Feature Interview
Kristen Brewer, PhD, MPA

This interview, conducted by by Nat Thomson, Simmons MSW Candidate, runs abridged in the April 2024 issue of the MPH Monthly.  Kristen Brewer, PhD, MPA is is an Assistant Professor in the Department of Public Health. Dr. Brewer has experience in community-building, teaching, and research in the field of sexual and reproductive health education. She is a co-founder of Ruth's Army, serving the Clarksburg area of Tennessee.

You recently spoke at the SOPHE conference; how was that? Could you tell us a bit about what you were there to present?

It was a lot of fun! The audience is generally a wide range of people focused on public health education. I am involved as a co-founder with a no cost clinic called REACH through a small Tennessee-focused organization called Ruth’s Army, so my friend and fellow co-founder of Ruth’s Army, Tracy Coffey from Queen City Women's Health Clinic, and I were there to present the process we went through in order to get the clinic set-up and running in the Clarksville-Montgomery County area of Tennessee. In order to offer the clinic at no cost to patients, we had to weave together as many regional resources and organizations as we could.

I’m glad you brought that up. In reading up for our conversation, I was struck by how many different types of folks and organizations were involved, as far as different health focuses and types of specialization.

Because we wanted to offer the full spectrum of sexual and reproductive health we had to think bigger than just our small budget and current resources. We had to look at how to do things with no cost and also see what other people might be offering at no cost, in an effort to ultimately get everyone all in one place. This way a visiting patient can access everything they might need in one stop. We had the idea in June of 2023 and opened in January of 2024, so while it felt like it was taking forever at the time, it came together a lot faster than we were imagining it would have when we started.

That’s great to hear. Sometimes parts of the public health universe can require a lot of patience. What was the work over those months mostly made up of?

Through Ruth’s Army and through our network of contacts, we were able to put together a pretty specific list of local people who we could reach out to about our idea. After that it primarily became a matter of getting everyone on board and then coordinating schedules to make it come together.

The clinic is in Clarksville, which is maybe 30 minutes outside of Nashville. What would you tell folks about that part of the state or of the country even?

Clarksville is the fifth largest city in Tennessee, on its way to becoming the fourth, and we joke that it's the biggest small town in the world. It doesn't know how big it's gotten and now finds itself under-resourced across the board, including reproductive health. The city is surrounded by a number of very rural counties that are maternal health deserts. And even though Nashville might be closer for some of these folks, there can be some worries related to the big city aspects of Nashville. These surrounding counties end up putting a lot of pressure on the reproductive and sexual health offerings in Clarksville but the city plans are not drawn up this way at all.

That’s an interesting insight, especially for many of us North-Eastern types at Simmons who may or may not have much hands-on experience with people who live more rurally. 

[Visiting Nashville] can tend to just raise a lot of questions about parking and traffic, even when health is involved. It took my father, a military veteran, about 10 years to get a VA meeting because he didn’t want to go to the Nashville location. I grew up about three highway stops from Nashville and we never went there unless it was a field trip.

Are there any other tips you might give to public health students about working with rural communities or communities they might just be personally unfamiliar with?

[In my work,] I tend to focus on a lot of community building or community organizing. I’ve found that in public health it can be pretty easy to go into a community and proclaim that “this is what’s wrong and this is how I can help fix it.” There [can be] a tendency to look at health outcomes and then make assumptions about what may be feeding into [those outcomes]. But if we’re an outsider, we can’t know that community. We can’t really know what other factors might be at play or what more pressing needs might be present. So [the folks I collaborate with and I] talk a lot about spending time and building rapport as a way to listen to the community and see what they have to say and what they think the problems are. This tends to create more trust and build community capacity for issues that arise down the road.

That makes a lot of sense. In a rural community setting, someone with an advanced public health degree and a lot of, like, “book learning” I guess you could call it, really could tend to run the risk of coming off like an interloper, even if intentions are appropriate. 

When I taught in Kentucky, the number one producer of tobacco, going in and just saying “hey you shouldn’t dip,” doesn’t work. For many, that is their livelihood and might have been in the family for generations. Also, educational interventions are often the first thing that tends to come to mind, but that’s also not typically enough to actually change behaviors. Tools, resources and considering what their environment might allow for are important things to explore, beyond just education alone and calling it a day.

I was wondering if you could talk a little bit about the grant aspect of the REACH clinic and tell us a little bit more about the coalition building aspect.

Someone important to the process was Chaz Uffleman here in Tennessee, who is on the board of Clarksville Q and someone who ran in the same circles as myself and Dr. Coffey who I run the clinic with. Fortunately, In sharing with him what we were looking to do, he let us know that there was a grant opportunity available through Clarksville Q. The grant was designed to focus on funding projects helping to further healthcare access and education for the LGBTQ+ community in the area, so we ended up being 100% aligned with what they were looking to fund. Dr. Coffey is part of a private practice with some other partners and so they agreed to stay open on Saturdays. The grant allowed us to cover those costs as well as marketing around the clinic offering and bringing in some other partners as well, like Music City Prep.

So it sounds like for those of us in the public health space it can really pay dividends to know who is doing what in your region, especially if you are looking to get a new idea off the ground.

Absolutely. A big piece of the work for Tracy and I was looking at what is happening in the public health and sexual/reproductive health space already and thinking about complimentary services, even though it can sometimes feel like we are working in silos.

Since you know Tennessee well, I wanted to ask you about the recent filing of a bill in the state to criminalize ‘abortion trafficking of minors.’

