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State-Level Recommendations to Reduce Inequities in Sexually Transmitted Infections

Published:August 09, 2022DOI:https://doi.org/10.1016/j.whi.2022.07.002
      Sexually transmitted infections (STIs) are common and costly in the United States, and people who are Black, American Indian/Alaskan Native, or Native Hawaiian or other Pacific Islander experience consistently higher rates of STIs (
      Centers for Disease Control and Prevention (CDC)
      CDC fact sheet: Incidence, prevalence, and cost of sexually transmitted infections in the United States.
      ;
      Centers for Disease Control and Prevention (CDC)
      Sexually transmitted disease surveillance 2019.
      ;
      Centers for Disease Control and Prevention (CDC)
      Sexually transmitted disease surveillance 2018: Tables.
      ). Furthermore, STI rates have been increasing across all racial/ethnic groups for the past several years at an alarming rate, particularly among those 15–24 years old (
      Centers for Disease Control and Prevention (CDC)
      Sexually transmitted disease surveillance 2019.
      ).
      STI acquisition is influenced by social determinants of health (e.g., poverty, residential racial segregation, and inadequate health care access), which disproportionately impact people of color and make it more difficult to be sexually healthy (
      National Academy of Sciences, Engineering, & and Medicine
      Sexually transmitted infections: Adopting a sexual health paradigm.
      ;
      • Tapp J.
      • Hudson T.
      Sexually transmitted infections prevalence in the United States and the relationship to social determinants of health.
      ). Historically embedded structures and functions of U.S. society maintain hierarchies of power based on social identity and underlie the unequal distribution of social determinants of health between socially defined groups (
      • Feagin J.
      • Bennefield Z.
      Systemic racism and U.S. health care.
      ). Both structural and social determinants of health, therefore, explain in part racial inequities in STIs (
      • Bowleg L.
      • Malekzadeh A.N.
      • Mbaba M.
      • Boone C.A.
      Ending the HIV epidemic for all, not just some: Structural racism as a fundamental but overlooked social-structural determinant of the US HIV epidemic.
      ).
      The federal government recently created an inaugural 5-year plan (2020–2025) to reverse the recent rise in STIs, including goals to reduce STI-related disparities and inequities (
      U.S. Department of Health and Human Services (DHHS)
      Sexually transmitted infections national strategic plan for the United States: 2021–2025.
      ). Specific objectives center on federal power; however, given that many domains of social determinants of health (such as education, employment, and incarceration) are under state jurisdiction, state governments must concurrently and urgently lay the groundwork to help decrease inequities in STIs (
      U.S. Department of Health and Human Services (DHHS)
      Sexually transmitted infections national strategic plan for the United States: 2021–2025.
      ).
      Addressing inequities in STIs means addressing the interrelated systemic factors that produce these inequities across local, state, and federal levels. Practice and policy interventions that focus on the experiences of historically oppressed groups can improve sexual health for all people (
      • Bowleg L.
      • Malekzadeh A.N.
      • Mbaba M.
      • Boone C.A.
      Ending the HIV epidemic for all, not just some: Structural racism as a fundamental but overlooked social-structural determinant of the US HIV epidemic.
      ). Sexual health care must be delivered to people of all genders, races, and socioeconomic backgrounds in a manner that upholds the tenets of reproductive justice (“the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities”) (
      SisterSong
      Reproductive justice.
      ).
      Louisiana exemplifies how state policy changes could have a large impact on STI rates and disparities. Louisiana ranks 49th for chlamydia, 45th for gonorrhea, and 46th for syphilis rates in the United States (
      Centers for Disease Control and Prevention (CDC)
      Sexually transmitted disease surveillance 2018: Tables.
      ) and 15- to 24-year-olds in Louisiana have some of the highest rates of STIs in the country (
      Centers for Disease Control and Prevention (CDC)
      Sexually transmitted disease surveillance 2018: STDs in adolescents and young adults.
      ;
      Louisiana Department of Health (LDH)
      Office of Public Health, & STD/HIV/Hepatitis Program. 2018 STD/HIV surveillance report.
      ). Moreover, STI rates are approximately four to six times higher among Black people than White people in Louisiana (
      Louisiana Department of Health (LDH)
      Office of Public Health, & STD/HIV/Hepatitis Program. 2018 STD/HIV surveillance report.
      ), and these racial disparities are evident across socioeconomic strata (poverty, unemployment, income inequality, median household income, and percentage of college graduates) (
      • Mary Amelia Center for Women’s Health Equity Research
      The health of women & girls in Louisiana: Sexual health.
      ).
      Using Louisiana as a case example, this commentary offers state-level policy recommendations to address various factors that underlie adverse sexual health outcomes within a conservative state hit relatively hard during the COVID-19 pandemic. The recommendations that follow are specific to Louisiana, but would have broad applications to many states across the nation. Despite several disappointing legislative defeats, advocates continue to seek bipartisan support for measures that will uphold sexual and reproductive health as fundamental human rights necessary to ensure all people have an equal chance of living healthy and safe lives.

