as 170 people. “If you go to a town of 170 people and you see 10 people, you’ve done a really good job at outreach,” Weinberg said. “Sometimes we travel 100 miles to see 10 people, and that’s OK.”
Education is a major component of the work her team does. Weinberg gave the example of a man who came in with syphilis and was concerned it might turn into HIV/AIDS. Encouraging patients to get Pap smears and mammograms – Weinberg said many don’t bother, because they think they won’t be able to get the follow-up care that’s needed if something is wrong – is also essential.
And her team has grown accustomed to dealing with crisis situations: “Basically never a week goes by without someone coming in…with blood pressure high enough to go to the emergency room.” One patient came in with blood pressure of 220/110. The team got her to the emergency room immediately, then followed up with her.
Without the mobile clinic, many patients may not get care at all. In some cases, “you have to choose between getting food on the table or getting your kid to a doctor or getting yourself to a provider,” Weinberg said.
The grant from Direct Relief and Bayer will help Plan A try new things, like doing education in high schools and hiring a community health worker to present at events. “Part of the problem with operating on a shoestring, which a lot of mobile clinics do…is that there’s not a lot of room to experiment and see what works,” Weinberg said. “You’re worried about every dime.”
In addition, she thinks it will increase trust in the community, because they’ll be able to fulfill more needs. “We really hate saying no to people,” Weinberg said.
Creating a comfortable environment
For safety-net clinics in Oklahoma, providing sexual and reproductive health services means making patients comfortable, whether that means culturally responsive care, trauma-informed care, or simply creating a place where vulnerable patients feel willing to discuss an often uncomfortable subject.
The organization Health Alliance for the Uninsured (HAU) is working to make patients more comfortable in central Oklahoma clinics, as part of a larger collaborative project with the group Thrive OKC, a sexual health collective aimed at youth. The goal? To provide trainings to up to 30 medical staff and volunteers from 10 clinics, with the goal of improving the family planning services they provide.
The collaborative wants to “help providers to help their patients to navigate their reproductive choices,” said Dr. Ronneal Mathews, Thrive OKC’s director of community engagement. The trainings are designed to help providers “create spaces where, when adolescents do come in to access their services, it’s an environment that’s comfortable for them.”
In particular, HAU and Thrive OKC are focused on “walking clinicians through some really practical steps that they can take to make their clinics…more accessible for a younger audience.”
The training, called the One Key Question Certification Training, is built from an evidence-based curriculum by the organization Power to Decide. Mathews said the goal is for providers to begin by asking patients if they plan to become pregnant in the next year, and help patients make family planning decisions from there.
Asked why Oklahoma in particular needed this intervention, Mathews explained, “It’s difficult in Oklahoma at this point in time for teens to find places where they can seek reproductive health services…it’s really important for them to provide care that is confidential…nonjudgmental and non-shaming.”