Reshaping Access: Community-Led Action for Contraceptive Access in Rural Appalachian Kentucky

Abstract

Access to contraception in the United States varies greatly based on geography. In Eastern Kentucky (EKY), access is limited due to geographic isolation, provider shortages, limited transportation and deeply rooted stigma around reproductive health services. All Access Eastern Kentucky (AAEKY) is a community-driven program that focuses on patient and provider education and access to contraception through an innovative no cost mailing system. This commentary reviews the initiative impacts, key insights and lessons learned through clinic and participant surveys. Since 2016, AAEKY has faced a global pandemic, adapted to a quickly changing political landscape, overcome regional flooding and expanded from a 10 county regional focus to a statewide initiative that is helping to reshape how Kentuckians perceive and access contraception.

1. Introduction

Ensuring equitable access to contraception remains a persistent challenge, particularly in rural and underserved communities where systemic barriers limit availability, affordability, and awareness^[1]. Geographic isolation, provider shortages, limited transportation options, and deeply rooted stigma around reproductive health all contribute to these disparities. In such environments, traditional public health approaches often fail to address the complex realities individuals face when trying to access care.

In Appalachia, contraceptive access is particularly scarce, with recent estimates indicating that nearly 1.2 million women live in counties without a single health center that offers the full range of contraceptive methods^[2]. Central Appalachia, of which Eastern Kentucky (EKY) comprises the majority of counties, was found to have the highest percentage (59.7%) of women living in these contraceptive deserts^[2]. Since the U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization^[3] there has been a 4.1% decline in oral contraceptive dispensing and a 65% decline in emergency contraceptive dispensing among the most restrictive states, including Kentucky^[4]. The result is a landscape in which contraception has become both more urgent and more difficult to access. In this commentary, we present the work of All Access Eastern Kentucky (AAEKY), a contraceptive access initiative that began in 2016 to address the barriers to contraception that were unique to Eastern Kentucky. We describe the history of AAEKY, formative research that informed the initiative’s approach, and key activities to expand access including a contraceptive mailing program and community driven events. Finally we reflect on our growth to become a statewide initiative, we reflect lessons learned, and discuss plans for next steps.

This commentary explores how All Access Eastern Kentucky (AAEKY) provides a compelling model for grassroots, community-driven strategies to expand contraceptive access and reduce stigma in settings like rural Appalachia.

1.1. Description of Initiative

AAEKY is Kentucky’s first and only statewide contraceptive access initiative, designed to ensure that young adults and marginalized populations, particularly in rural areas, can make informed decisions about their reproductive health and future. The program began in 2016 as a regional 10-county pilot in Eastern Kentucky, in response to grassroots concerns about the lack of youth-friendly contraceptive services, community misinformation, and persistent barriers to care. AAEKY later expanded to a statewide initiated but has maintained a strong presence in Appalachian Kentucky while scaling up its services in response to legal and policy changes affecting reproductive autonomy across the state.

AAEKY was created through a collaboration with Appalshop, a media and education center dedicated to telling the stories of Appalachian voices. AAEKY currently operates with limited resources with funding for one full-time and one part-time staff position, and is further sustained through the contributions of community volunteers and an Advisory Board of seven local stakeholders. Despite limitations, the program has sustained activities and achieved measurable reach. By centering the lived experiences of those most affected by barriers to care, AAEKY has developed a flexible and responsive model of service delivery that emphasizes dignity, privacy, and cultural relevance to build sustainable solutions for reproductive well-being.

AAEKY’s approach is multifaceted and grounded in principles of health equity and community collaboration. The initiative’s core strategies include distributing free contraceptive supplies through a confidential mailing program, providing community education, developing local storytelling and media campaigns, and equipping healthcare providers with tools and training to offer comprehensive care. The mailing program, in particular, has become a cornerstone of AAEKY’s work, offering discreet, no-cost access to contraception for individuals who face transportation, cost, or privacy-related barriers. AAEKY’s contraception supply includes emergency contraception, condoms, pregnancy tests, and over the counter contraceptives.

Demographically, the program primarily serves young adults (ages 19–30), many of whom are navigating reproductive health care independently for the first time, as well as individuals living in medically underserved counties. AAEKY also partners closely with local health departments, primary care clinics, schools, and grassroots organizations across the state to ensure that materials, training, and outreach are responsive to the diverse cultural and geographic contexts in which Kentuckians live and seek care.

2. Formative Evaluation

The focus of the initiative was informed by a 2017 regional assessment of contraceptive access and clinic capacity, conducted by project staff through both virtual and in-person methods during the planning phase prior to AAEKY’s implementation. This assessment identified areas of potential impact and opportunities for intervention.

