Knowledge of Oral Emergency Contraception Among Pharmacy Students

Background

Access to emergency contraception is an important consideration in preventing unintended pregnancies. Inconsistent information about emergency contraceptive given to patients at retail pharmacies may limit access.

Objective

In this study, we aimed to assess pharmacy students' knowledge of oral emergency contraception.

Methods

Students in a Doctor of Pharmacy program completed a confidential survey about their knowledge of and training on oral emergency contraception. Respondents self-reported demographics included age, race, ethnicity, gender, and year in pharmacy school. The survey questions assessed student knowledge of indications, availability, side effects, and mechanisms of action of oral emergency contraception, as well as their training on emergency contraception. Chi-squared and Fisher's exact tests were used to determine if demographics influenced knowledge outcomes. A multivariate logistic regression, including age, gender, ethnicity, religion, year of training, hours of education, and source of knowledge acquisition, was used to adjust for confounding variables.

Results

Among 296 pharmacy students, 31% (92/296) completed the survey. Among respondents, 34% (31/92) showed adequate knowledge of oral emergency contraception based on four critical knowledge questions. Third- and fourth-year students were more likely to have adequate knowledge than first- and second-year students (odds ratio [OR], 2.70; confidence interval [95% CI], 1.07-6.80). Students who reported learning about emergency contraception through reading assignments were more likely to have adequate knowledge than students who did not report learning from reading assignments (OR, 2.09; 95% CI, 1.30-3.35).

Conclusions

Most pharmacy students at a single academic center did not have adequate knowledge of oral emergency contraception. These findings highlight the need for trainings to improve pharmacy student knowledge of oral emergency contraception.

Over-the-counter provision of emergency contraceptive pills: a systematic review

OBJECTIVE

To synthesise evidence around over-the-counter (OTC) emergency contraceptive pills (ECPs) to expand the evidence base on self-care interventions.

DESIGN

Systematic review (PROSPERO# CRD42021231625).

ELIGIBILITY CRITERIA

We included publications comparing OTC or pharmacy-access ECP with prescription-only ECPs and measuring ECP uptake, correct use, unintended pregnancy, abortion, sexual practices/behaviour, self-efficacy and side-effects/harms. We also reviewed studies assessing values/preferences and costs of OTC ECPs.

DATA SOURCES

We searched PubMed, CINAL, LILACS, EMBASE, clinicaltrials.gov, WHO International Clinical Trials Registry Platform, Pan African Clinical Trials Registry, Australian New Zealand Clinical Trials Registry, Cochrane Fertility Regulation and International Consortium for Emergency Contraception through 2 December 2020.

RISK OF BIAS

For trials, we used Cochrane Collaboration's tool for assessing risk of bias; for other studies, we used the Evidence Project risk of bias tool.

DATA EXTRACTION AND SYNTHESIS

We summarised data in duplicate using Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence Profile tables, reporting findings by study design and outcome. We qualitatively synthesised values/preferences and cost data.

RESULTS

We included 19 studies evaluating effectiveness of OTC ECP, 56 on values/preferences and 3 on costs. All studies except one were from high-income and middle-income settings. Broadly, there were no differences in overall ECP use, pregnancy or sexual behaviour, but an increase in timely ECP use, when comparing OTC or pharmacy ECP to prescription-only ECP groups. Studies showed similar/lower abortion rates in areas with pharmacy availability of ECPs. Users and providers generally supported OTC ECPs; decisions for use were influenced by privacy/confidentiality, convenience, and cost. Three modelling studies found pharmacy-access ECPs would lower health sector costs.

CONCLUSION

OTC ECPs are feasible and acceptable. They may increase access to and timely use of effective contraception. Existing evidence suggests OTC ECPs do not substantively change reproductive health outcomes. Future studies should examine OTC ECP's impacts on user costs, among key subgroups and in low-resource settings.

Pharmacy-based initiatives to reduce unintended pregnancies: A scoping review

BACKGROUND

Community pharmacy contraception services are thought to improve access, with the potential to reduce the persistent sexual and reproductive health inequities observed globally.

OBJECTIVES

We aimed to identify the range of pharmacy-based initiatives addressing unintended pregnancy in the primary literature and examine their feasibility, acceptability and effectiveness.

METHOD

Using the Joanna Briggs Institute Methodology for Scoping Reviews, we searched seven bibliographic databases using combinations of keywords and subject headings for related to contraception and community pharmacy. Studies of any design undertaken in high income countries for reproductive-aged women were eligible provided they evaluated intervention or legislation after the implementation of these initiatives. Included articles were critically appraised and findings summarised narratively.

