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Partnership as a Key Mechanism for Sustainability in Health Equity Work

Perspective from a Reproductive Justice Project in Southern Arizona - As fellows from the University of Arizona College of Medicine - Tucson Chapter of the Aequitas Health Honor Society, we wanted to share a perspective piece on the reproductive health equity work our chapter has focused on for the past year. Given our desire to promote equity in the most sustainable way possible, we have particularly focused this piece on our process and the evolution of our project in a way that centered on sustainable partnership. We hope this work will inspire and guide future Aequitas Fellows at the University of Arizona and around the country in their health equity projects.


Alexander Alvarez, MD, PhD

Rosemarie Turk, MD

Christine Hall, MD

Gabrielle Mintz, MD

Efreim Joseph D. Morales, MD

Brooke Anderson, MD

Fellows, University of Arizona College of Medicine - Tucson, 2022


Alexander Alvarez, MD, PhD 1, Rosemarie Turk, MD 1, Levi J. Anderson 2, Christine Hall, MD 1, Gabrielle Mintz, MD 1, Efreim Joseph D. Morales, MD 1, Brooke Anderson, MD 1, Julie S. Armin, PhD 1,✝, Rachel E.M. Cramton, MD 1,✝


1 University of Arizona College of Medicine – Tucson, Tucson, AZ

2 Planned Parenthood Arizona, Inc. – Phoenix, AZ

✝ Authors share position as last author (listed alphabetically)


Background & Motivation


University of Arizona College of Medicine - Tucson Aequitas Fellowship


The University of Arizona College of Medicine - Tucson (UACOM-T) founded its inaugural Aequitas Honors Society Chapter in 2022. To be selected as fellows in the chapter, we, as rising senior UACOM-T students, submitted a self-nomination form describing our commitment to health equity, our previous health equity work during medical school, and our potential thoughts on what the chapter might be able to work on during our tenure as fellows.


Upon our selection, we met numerous times to attempt to identify a single health equity project within Southern Arizona (AZ) on which we could focus our work. These project ideas included topics as broad as community health literacy, local childhood education, and access to reproductive care. Given the Dobbs v. Jackson decision that was poised to severely limit the availability and access to abortion care in AZ, we decided that working on a project related to reproductive health would be timely. We felt that this was especially true for those marginalized populations that would experience even greater limitations in their access to reproductive healthcare in the wake of this decision. To better understand our motivations for doing this work, it is important to examine the reproductive health landscape in Southern AZ and the inequities that have arisen from that landscape.


Reproductive Health Inequities in Southern Arizona


Individuals with uteruses have struggled to achieve health equity and autonomy for centuries in Southern AZ due to restrictions on what they can and cannot do with their own bodies. In this piece, we will specifically discuss the choice to terminate a pregnancy though this is not the only way in which this population’s bodies are inequitably restricted.


One year after AZ was established as a territory, it developed its first set of laws known as the “Howell Code”. This legislature, established in 1864, included the ban of all abortions in AZ (1). In 1901, a new set of laws were passed which not only adopted the Howell Code, but also expanded to prohibit the advertisement or performance of abortion or contraceptive care in AZ (2). Laws banning abortion remained largely unchanged in AZ until the 1972 case of Planned Parenthood Association v. Nelson (3), which deemed abortion restrictions as unconstitutional, issuing an injunction on their enforcement. In January 1973, Nelson appealed this decision and abortions were made illegal once again. However, the United States (US) Supreme Court’s ruling in Roe v. Wade two weeks later (4) led the AZ Court of Appeals to amend their decision on Nelson’s appeal, making abortion officially legal in AZ.