2.1. Geographic Access

AAEKY’s initial 10 county KY region (Floyd, Harlan, Knott, Lee, Leslie, Letcher, Owsley, Perry, Pike and Wolfe) were selected for their high poverty rates, limited health services, proximity to Appalshop’s headquarters in Letcher County, and representation of Eastern Kentucky and Central Appalachia. Following devastating regional flooding throughout eastern Kentucky in 2022, the AAEKY service region expanded to 14 counties to include four additional federally declared disaster areas requiring urgent support (Bell, Breathitt, Clay and Martin). This expansion was driven both by the federal disaster declarations and by AAEKY’s existing strong community ties in these counties. According to Power to Decide’s Contraceptive Desert Map ^{[Figure 1]}, the 14 counties in AAEKY’s initial priority region (Bell, Breathitt, Clay, Floyd, Harlan, Knott, Lee, Leslie, Letcher, Martin, Owsley, Perry, Pike, and Wolfe) are all classified as contraceptive deserts ^{[2, Figure 1]}. This designation highlights the severe gap in reasonable access to health centers that provide the full range of contraceptive methods, including LARC devices, and emphasizes the ongoing structural barriers to reproductive health care in the region.

Figure 1:

Power to Decide. Contraceptive Deserts^[2]

2.2. Clinic Survey Results

To assess contraceptive service availability and clinic-level barriers, AAEKY conducts an annual survey of approximately 50 health centers identified by community members as primary providers of comprehensive reproductive health services. The survey is distributed to clinic administrators both virtually and during in-person site visits from February - March each year. In 2023, a total of 23 clinics responded across the 14-county region. One clinic reported it was no longer offering family planning services so the responses from this survey are not reflected in the results discussed below. Among the remaining 22 clinics, only four offered intrauterine device (IUD) placements and nine offered contraceptive implants. The most frequently cited barriers to offering long-acting reversible contraception (LARC) were a lack of providers trained in LARC insertion (50% of clinics, n=11) and the high cost of stocking and dispensing these methods on site (36% of clinics, n=8).

Additional infrastructure barriers further limited contraceptive access. Only 18% (n=4) of responding clinics had an onsite pharmacy, a critical resource for dispensing hormonal contraception in a timely and patient-centered manner. Furthermore, 45.5% (n=10) of clinics reported a decline in patients seeking sexual and reproductive health services since 2020.

Several clinics noted that they rely on a single provider to deliver family planning services—often rotating between multiple sites and serving as the sole clinician offering contraception to multiple counties within their district. The limited number of OB/GYNs^[5] in the region further constrains service availability, demonstrating the need to expand training opportunities for family practitioners, nurses, and other primary care providers to deliver essential contraceptive care.

In response to the identified challenges, many clinics expressed strong interest in training and professional development to expand their capacity and improve service delivery. In addition to indicating interest in ‘IUD and implant insertion/removal and troubleshooting for complicated cases’, commonly requested training topics included contraceptive method updates, teen-friendly clinical practices, sexually transmitted infection (STI) and human immunodeficiency virus (HIV) updates, and evidence-based/patient-centered contraceptive counseling. Collectively, these clinic-level findings confirm substantial gaps in contraceptive access across the region and highlight the need for both alternative, community-centered delivery models and sustained support for provider training and infrastructure development.

3. AAEKY’s Response to Identified Needs

AAEKY developed a multi-tiered approach to respond to the region’s contraceptive needs. This approach included an innovative mailing distribution program as well as a focus on both community and professional education and outreach.

3.1. Mailing Program

In 2020, AAEKY launched a free contraceptive mailing program in Eastern Kentucky in response to local concerns that the COVID-19 pandemic would exacerbate barriers to sexual and reproductive health services. Community input that was gathered through social media and regional conversations highlighted the need for an intervention to overcome logistical and structural barriers. AAEKY implemented a direct-to-consumer distribution model that allowed individuals to request supplies through a Google Form and receive them by mail at no cost. Initially limited to Eastern Kentucky residents, the mailing program was expanded to a statewide model in 2022 in response to increased demand for contraception following the Dobbs decision.

The request form collects only essential information: name, email, and product selection (from a dropdown menu), with an optional space for feedback or questions. Messaging on the form encourages participants to order in advance, as shipping could take 1–2 weeks depending on carrier and current stock. Monthly requests are limited to one per person to promote equitable distribution, and the form alerts users when supplies are out of stock. The program is systematically monitored, with requests processed daily and monthly reports generated to track utilization patterns, emerging needs, and geographic demand across counties.