It can really be tough to be a person who can become pregnant in Tennessee. And then it can also be really tough to be someone who is trying to help these people. Tennessee has done a really good job making anything related to education or resources around the sexual and reproductive health realm hard to access or non-existent. And it’s heavily influenced by conservative Christian values that have infiltrated the state politics. What Tennessee has done is very different from what Texas has done. Texas very much directly went after the individual seeking an abortion, whereas Tennessee has instead criminalized the people around that person. The first trigger ban that went into place in Tennessee was focused on restricting organized health professionals. In many ways what is happening here deserves as much attention as what happens in Texas, but it seems like the media focus is mostly on Texas alone.

From what I had read about, it definitely seemed like there was that kind of chilling effect on practitioners and maybe a lot of muddying of the waters to boot.

There was a lot of miscommunication around how the law regarding terminating ectopic pregnancies was actually going to be enforced. Many health providers didn't know what constituted [the acceptable scenario for legal termination]. There have been quotes [in the media] where doctors were talking about just sitting there waiting to determine how close to death a patient had to be before they’re allowed to perform the procedure [without fear of legal repercussions for themselves]. Ultimately, a doctor is automatically charged with a crime and then has to go and prove that the inevitable outcome would have been death for the pregnant person. So it's not even an innocent until proven guilty situation. So with this new bill, it’s aimed at anyone who provides a young person with access to abortion care.

Aiming to intervene with young people specifically is kind of dark, knowing that we’re talking about a more vulnerable population.

These are the people who need the help the most. They may be in an unsafe home environment. Tennessee unfortunately tends to have high rates of abuse as well as incest and we already know that a parent or guardian may not always be a safe person in a minors life.

And would you pinpoint rural, southern, Christian ideas about values as a primary driver of these types of legislation?

Very much so. There has been a pretty striking integration of church and state in terms of Tennessee’s legislation of late. It’s what they are fighting for and they want more of it. A number of people feel like they are fighting a righteous fight, but there are also politicians exploiting these ideas or values for votes. There is a lot of passion and emotion around the topics and so it’s known that voters [who are moved by this rhetoric] tend to show up and cast their votes.

I wanted to talk about your dissertation, which I found really intriguing, that focused on teaching sex and drugs in what you called a “relevant” way, based on what you found in some qualitative research with undergraduate students. What did you find to be the difference between irrelevant and relevant ways of teaching these topics?

I did the study because I taught the personal health class, which is about nutrition, exercise, mental health and the other dimensions of health. It really focused on an educational intervention approach. So I’m telling students that they should eat healthy and exercise. One, I’m not the first person to tell them this. Two, these are often broke college students working to pay for school, so we’re just telling them that they should do something but not really “how” they can do it [in the context of their lives]. Even if the cafeteria has the right food options, if you work during the cafeteria hours, [then that solution isn’t relevant]. I was inspired by a study that showed that when it comes to education on alcohol consumption, students don’t really want fundamental education, they more-so want to know what to do in the scenarios that might present themselves in the context of drinking; what do you when you need a ride home or when your roommate gets alcohol poisoning.

So maybe more of a risk reduction approach versus baseline education with a strong suggestion towards abstinence?

Yes, they were really begging for risk reduction ideas. So when I performed my own study in focus groups, that’s exactly what I saw in other areas as well. Students didn’t want to hear about not having sex, they wanted to know what to do when certain things happen or how to discuss certain topics with a partner or what is available to me on campus if I contract an STI. Free condoms. IUDS. These were the kinds of things they asked for.

Were there any other surprising learnings through the process?

[Our focus group participants] were also really focused on how to be a good friend; how can I make sure that I’m supporting my friend’s mental health and that I’m choosing to be around people who support my mental health. It was interesting to see the focus on community and interpersonal relationships. Because we conducted the study during the early COVID quarantines, it seemed like many were feeling cut-off and so that context tended to highlight the discussions around friendships and social relationships. In college you could already be feeling a little lonely, so the lockdown aspect seemed to help shine a bright light on an issue that we were already facing with college students.

You’ve also done some writing about reducing teen pregnancies in restrictive educational environments; what are the hallmarks of these restrictive educational environments? And then what are the things that can be done to reduce teen pregnancies in that kind of cultural environment?

It’s really hard. I’ll use my home state of Tennessee again as a prime example. In Tennessee, the law doesn’t require any teaching of sex education unless the teen pregnancy rate tracks above 19.5%. So [the state] waits until it’s a problem and then when they do the education around sexual and reproductive health, they teach an abstinence centered version.

So the plan is to wait until the problem has already manifested itself and then they provide an insufficient solution, did I get that right?

Yes, exactly. Not only do we know overwhelmingly that abstinence education does not work, but it also doesn’t pass students the information to make informed decisions at any point in their life,  when it comes to sexual and reproductive health. So even if a young person follows the presented “correct” path of waiting until marriage, they’re still uninformed. So how can they make healthy decisions? How can they communicate with their partner? These skills are not developed because [the state] has kept those answers from them. And then the state also cuts them off from healthcare access as well. This means that even if you need reproductive sexual health care that isn’t about abortion, buy maybe more about a healthy conception, you wouldn’t even know where to go or how to discuss it.

It sounds like a very frustrating system to be faced with or especially working within.

The question then becomes what can we do to get that education out to [young] people. So one thing that we’re putting together at Ruth’s Army are ideas about how to talk to the kid in your life about sex. So if you’re a parent, guardian, aunt, uncle or older sibling with someone in your life, you know what information needs to be put out there and how to have the conversations. This tends to take the form of training, especially through Planned Parenthood, on how to have these conversations. We are working on some workshops and panels around the topic. There’s an idea that parents might not want anyone talking to their kids about sex besides themselves, but then “how exactly are you going to go about that?” becomes the question, along with making sure that these folks are working from the right information to begin with.