      Health Insurance Coverage

      Health insurance coverage is an important first step in accessing and using health care. Louisiana's Democratic Governor John Bel Edwards expanded Medicaid health insurance coverage by executive order immediately upon his election in 2016, which resulted in one of the sharpest state-level declines in the uninsured rate among women of childbearing age (26% in 2013 to 11% in 2017) in the United States (
      • Searing A.
      • Ross D.C.
      Medicaid expansion fills gaps in maternal health coverage leading to healthier mothers and babies.
      ). Results are mixed as to whether states that expanded Medicaid improved reproductive health care use (e.g., earlier entry into prenatal care) (
      • Searing A.
      • Ross D.C.
      Medicaid expansion fills gaps in maternal health coverage leading to healthier mothers and babies.
      ) or not (e.g., STI screening) (
      • Hatch B.
      • Hoopes M.
      • Darney B.G.
      • Marino M.
      • Templeton A.R.
      • Schmidt T.
      • Cottrell E.
      Impacts of the Affordable Care Act on receipt of women's preventive services in community health centers in Medicaid expansion and nonexpansion states.
      ). Although this step was taken through executive order, legislatures are also critical for expanding health insurance coverage. For example, on April 1, 2022, Louisiana became the first state to extend postpartum Medicaid coverage through the American Rescue Plan (
      U.S. Department of Health & Human Services (DHHS)
      Thousands more people with Medicaid and CHIP coverage now eligible to access critical postpartum coverage thanks to the American Rescue Plan.
      ), encouraged by a bipartisan legislative resolution. Extended postpartum Medicaid coverage will give more than 14,000 women in Louisiana greater access to reproductive health access, including STI services (
      U.S. Department of Health & Human Services (DHHS)
      Thousands more people with Medicaid and CHIP coverage now eligible to access critical postpartum coverage thanks to the American Rescue Plan.
      ); such extensions are associated with improved postpartum reproductive health access (
      • Dunlop A.L.
      • Joski P.
      • Strahan A.E.
      • Sierra E.
      • Adams E.K.
      Postpartum Medicaid coverage and contraceptive use before and after Ohio's Medicaid expansion under the Affordable Care Act.
      ;
      • Thiel de Bocanegra H.
      • Chang R.
      • Howell M.
      • Darney P.
      Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage.
      ). This initiative shows how partnerships between the federal government and a state's executive and legislative branches can work together to unlock resources to expand health care coverage for vulnerable populations.