Eligibility was also extended to community partners, including traditional providers (clinics, health departments) and nontraditional spaces including bookstores, restaurants, salons, campus housing and other accessible spaces. Partners receive contraceptive care baskets containing products, educational materials, and QR code–labeled items linking back to AAEKY resources for refills or usage guidance. Supplies are also distributed at festivals, health fairs, and campus events directly by staff or through vetted partners.

The program began with condoms and educational inserts and has since expanded through partnerships to include Plan B, Julie, and Opill. A monthly stipend from a local philanthropic partner funds bulk pregnancy test purchases and covers mailing expenses, including postage and shipping materials. Due to limited funding, the program is currently supported by a single part-time staff member, however, additional resources and staffing will be required to sustain operations and support future growth.

3.2. Storytelling & Social Media Outreach

In addition to direct distribution, AAEKY leverages storytelling and media to combat stigma and misinformation. Drawing on Appalachia’s strong storytelling traditions, AAEKY leverages media to share perspectives of young adults, community members, and local providers to normalize and facilitate conversations about reproductive health. Engagement typically begins with informal conversations, held either in community spaces or virtually. Depending on the topic and the storyteller’s capacity, narratives are developed into formats such as film, blog posts, podcasts, or social media content that translate lived experiences into accessible, community-driven narratives. These testimonies are disseminated across AAEKY platforms, including the website, social media, and newsletters, as well as through occasional film screenings and coverage by local news outlets. This strategy fosters accurate and relatable reproductive health discussions while countering inaccurate portrayals of Appalachia often featured in broader media. It also informs AAEKY’s program development, as recurring topics and common themes emerge.

“No Such Right” (supplemental Video 1) is one example of a film produced in Appalshop’s Appalachian Media Institute and funded by AAEKY to highlight the voices of those in Appalachia impacted by the Dobbs decision, offering both testimony and context that strengthen our broader efforts.

3.3. Community Events

AAEKY engages Appalachian communities through both formal training opportunities and community events. At local county-wide celebrations and festivals, the team hosts interactive booths where community members can obtain contraceptive kits, brochures, and quick guides. AAEKY also participates in local health fairs, which remain popular across the region. These complementary strategies broaden visibility, extend the scope of reproductive health education, and ensure engagement with diverse populations who may not otherwise encounter such resources.

3.4. Trainings on Clinical Advocacy

Guided by the expertise of its Advisory Board, which includes various medical specialties (OB-GYN, DNP, PharmD, etc.), as well as policy and education experts, AAEKY conducts trainings and workshops on topics such as gender-inclusive care, the full range of contraceptive methods, and teen-friendly clinic models. Training priorities are shaped by an annual community needs assessment conducted with local clinics and community groups, which identifies service gaps and opportunities for expanded education. Clinic focused trainings serve audiences such as university health staff, medical students, pharmacists, and health educators, while advocacy-oriented sessions equip policymakers, community organizers, faith leaders, and school administrators with insights into reproductive well-being in Kentucky.

4. Evaluation of Mailing Program

To evaluate the impact of the mailing program, the AAEKY team conducted a follow-up survey in 2025 with individuals who had previously used the service. The survey, distributed via email, gathered responses from 63 participants representing 28 Kentucky counties. Data collected included demographic characteristics, motivations for using the service, and satisfaction with the program.

4.1. Motivation for Using the Service

Participants most frequently cited financial constraints (71%, n=45), privacy concerns (62%, n=39), and lack of transportation (37%, n=23) as the primary motivators for using the mailing service. These practical barriers prevent individuals from accessing care even when clinics are geographically present. While very few respondents (8%, n=5) were willing to drive more than one hour to a centralized pick up location in- person, more than 50% (n=32) of respondents indicated a strong preference for mailing, suggesting that discretion, convenience, and accessibility are key to meeting the needs of individuals living in these contraceptive deserts. Notably, 100% (n=63) of respondents indicated they would recommend the service to others, and most (62%, n=39) reported learning about the program through social media, affirming both the value of the intervention and the importance of community-informed outreach strategies.

4.2. Satisfaction with the Program

Participant testimonials provide helpful insight into the mailing program’s benefits and highlights the unique challenges facing individuals in Eastern Kentucky. Key themes emerged from participant feedback:

1. Privacy & Confidentiality

   “It was private and way less embarrassing than going to the store. I live with very religious and judgmental people so it’s always been difficult to get supplies needed, even tampons.”

2. Accessibility

   “I’m 19 years old with a 5 months old. I don’t have transportation right now and I really can’t afford to get pregnant again. Thank you!”

3. Non-judgmental Support

   “It was such a simple process and at the end of it I still feel like I have my dignity.”

4. Equity in an underserved area

   “Your healthcare items for reproductive health are very much needed in EKY communities.”

The program’s success illustrates the ongoing contraceptive access crisis in Appalachian Kentucky and demonstrates how community-rooted interventions like AAEKY’s mailing program can effectively reduce barriers to care in underserved, rural regions.