Despite Roe v. Wade, in Southern AZ, the fight against abortion did not stop. The “stadium bill” of 1974, an appropriations bill aimed at providing funding for the University of AZ Stadium expansion further looked to restrict abortion. While the intent of this bill was unrelated to abortion care, a rider was added to the bill stating, "No abortions shall be performed at any facility under the jurisdiction of the board of regents unless such abortion is necessary to save the life of the woman having the abortion (5)." In 1976, the AZ Supreme Court upheld this bill restricting abortion procedures at any sites associated with this hospital system except if the mother’s life is in danger (6). Not only has this had a dramatic effect on access to abortion for community members who already struggle to find accessible abortion resources, but it has also limited the training of medical practitioners in AZ. Trainees at institutions under the jurisdiction of the AZ Board of Regents cannot observe or participate in abortion procedures during their core curriculum at these institutions and must seek elective rotations in order to do so.


Since this ruling in 1976, AZ legislative actions have gone further to restrict abortion access. In April 2021, Senate Bill (SB) 1457 dictated that abortions may not be performed on the basis of genetic abnormality (7). In addition, SB 1457 also prohibited abortion inducing medications distributed through the mail, public contracts with abortion providers or affiliates, and public school promotion of abortion (7). Furthermore, in March 2022, SB 1164 limited abortions to only 15 weeks gestation (8). Despite this legislation, abortions were still protected federally under Roe v. Wade. However, in June 2022, a landmark decision was made to overturn Roe v. Wade in the case of Dobbs v. Jackson leaving the matter of abortion up to the individual states (9).


Since Dobbs v. Jackson, courts and laws in AZ have tried to determine which of its previous legal precedents takes effect – the total ban from the territorial abortion laws of 1864 (1) or the 15 week ban from the more recent SB 1164 (8). In December 2022, the AZ Court of Appeals reconciled the laws in another case that ruled against a total ban of abortion, and decreed that abortions may remain legal in AZ for up to 15 weeks gestation (10). As a result of these limited federal protections, the absolute restriction on abortion after 15 weeks, and the inability to access abortion services at one of the major health centers in Southern AZ, all individuals in Southern AZ with uteruses face severe inequity in their reproductive health. This inequity is only compounded by other marginalizing intersectional factors that individuals with uteruses might face due to their race, ethnicity, socioeconomic status, sexual orientation, gender identity, disability, and more (11).


Case Study: Partnership on a Reproductive Justice Project in Southern Arizona


Project Evolution: From Siloed Work to Partnership with Community Organizations


Given the developing dynamics of the laws while we began our fellowship project in June 2022, we settled on attempting to address reproductive health inequity in Southern AZ. We initially brainstormed ideas including health fairs, a narrative describing women’s experiences with abortion, and community reproductive education to work for reproductive justice. Because of the stadium bill and potential difficulties in a project targeting education regarding abortion services or the provision of those services, we chose to instead focus on the prevention of pregnancy with the provision of long-acting reversible contraception (LARCs).


Initially, we deemed this as an idea that could bring further access to reproductive healthcare services that may have been lacking for uninsured and undocumented individuals in our community, especially in light of abortion restrictions. Though there were other clinics throughout the region that provided these devices, without insurance they cost upwards of one thousand dollars, restricting who might be able to access them. As such, we saw this as an opportunity to help increase equity: we could host a series of clinics in community spaces in primarily black, Latinx, and indigenous neighborhoods in Tucson to provide LARCs (including a hormonal implant or intrauterine device) to individuals with uteruses.


Despite initial excitement surrounding the thought of affecting an immediate change in the community, three issues caused us to pause the project at this stage: the feasibility of carrying out the project, the actual community need for the project, and the sustainability of the project to continue to impact health equity. In the feasibility category, we found that the cost of implementing a LARC clinic would require significant funds. Additionally, the logistics around staffing, reserving space to carry out the clinics, advertising, medical licensure in the clinic, pre-screening and follow-up did not seem to be feasible in the timeline of the project.