RESULTS

We identified 49 articles, 80% of which involved pharmacist supply of emergency contraception (EC), 14% of regular contraception methods, and 6% involved adjuncts of EC dispensing: counselling (2%) and bridging initiatives to link clients with regular contraception (4%). EC initiatives were perceived as feasible and were facilitated by interdisciplinary partnerships but there are persistent barriers to the provision of initiatives congruous with the retail pharmacy setting. Furthermore, consumers may be reluctant to receive contraceptive counselling from pharmacists but often value the convenience and anonymity pharmacy services offer. Overall, interventions improved access to contraceptive products but did not consistently reduce inequities, and the health benefits of pharmacy initiatives are either small (EC) or lacking description in the literature (other contraceptive methods and contraceptive counselling).

CONCLUSIONS

Pharmacy initiatives may not negate all barriers to access or reduce unintended pregnancy rates, however they are valued by pharmacists and consumers. Evidence gaps including the lack of description of health outcomes of regular contraception provision, contraceptive counselling and the perceived barriers and facilitators of access and provision from end-user perspectives, should be pursued in future research, to establish initiatives' utility and effectiveness.

Student knowledge and confidence with prescribing hormonal contraception

INTRODUCTION

Pharmacists' scope of practice has expanded in several states to include independently prescribing and dispensing hormonal contraceptive products. The objective of this research was to assess student knowledge and confidence with prescribing hormonal contraception following a simulated patient case activity.

METHODS

This was a descriptive, exploratory, nonexperimental study utilizing educational assessments and survey data from second professional year students during the 2017 to 2018 and 2018 to 2019 academic years. Student performance was assessed using a five-question readiness assurance test at the beginning of class, documented patient assessment and plan, and five-question post-activity quiz. Student confidence with interpreting legal regulations and following protocol instructions, performing a patient assessment, prescribing an appropriate contraceptive product, and providing verbal and written communication to patients and providers was assessed using a nine-question survey at the end of class.

RESULTS

Average student performance was consistent on the readiness assurance test between the two years. Students scored an average of 84.2% and 91.6% on the documented assessment and plan and 96.4% and 91.2% on the post-activity quiz for each year, respectively. Students felt most confident with navigating and interpreting a prescription drug formulary, providing the patient with written documentation, and communicating with the patient's prescriber. Students were less confident with selecting an appropriate product based on patient-specific factors and providing education on missed doses.

CONCLUSIONS

This case-based activity demonstrated student knowledge and confidence with prescribing hormonal contraceptives.

Clinical outcomes of community pharmacy services: A systematic review and meta-analysis

Community pharmacy services (CPS) have been shown to be positive in many disease management and patient care programs, but clinical outcomes were followed by process indicators and methodological flaws in previous researches made it difficult to prove the effectiveness of clinical outcomes of CPS. Therefore, this study attempted to review the clinical outcomes of CPS. Interventions included are provision of medication review, patient education, adherence assessment, health/lifestyle advice, physical assessment, monitoring, prescribing, or adjusting and administering therapy from community pharmacists. By searching for key words like community pharmacists, pharmaceutical services, clinical outcomes in MEDLINE and EMBASE and manually searching (up to June 2017), 1910 studies investigating the clinical outcomes of CPS were obtained. After screening the titles, abstracts and full texts for relevancy, 52 researches with controlled groups were included and assessed for methodological quality. Finally, 25 studies were selected for the meta-analysis based on their common endpoints: systolic blood pressure, diastolic blood pressure and glycosylated haemoglobin. The Cochrane tool was used to assess the risk of bias. Chi-square and I-square tests were performed to assess heterogeneity, and the weighted mean differences were estimated using random effect models. Of the 52 articles, 47 studies demonstrated that CPS had positive clinical outcomes, 3 studies showed mixed outcomes and 2 studies revealed no effects. In the meta-analysis, intervention groups displayed greater reductions in systolic BP (95% CI: -8.198-2.356), diastolic BP (95% CI: -3.648-0.645) and HbA1c (95% CI: -0.905-0.224) than usual care groups. CPS have positive clinical outcomes, particularly significant reductions in systolic BP, diastolic BP and HbA1c. It was difficult to find out which intervention(s) of CPS directly led to certain changes and influence of CPS might be underestimated for only three common surrogate endpoints. More researches should be conducted with sufficient data.

Role of the community pharmacist in emergency contraception counseling and delivery in the United States: current trends and future prospects