5. Lessons Learned

The AAEKY project offers a compelling example of how community-rooted, adaptable interventions can address entrenched contraceptive access barriers in underserved regions. This adaptability has not only sustained the program through periods of uncertainty but has also underscored the continued need for such programming within the communities it serves.

A key lesson from this work is the importance of designing interventions with, rather than for, the community. AAEKY engaged young adults, healthcare providers, and community leaders as co-creators, ensuring that support and messaging was culturally relevant, locally informed, and reflective of community priorities.

Another critical lesson is that contraceptive access involves more than simply living near a clinic. Even where services exist, individuals, especially young adults, encounter stigma, confidentiality concerns, misinformation, financial and logistical barriers. AAEKY’s contraceptive mailing program emerged as a widely accepted solution by offering privacy and convenience that traditional models did not. Its rapid uptake confirmed that flexibility, discretion, and patient-centered design are essential features of equity, especially in rural environments.

Clinic surveys reinforced that many healthcare providers are eager to offer comprehensive contraceptive care, including long-acting methods but their ability to do so is often limited by inadequate infrastructure, training gaps, and workforce shortages. In many rural counties, a single nurse or family practitioner is responsible for reproductive health services across multiple sites. Additionally, building relationships with local health departments allowed AAEKY to provide education and resources directly to health educators, who in turn influenced the content delivered to young people across the state. Strengthening the broader ecosystem requires both educating and training frontline providers as well as equipping support staff with accurate, evidence-based information.

AAEKY also learned that young adults are not just beneficiaries, but powerful messengers and leaders. With the right tools and support, these advocates can advance reproductive autonomy through peer storytelling, social media campaigns, and advocacy to reduce stigma and normalize reproductive health conversations. Involving medical students, residents, and early-career public health professionals both as presenters and captive audiences for advocacy trainings created pathways to shape the next generation of providers as advocates. AAEKY recognized young adult leadership as a core element of programmatic efforts, not only as an effective communication strategy, but also as a long-term investment in systemic change.

Perhaps most vital to the program’s evolution has been its emphasis on cross-sector collaboration. Allies spanning healthcare, education, media, policy, nonprofits (both local and national), and community and faith leaders expanded the initiative’s reach well beyond direct service provision. These collaborations created important feedback loops that surfaced community concerns, highlighted individual and system-level barriers, and informed program adaptations in real time. By embedding reproductive health access into multiple systems, AAEKY reduced dependency on any single institution and laid a foundation for long-term sustainability and systemic change.

Together, these lessons illustrate that expanding contraceptive access in underserved regions requires more than a single intervention. It demands a holistic and adaptive approach rooted in community trust and leadership. AAEKY’s experience shows that centering lived experience, addressing barriers beyond geography, and embedding resilience into program design are all critical for long-term success. While challenges such as limited data collection and resource constraints persist, the AAEKY model offers a replicable approach for communities facing similar barriers.

6. Conclusion

What began as a regional response to entrenched contraceptive barriers in Appalachian Kentucky has evolved into a statewide, community-led initiative that is reshaping how reproductive health access is delivered across Kentucky. AAEKY offers a blueprint for addressing reproductive health inequities not only in Kentucky, but in rural and underserved communities nationwide. In an era of increasing restrictions and shifting policies, AAEKY demonstrates that adaptable, locally driven solutions can thrive even in the most challenging circumstances.

Looking ahead, AAEKY aims to build on this foundation. As additional over-the-counter contraceptive methods become available, AAEKY will prioritize support for pharmacists through targeted outreach, training, and policy advocacy, recognizing their increasingly central role in care provision. AAEKY also identifies the need for expanded research and data collection to better document patient and provider experiences, as well as for technical assistance in the context of rural clinic closures, which remain an ongoing threat. The long-term vision is to sustain, adapt, and grow this work across Kentucky while extending the framework to additional Appalachian states. However, such growth will require sustained investment to expand program reach without compromising quality or responsiveness.

AAEKY’s success showcases a broader truth: sustainable reproductive health programming must be grounded in trust, flexibility, and the experiences of the communities they serve. As AAEKY continues to expand its impact, the initiative is positioned to inform similar efforts across the country, particularly in Appalachian or rural regions, where geographic, political, and economic barriers jeopardize reproductive well-being. By investing in community partnerships, workforce training, and scalable service delivery models, AAEKY is not only meeting urgent needs today, but laying the groundwork for a more resilient, equitable future in reproductive healthcare in this country.

Figure 2.

Geographic dispersion of contraceptive distributions by the All-Access EKY Program’s mailing initiative and program expansion beyond initial service region