      Sexual Health Services

      Increase Availability of Sexual Health Services

      Obstetricians/gynecologists and family planning clinics are primary sources of sexual health care in the United States (
      • Hall K.S.
      • Patton E.W.
      • Crissman H.P.
      • Zochowski M.K.
      • Dalton V.K.
      A population-based study of US women's preferred versus usual sources of reproductive health care.
      ), but access in Louisiana greatly depends on where one lives. Approximately one in four women of reproductive age reside in a parish with limited or no obstetric health care (
      • Wallace M.
      • Dyer L.
      • Felker-Kantor E.
      • Benno J.
      • Vilda D.
      • Harville E.
      • Theall K.
      Maternity care deserts and pregnancy-associated mortality in Louisiana.
      ). However, Louisiana has at least one publicly supported reproductive health clinic per parish (
      • Frost J.J.
      • Blades N.
      • Zolna M.R.
      • Douglas-Hall A.
      • Bearak J.
      Publicly funded contraceptive services at U.S. clinics, 2015.
      ), which provides essential reproductive health services (e.g., STI testing and treatment) (
      • Frost J.J.
      • Frohwirth L.F.
      • Douglas-Hall A.
      • Blades N.
      • Mueller J.
      • Pleasure Z.H.
      • Kochar S.
      Publicly supported family planning services in the United States: Likely need, availability and impact, 2016.
      ). This care is indispensable. In 2016, such services helped to avert 2,460 cases of chlamydia and 530 cases of gonorrhea, and they are estimated to have saved Louisiana nearly $17.5 million in health care costs otherwise associated with undiagnosed STIs (
      • Frost J.J.
      • Frohwirth L.F.
      • Douglas-Hall A.
      • Blades N.
      • Mueller J.
      • Pleasure Z.H.
      • Kochar S.
      Publicly supported family planning services in the United States: Likely need, availability and impact, 2016.
      ). However, many states, including Louisiana, experienced an increase in the number of women in need of publicly supported reproductive health services from 2010 to 2016 (
      • Frost J.J.
      • Frohwirth L.F.
      • Douglas-Hall A.
      • Blades N.
      • Mueller J.
      • Pleasure Z.H.
      • Kochar S.
      Publicly supported family planning services in the United States: Likely need, availability and impact, 2016.
      ). Thus, state legislatures must meet the growing need for such services by appropriating operational funding for publicly supported reproductive health clinics (
      • Frost J.J.
      • Frohwirth L.F.
      • Douglas-Hall A.
      • Blades N.
      • Mueller J.
      • Pleasure Z.H.
      • Kochar S.
      Publicly supported family planning services in the United States: Likely need, availability and impact, 2016.
      ). These allocations should also be present in gubernatorial budget proposals.
      Nationally, sexual health services are less available in rural areas (
      • Jenkins W.D.
      • Williams L.D.
      • Pearson W.S.
      Sexually transmitted infection epidemiology and care in rural areas: A narrative review.
      ). To entice more sexual health providers into rural and underserved areas, state legislatures and departments of health should develop adequate reimbursement models, residency training programs, and financial incentives (
      Centers for Medicare and Medicaid Services
      Improving access to maternal health care in rural communities: Issue brief.
      ). Financial incentives such as scholarships and loan repayment programs may offer only a short-term solution to the workforce shortage; results are mixed as to whether providers remain after the fulfilment of their commitment (
      • Grobler L.
      • Marais B.J.
      • Mabunda S.
      Interventions for increasing the proportion of health professionals practising in rural and other underserved areas.
      ). Retention programs and ongoing professional support may help to retain providers after their initial obligation period (
      • Grobler L.
      • Marais B.J.
      • Mabunda S.
      Interventions for increasing the proportion of health professionals practising in rural and other underserved areas.
      ). The Louisiana State Loan Repayment Program within the Louisiana Department of Health offers a reduction of education debt (≤$30,000 per year) in return for a 3-year commitment to serving in a designated health professional shortage area (
      Louisiana Department of Health and Hospitals (LDH), & Bureau of Primary Care and Rural Health
      Louisiana state loan repayment program.
      ). Eligibility includes reproductive health care providers such as obstetricians/gynecologists, certified nurse practitioners, and certified nurse midwives (
      Louisiana Department of Health and Hospitals (LDH), & Bureau of Primary Care and Rural Health
      Louisiana state loan repayment program.
      ).
      Gaps in health care provision could also be filled if the state eliminated the collaborative practice agreement or provided exemptions that allow advanced practice nurse practitioners (APRNs) to practice in the state more freely (
      New Orleans Maternal and Child Health Coaltion
      Enhance access to quality care: Eliminate Louisiana’s Collaborative Practice Agreement Law [White paper].
      ). In 2021, Louisiana state legislative efforts to allow full practice authority for APRNs (i.e., to practice independently without the oversight of a collaborating physician) was denied (
      • House Bill 495
      Nurses: Allows full practice authority for advanced practice registered nurses.
      ). In 2022, Senate Bill 175 and House Bill 543 were put forth by a Democratic senator and Republican representative and would allow exemptions for collaborative practice agreements (e.g., the APRN has a valid APRN license in Louisiana and has experience as recognized by the State Board of Nursing to be ≥ 1,000 hours in collaborative practice); time will tell if these versions are less controversial and, therefore, more likely to pass (
      • House Bill 543
      Nurses/registered: Provides with respect to advanced practice registered nursing.
      ;
      • Senate Bill 175
      Nurses: Provides relative to advanced practice registered nursing.
      ). Reducing regulation of a particular industry, such as advanced practice nursing without additional oversight from a physician, may appeal to Republican legislators who may be willing to partner with Democratic colleagues seeking to expand care by APRNs.