Though we had assumed that there was a need in the community for more LARC provision, we did not have any evidence to back up this assumption. Thus, while we could work to host one or more of these LARC clinics, we may have found that we had addressed a nonexistent problem in the community. Finally, we recognized that at the end of our tenure, we would not be able to continue these clinics; thus, even though we might have had an impact on the community temporarily, that would have non-lasting effects on equity.


Because of these three factors, we decided to pivot the project in December 2022. In the new project, we would still focus on achieving reproductive health equity. However, rather than a LARC clinic, we would instead carry out a reproductive health needs assessment in the Southern AZ community. This project would be much more feasible with little to no cost and much easier logistics to coordinate and would actively center community need so that future interventions could target that need.


To achieve the last factor - sustainability - we decided to engage with local community organizations to see if there was an opportunity to carry out a reproductive health needs assessment, the results of which those organizations could then act on. In this search for partners, some members of our group had a pre-existing relationship with PPAZ, the community arm of the larger national organization. This allowed for conversations with PPAZ surrounding potential partnership, where we learned of their new Black Health Equity Initiative. This new initiative focused on increasing the equitable provision of care to black individuals at PPAZ clinics. After multiple meetings, we worked with PPAZ to define a project that we could complete that would aid them – a reproductive health needs assessment that would capture the needs of black and brown people with uteruses in Southern AZ.


A Reproductive Health Needs Assessment for the Black Health Equity Initiative of Planned Parenthood Arizona


With this partnership in place, we began crafting a survey that would assess individuals’ perceived needs for contraceptive and abortion care after the Dobbs v. Jackson decision had passed. In this process, we used a variety of validated instruments with questions and integrated partner feedback to create an annotated question bank with two larger sections - one that asked extensive demographics questions and the other which discussed past, present, and planned contraceptive use and abortion care by individuals in Southern AZ.

Appendix 1
.pdf
Download PDF • 127KB

We planned to implement this not only at PPAZ clinics but also in two free community clinics to see what the needs of different populations in the community might be. By collecting these demographic data and reproductive health needs, we hoped to explore the disparities that black and brown people face in accessing care and to determine what other factors (e.g., socioeconomic status, gender identity, language spoken) might predispose to even greater inequity.


In reviewing the survey with PPAZ at this stage, we learned that despite the potential utility of the material in this annotated survey to other organizations, it did not meet the immediate needs of PPAZ and their Black Health Equity Initiative. Because of the input and guidance of our partners, we pivoted our project to focus more on how we might be able to re-craft the survey to work toward health equity for black individuals. To this end, we developed a new annotated survey that utilized some of the same demographic questions but instead focused on where individuals in the community accessed all sorts of reproductive health services (not just contraception and abortion).

Appendix 2
.pdf
Download PDF • 103KB

Rather than implementing this survey in the clinic, PPAZ could implement it throughout the AZ community to focus on how they could ensure reproductive justice was achieved for black individuals. Additionally, the survey could allow PPAZ to address reproductive health needs specific to the black community.


Discussion


Feasibility, Sustainability, and Centering Community Health Needs in Equity Work


We started our project with the goal of increasing equitable reproductive care for individuals with uteruses who would no longer be able to access abortion services after Dobbs v. Jackson. Though we went through several iterations of how to accomplish this work, the final project accomplishes just that. With an enormous amount of input from our community partner, PPAZ, we crafted a survey that is targeted to increase the provision of reproductive health services to black individuals with uteruses in AZ, a population that has been marginalized and minoritized by the healthcare system for centuries (12). Though we were not able to collect preliminary data during our fellowship tenure, PPAZ plans to implement this survey and will be able to further gauge the accessibility of reproductive healthcare in AZ amongst black community members with its results.


Additionally, the work that we did with our community partners helped us build capacity in our home institution to do more inclusive research. In crafting our initial survey with PPAZ, we were able to create and archive an annotated instrument available to researchers both at the university and more broadly. This has the potential to lead to further studies and needs assessments that could bring about greater health equity not just in Southern AZ but in communities far beyond.