      LGBTQ+ Protections

      Further contributing to stigma that impacts health-seeking services, the Louisiana State Legislature continuously facilitates LGBTQ+ discrimination and stigma by introducing bills to limit rights of LGBTQ+ adolescents. In 2020, state legislators tried to require parental consent for gender-affirming care (Senate Bill 104) and require athletic teams or school-sponsored sporting events to be designated based on “biological sex” (House Bill 466 and Senate Bill 172) (
      • SIECUS
      Louisiana state profile fiscal year 2021.
      ). These attempts, which died in committee, would have further stigmatized LGBTQ+ persons and would have led to an avoidance of health care owing to anticipated discrimination (
      • Alencar Albuquerque G.
      • de Lima Garcia C.
      • da Silva Quirino G.
      • Alves M.J.
      • Belem J.M.
      • dos Santos Figueiredo F.W.
      • Adami F.
      Access to health services by lesbian, gay, bisexual, and transgender persons: systematic literature review.
      ;
      • Casey L.S.
      • Reisner S.L.
      • Findling M.G.
      • Blendon R.J.
      • Benson J.M.
      • Sayde J.M.
      • Miller C.
      Discrimination in the United States: Experiences of lesbian, gay, bisexual, transgender, and queer Americans.
      ). Legislators should stop introducing such bills.
      One bright spot for LGBTQ+ rights in recent years occurred in 2017 when HB27, introduced by Republican Patrick Connick, was signed into law by Governor Edwards (
      Act No. 79
      Domestic abuse: Amends the definition of "household member" for purposes of assistance and protection from domestic abuse.
      ). By removing language that limited domestic violence protections to those in opposite-sex relationships, Democrats and Republicans expanded the rights of domestic violence victims to include those who are LGBTQ+ (
      Act No. 79
      Domestic abuse: Amends the definition of "household member" for purposes of assistance and protection from domestic abuse.
      ).

      Strengthen Sex Education

      Mandate Comprehensive Sex Education Curriculum

      Comprehensive sex education is crucial to equipping young people with the knowledge and skills necessary to reduce the risk of STIs and live sexually healthy lives (
      • American Public Health Association
      Sexuality education as part of a comprehensive health education program in K to 12 Schools.
      ). Schools are not legally required to teach sex education (
      • Permitted Courses of Study
      ), and approximately one-third of parishes have opted not to teach any sex education (
      Louisiana Public Health Institute (LPHI)
      School sex ed policy matrix 2018-2019. Personal email communication between LPHI and Melissa Goldin Evans.
      ). However, like many other states, Louisiana permits abstinence-plus sex education in grades 7-12, which includes information about contraception and condoms in the context of abstinence messages (
      • Permitted Courses of Study
      ). Among parishes with a sex education policy, there is no standardized curriculum (
      • Permitted Courses of Study
      ), despite the majority (74%) of K-12 parents in a statewide survey reporting they would prefer their children were taught how to use and obtain birth control and condoms (
      Louisiana Public Health Institute (LPHI)
      Louisiana parent survey.
      ). Because most Louisiana public school districts are majority Black and tend to be in impoverished areas (
      • Louisiana Budget Project
      Separate and unequal: School segregation in Louisiana 65 years after Brown v. Board.
      ), a combination associated with pediatric health inequities (
      • Heard-Garris N.
      • Boyd R.
      • Kan K.
      • Perez-Cardona L.
      • Heard N.J.
      • Johnson T.J.
      Structuring poverty: How racism shapes child poverty and child and adolescent health.
      ), it is imperative that all public schools in Louisiana teach evidence-based sex education to decrease the risk of STIs among Black youth and low-income youth, who are at greater risk of STIs.
      All students in secondary school should receive evidence-based comprehensive sexual education that includes risk reduction strategies for unintended pregnancy, STI and sexual violence prevention, and LGBTQ+ -specific guidance. The CrAFT Curriculum, for example, developed by the Institute of Women and Ethnic Studies to serve Louisiana students, is currently in three New Orleans schools, and it integrates comprehensive sex education with gender-transformative and trauma-informed concepts within a human rights framework (
      Institute of Women and Ethnic Studies
      The CrAFT curriculum: A deeper dive into the how’s and why’s of IWES’ unique spin on comprehensive sex ed.
      ).

      Allow Data Collection on Sexual Health Among Adolescents

      Louisiana is one of several states where state law forbids testing, quizzing, or surveying students about their personal beliefs or practices regarding sex (
      • Permitted Courses of Study
      ). Without robust data collection, evaluation of sex education programs and teen sexual health will remain incomplete and insufficient. Thus, to understand and support adolescent teen sexual health, the Louisiana state legislature should allow data collection on sexual risk behaviors (
      Centers for Disease Control and Prevention
      Youth risk behavior survey: Louisiana 2019.
      ). Last, school-based health care programs in Louisiana should be allowed to provide contraceptive services, as such services have a demonstrated ability to increase STI testing (
      • Dittus P.J.
      • De Rosa C.J.
      • Jeffries R.A.
      • Afifi A.A.
      • Cumberland W.G.
      • Chung E.Q.
      • Ethier K.A.
      The project connect health systems intervention: Linking sexually experienced youth to sexual and reproductive health care.
      ;
      • Ethier K.A.
      • Dittus P.J.
      • DeRosa C.J.
      • Chung E.Q.
      • Martinez E.
      • Kerndt P.R.
      School-based health center access, reproductive health care, and contraceptive use among sexually experienced high school students.
      ).

      Conclusions

      This commentary describes how state-level policies contribute to disparities in STIs and highlights several opportunities to improve sexual health and advance health equity. Although specific to policies in Louisiana, the recommendations could be applicable to other states. Recommendations include policies that increase investment in sexual and reproductive health care services, protect and promote LGBTQ + sexual and reproductive health needs, and strengthen sexual health education. Furthermore, inequities in STIs can be decreased when policies purposefully aim to create equitable opportunities for health and well-being where all women and their families live, work, and play, and there is an understanding of how interconnected systems (well beyond health care) function as a whole to shape inequities (
      • Gee G.C.
      • Hicken M.T.
      Structural racism: The rules and relations of inequity.
      ). In particular, poverty reduction efforts would have an outsized impact by combating deep-seated structural conditions that shape people's ability to lead healthy lives. These are not intractable problems and state policies alone cannot rectify them. The federal government has an important role in STI prevention and family planning services through the CDC, Title X, and workforce programs. Thus, solutions will require cooperation across sectors and political party to decrease disparities in sexual health, enhance opportunities for equitable health, and enable all people in Louisiana and beyond to live healthy and happy lives.