On reflecting on the progression of this project, we think it is important to highlight three principles that might help guide future generations of Aequitas fellows in crafting and implementing their projects. The first is feasibility. Fellows must ensure that the project can be accomplished with the financial and human resources available during a busy year of residency applications, interviews, and finishing medical school curriculum requirements. Though it took us several iterations to settle on a feasible project, our final project with PPAZ achieved this feasibility for our group of fellows. The second is sustainability. Though fellows can do any number of health equity projects, we believe that more impactful health equity work will center on sustainability. We especially would encourage other groups to partner with local organizations and interprofessional groups that can continue their work after they have graduated. We were particularly lucky to work with an organization that will continue to benefit sustainable equity in our community for many years to come – PPAZ. The third is flexible centering of community needs. Though we may have assumptions and anecdotal evidence on what equity work needs to be done in our community, it is essential to ask what the community needs, acknowledge past harm that has been inflicted, follow the examples, knowledge, and lived experience of the people leading movements already in our communities, and build trust with communities and community organizations as humble partners in their work (13). By focusing on partnerships with community organizations and/or utilizing evidence about their community’s needs, fellows can ensure their project truly centers equity. In this process, it is important to listen and learn when projects are not actually meeting community needs, and flexibly adjust to accomplish what community members and community organizations desire.


Disclaimer


The findings and conclusions in this article are those of the authors and do not necessarily reflect the views of Planned Parenthood Federation of America, Inc.


Acknowledgments

We would like to acknowledge all the hard work and support from our collaborators at PPAZ without whom this project would not have been possible. Dr. Sigrid Williams, Kischea Talbert, and April Avilés have been integral to the success of this project and have been massively helpful throughout the past six months.


We would also like to acknowledge the work and input of many of the Aequitas fellows and mentors throughout our project including Drs. Kathy Kuang, Raymond Larez, Iliana Manjon, Francisco Romo, Tala Shahin, Lloyd Spece, and Celia Valenzuela.


References

  1. AZ Howell Code § X-5-45 (1864)

  2. Ariz. Rev. Stat. § 13-211, 13-212, 13-213 (1901)

  3. Planned Parenthood Association v. Nelson. 327 F. Supp. 1290 (D. Ariz. 1971)

  4. Roe v. Wade. 410 U.S. 113 (1973)

  5. Ariz. Rev. Stat. § 15-730 (1974)

  6. Roe v. Arizona Board of Regents. 113 Ariz. 178 (1976)

  7. S.B. 1457, Fifty-Fifth Legislature, First Regular Sess. (Ariz. 2021). https://www.azleg.gov/legtext/55leg/1R/bills/sb1457c.pdf

  8. S.B. 1164, Fifty-Fifth Legislature, Second Regular Sess. (Ariz. 2022). https://www.azleg.gov/legtext/55leg/2R/bills/sb1164p.pdf

  9. Dobbs v. Jackson Women’s Health Organization. 597 U.S. _ (2022).

  10. Planned Parenthood of Arizona, Inc. v. Mark Brnovich. _ Ariz. _ (2022).

  11. Kaufman R, Brown R, Martínez Coral C, Jacob J, Onyango M, Thomasen K. Global impacts of Dobbs v. Jackson Women’s Health Organization and abortion regression in the United States. Sexual and Reproductive Health Matters. 2022;30(1):2135574. doi:10.1080/26410397.2022.2135574

  12. Sutton MY, Anachebe NF, Lee R, Skanes H. Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020. Obstet Gynecol. 2021;137(2):225-233. doi:10.1097/AOG.000000000000422

  13. Chinekezi O, Andress L, Agonafer EP, et al. From the national to the local: Issues of trust and a model for community-academic-engagement. Frontiers in Public Health. 2023;11. Accessed April 16, 2023. https://www.frontiersin.org/articles/10.3389/fpubh.2023.1068425





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