      References

        • Act No. 79
        Domestic abuse: Amends the definition of "household member" for purposes of assistance and protection from domestic abuse.
        (Available:)
        www.legis.la.gov/legis/BillInfo.aspx?s=17RS&b=HB27&sbi=y
        Date: 2017
        Date accessed: January 3, 2022
        • Alencar Albuquerque G.
        • de Lima Garcia C.
        • da Silva Quirino G.
        • Alves M.J.
        • Belem J.M.
        • dos Santos Figueiredo F.W.
        • Adami F.
        Access to health services by lesbian, gay, bisexual, and transgender persons: systematic literature review.
        BMC International Health and Human Rights. 2016; 16: 2
        • American Public Health Association
        Sexuality education as part of a comprehensive health education program in K to 12 Schools.
        (Available:)
        • Bowleg L.
        • Malekzadeh A.N.
        • Mbaba M.
        • Boone C.A.
        Ending the HIV epidemic for all, not just some: Structural racism as a fundamental but overlooked social-structural determinant of the US HIV epidemic.
        Current Opinion in HIV and AIDS. 2022; 17: 40-45
        • Casey L.S.
        • Reisner S.L.
        • Findling M.G.
        • Blendon R.J.
        • Benson J.M.
        • Sayde J.M.
        • Miller C.
        Discrimination in the United States: Experiences of lesbian, gay, bisexual, transgender, and queer Americans.
        Health Services Research. 2019; 54: 1454-1466
        • Centers for Disease Control and Prevention (CDC)
        Sexually transmitted disease surveillance 2018: STDs in adolescents and young adults.
        (Available:)
        www.cdc.gov/std/stats18/adolescents.htm
        Date: 2019
        Date accessed: April 12, 2021
        • Centers for Disease Control and Prevention
        Youth risk behavior survey: Louisiana 2019.
        2019 (Division of STD Prevention)
        Date accessed: February 10, 2021
        • Centers for Disease Control and Prevention (CDC)
        Sexually transmitted disease surveillance 2018: Tables.
        (Available:)
        www.cdc.gov/std/stats18/tables.html
        Date: 2019
        Date accessed: December 15, 2020
        • Centers for Disease Control and Prevention (CDC)
        CDC fact sheet: Incidence, prevalence, and cost of sexually transmitted infections in the United States.
        (Available:)
        • Centers for Disease Control and Prevention (CDC)
        Sexually transmitted disease surveillance 2019.
        (Atlanta: U.S. Department of Health and Human Services; 2021)2021
        • Centers for Medicare and Medicaid Services
        Improving access to maternal health care in rural communities: Issue brief.
        (Available:)
        • Dittus P.J.
        • De Rosa C.J.
        • Jeffries R.A.
        • Afifi A.A.
        • Cumberland W.G.
        • Chung E.Q.
        • Ethier K.A.
        The project connect health systems intervention: Linking sexually experienced youth to sexual and reproductive health care.
        Journal of Adolescent Health. 2014; 55: 528-534
        • Dunlop A.L.
        • Joski P.
        • Strahan A.E.
        • Sierra E.
        • Adams E.K.
        Postpartum Medicaid coverage and contraceptive use before and after Ohio's Medicaid expansion under the Affordable Care Act.
        Women’s Health Issues. 2020; 30: 426-435
        • Ethier K.A.
        • Dittus P.J.
        • DeRosa C.J.
        • Chung E.Q.
        • Martinez E.
        • Kerndt P.R.
        School-based health center access, reproductive health care, and contraceptive use among sexually experienced high school students.
        Journal of Adolescent Health. 2011; 48: 562-565
        • Feagin J.
        • Bennefield Z.
        Systemic racism and U.S. health care.
        Social Science and Medicine. 2014; 103: 7-14
        • Frost J.J.
        • Blades N.
        • Zolna M.R.
        • Douglas-Hall A.
        • Bearak J.
        Publicly funded contraceptive services at U.S. clinics, 2015.
        (Avaialble:)
        • Frost J.J.
        • Frohwirth L.F.
        • Douglas-Hall A.
        • Blades N.
        • Mueller J.
        • Pleasure Z.H.
        • Kochar S.
        Publicly supported family planning services in the United States: Likely need, availability and impact, 2016.
        (Avaialble:)
        • Gee G.C.
        • Hicken M.T.
        Structural racism: The rules and relations of inequity.
        Ethnicty & Disease. 2021; 31: 293-300
        • Grobler L.
        • Marais B.J.
        • Mabunda S.
        Interventions for increasing the proportion of health professionals practising in rural and other underserved areas.
        Cochrane Database of Systematic Reviews. 2015; 6: CD005314
        • Hall K.S.
        • Patton E.W.
        • Crissman H.P.
        • Zochowski M.K.
        • Dalton V.K.
        A population-based study of US women's preferred versus usual sources of reproductive health care.
        Amerian Journal of Obstetrics & Gynecology. 2015; 213: 352-414
        • Hatch B.
        • Hoopes M.
        • Darney B.G.
        • Marino M.
        • Templeton A.R.
        • Schmidt T.
        • Cottrell E.
        Impacts of the Affordable Care Act on receipt of women's preventive services in community health centers in Medicaid expansion and nonexpansion states.
        Womens Health Issues. 2021; 31: 9-16
        • Heard-Garris N.
        • Boyd R.
        • Kan K.
        • Perez-Cardona L.
        • Heard N.J.
        • Johnson T.J.
        Structuring poverty: How racism shapes child poverty and child and adolescent health.
        Academic Pediatrics. 2021; 21: S108-S116
        • House Bill 495
        Nurses: Allows full practice authority for advanced practice registered nurses.
        (Available:)
        www.legis.la.gov/legis/BillInfo.aspx?s=21RS&b=HB495&sbi=y
        Date: 2021
        Date accessed: January 21, 2022
        • House Bill 543
        Nurses/registered: Provides with respect to advanced practice registered nursing.
        (Available:)
        www.legis.la.gov/legis/BillInfo.aspx?s=22RS&b=HB543&sbi=y
        Date: 2022
        Date accessed: January 15, 2022
        • Institute of Women and Ethnic Studies
        The CrAFT curriculum: A deeper dive into the how’s and why’s of IWES’ unique spin on comprehensive sex ed.
        (Available:)
        • Jenkins W.D.
        • Williams L.D.
        • Pearson W.S.
        Sexually transmitted infection epidemiology and care in rural areas: A narrative review.
        Sexually Transmitted Diseases. 2021; 48: e236-e240
        • Louisiana Budget Project
        Separate and unequal: School segregation in Louisiana 65 years after Brown v. Board.
        (Available:)
        • Louisiana Department of Health (LDH)
        Office of Public Health, & STD/HIV/Hepatitis Program. 2018 STD/HIV surveillance report.
        (Available:)
        • Louisiana Department of Health and Hospitals (LDH), & Bureau of Primary Care and Rural Health
        Louisiana state loan repayment program.
        (Available:)
        https://ldh.la.gov/index.cfm/faq/category/55
        Date accessed: February 1, 2022
        • Louisiana Public Health Institute (LPHI)
        Louisiana parent survey.
        (Available:)
        • Louisiana Public Health Institute (LPHI)
        School sex ed policy matrix 2018-2019. Personal email communication between LPHI and Melissa Goldin Evans.
        2020
        Date: 2018
        Date accessed: January 21, 2022
        • Mary Amelia Center for Women’s Health Equity Research
        The health of women & girls in Louisiana: Sexual health.
        (Available:)
        https://bit.ly/3IkLixp
        Date: 2021
        Date accessed: February 24, 2022
        • National Academy of Sciences, Engineering, & and Medicine
        Sexually transmitted infections: Adopting a sexual health paradigm.
        (Washington, DC: The National Academies Press)2021
        • New Orleans Maternal and Child Health Coaltion
        Enhance access to quality care: Eliminate Louisiana’s Collaborative Practice Agreement Law [White paper].
        (Available:)
        https://nolamch.org/research-reports/
        Date: 2020/2021
        Date accessed: January 16, 2022
        • Permitted Courses of Study
        (Available:)
        www.legis.la.gov/Legis/law.aspx?d=80423
        Date: 1993
        Date accessed: January 16, 2022
        • Searing A.
        • Ross D.C.
        Medicaid expansion fills gaps in maternal health coverage leading to healthier mothers and babies.
        (Available:)
        • Senate Bill 175
        Nurses: Provides relative to advanced practice registered nursing.
        (Available:)
        www.legis.la.gov/legis/BillInfo.aspx?s=22RS&b=SB175&sbi=y
        Date: 2022
        Date accessed: January 17, 2022
        • SIECUS
        Louisiana state profile fiscal year 2021.
        (Available:)
        • SisterSong
        Reproductive justice.
        (Available:)
        www.sistersong.net/reproductive-justice
        Date: 1997
        Date accessed: April 2, 2020
        • Tapp J.
        • Hudson T.
        Sexually transmitted infections prevalence in the United States and the relationship to social determinants of health.
        Nursing Clinics of North America. 2020; 55: 283-293
        • Thiel de Bocanegra H.
        • Chang R.
        • Howell M.
        • Darney P.
        Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage.
        Amerian Journal of Obstetrics & Gynecology. 2014; 210: 311.e1-311.e8
        • U.S. Department of Health and Human Services (DHHS)
        Sexually transmitted infections national strategic plan for the United States: 2021–2025.
        (Available:)
        • U.S. Department of Health & Human Services (DHHS)
        Thousands more people with Medicaid and CHIP coverage now eligible to access critical postpartum coverage thanks to the American Rescue Plan.
        (Available:)
        • Wallace M.
        • Dyer L.
        • Felker-Kantor E.
        • Benno J.
        • Vilda D.
        • Harville E.
        • Theall K.
        Maternity care deserts and pregnancy-associated mortality in Louisiana.
        Womens Health Issues. 2021; 31: 122-129

      Biography

      Melissa Goldin Evans, PhD, MsPH, is a Research Scientist at the Mary Amelia Center for Women's Health Equity Research (MAC), within the Tulane University School of Public Health and Tropical Medicine Department (TUSPHTM), and is involved in several maternal and child health equity research projects.

      Biography

      Maeve Wallace, PhD, a Reproductive and Perinatal Epidemiologist at MAC and an assistant professor at TUSPHTM, focuses on the social, structural, and policy determinants of maternal and child health and health inequities, including structural racism, violence, health policy, and human rights.

      Biography

      Katherine P. Theall, PhD, a Social Epidemiologist, is the director at MAC and professor at TUSPHTM. She focuses on reducing health inequities by understanding and altering built and social neighborhood environments and social policies for better health in vulnerable populations.

      Biography

      Anna Mitchell Mahoney, PhD, is an Administrative Associate Professor of Women's Political Leadership and Director of Research at the Newcomb Institute at Tulane University. Her research is centered on women's representation and gendered institutions.

      Biography

      Lisa Richardson, PhD, Chief Impact Officer at the Institute of Women and Ethnic Studies, focuses on community development, analyzing social determinants of health, sexual health education and advocacy (particularly for women of color and youth), and participatory action research.

      Biography

      Clare M. Daniel, PhD, is an Administrative Associate Professor of Women's Leadership and Assistant Director of Community Engagement at the Newcomb Institute at Tulane University. Her research, teaching, and student program administration focus on reproductive rights, health, and justice.