Women and couples continue to experience unintended pregnancies at high rates. In the US, 45% of all pregnancies are either mistimed or unwanted. Mishaps with contraceptives, such as condom breakage, missed pills, incorrect timing of patch or vaginal ring application, contraceptive nonuse, forced intercourse, and other circumstances, place women at risk of unintended pregnancy. There is a critical role for emergency contraception (EC) in preventing those pregnancies. There are currently three methods of EC available in the US. Levonorgestrel EC pills have been available with a prescription for over 15 years and over-the-counter since 2013. In 2010, ulipristal acetate EC pills became available with a prescription. Finally, the copper intrauterine device remains the most effective form of EC. Use of EC is increasing over time, due to wider availability and accessibility of EC methods. One strategy to expand access for both prescription and nonprescription EC products is to include pharmacies as a point of access and allow pharmacist prescribing. In eight states, pharmacists are able to prescribe and provide EC directly to women: levonorgestrel EC in eight states and ulipristal acetate in seven states. In addition to access with a prescription written by a pharmacist or other health care provider, levonorgestrel EC is available over-the-counter in pharmacies and grocery stores. Pharmacists play a critical role in access to EC in community pharmacies by ensuring product availability in the inventory, up-to-date knowledge, and comprehensive patient counseling. Looking to the future, there are opportunities to expand access to EC in pharmacies further by implementing legislation expanding the pharmacist scope of practice, ensuring third-party reimbursement for clinical services delivered by pharmacists, and including EC in pharmacy education and training.

Nova Scotia pharmacists' knowledge of, experiences with and perception of factors interfering with their ability to provide emergency contraceptive pill consultations

Objective

The objective of this research was to explore pharmacists' knowledge of, experiences with and perception of factors interfering with their ability to provide non-prescription emergency contraceptive pill consultations in the Canadian province of Nova Scotia.

Methods

A self-administered paper questionnaire was mailed, using Dillman's tailored design method, to all pharmacists (n = 1123) registered with the Nova Scotia College of Pharmacists.

Key findings

The response rate was 53.0% (595/1123), with 451 respondents working in community practice. Most respondents reported that they had provided consultations for the emergency contraceptive product Plan B since it became available without a prescription (93.6%), and that Plan B is kept behind the pharmacy counter (83.6%). Pharmacists most frequently (47.8%) reported spending 6–10 min providing Plan B consultations. Respondents were generally knowledgeable about Plan B; however, only 39.2% knew that it can be effective for up to 5 days and 69.3% knew that the incidence of vomiting is less than 50%. The factors interfering the most with providing Plan B consultations were lack of privacy (46.1%) and lack of staff to cover during the consultation (50.9%).

Conclusions

In general, Nova Scotia pharmacists are knowledgeable about emergency contraceptive pills; however, education regarding effective timing for use of such pills would be helpful. Private areas for counselling and consideration of pharmacy staffing schedules in community pharmacies may help address pharmacist concerns regarding their ability to provide Plan B consultations.

What do we know about males and emergency contraception? A synthesis of the literature

CONTEXT

Unintended pregnancy rates are high in the United States. It is important to know whether improving males' access to emergency contraceptive pills may help prevent unintended pregnancy, especially in cases of -condom failure.

METHODS

A search of the PubMed, PsycINFO and Cumulative Index of Nursing and Allied Health Literature databases was conducted to identify studies published from January 1980 to April 2011 concerning males and emergency contraception. Forty-three studies met the specified criteria and examined relevant knowledge, attitudes, beliefs, intentions or behaviors, from the perspectives of males, clinicians or pharmacists.

RESULTS

The proportion of males who were familiar with emergency contraception ranged from 38% among teenagers to 65-100% among adults. Small proportions reported that they and their partner had used or discussed using emergency contraceptive pills (13-30%) or that they themselves had ever purchased them (11%). Most providers (77-85%) reported general knowledge about emergency contraceptives, but the proportions who knew the time frame within which the pills can be prescribed were smaller (28-63%). Most males approved of emergency contraceptive use following contraceptive failure (74-82%) or unprotected sex (59-65%), or in cases of rape (85-91%), but both pharmacists and college students reported concerns that females might feel pressured to use the method. No study examined clinicians' attitudes and behaviors (e.g., counseling or advance provision) regarding males and emergency contraception.

CONCLUSIONS

Studies are needed to determine whether male involvement in emergency contraception can reduce rates of unintended pregnancy and to assess health professionals' ability to counsel males about the method.

Updates in hormonal emergency contraception

In recent years, there have been many updates in hormonal emergency contraception. Levonorgestrel emergency contraception has been available for several years to prevent pregnancy when used within 72 hours after unprotected intercourse or contraceptive failure, and it was recently approved for nonprescription status for patients aged 17 years or older. Current research suggests that the primary mechanism of action is delaying ovulation. Ulipristal is the newest emergency contraception, available by prescription only, approved for use up to 120 hours after unprotected intercourse or contraceptive failure. The primary mechanism of action is delaying ovulation. When compared with levonorgestrel emergency contraception, ulipristal was proven noninferior in preventing pregnancy. Evidence suggests that ulipristal does not lose efficacy from 72-120 hours; however, more studies are warranted to support this claim. Many misconceptions and controversies about hormonal emergency contraception still exist. Research does not support that increased access to emergency contraception increases sexual risk-taking behavior. Several studies suggest that health care providers, including pharmacists, could benefit from increased education about emergency contraception. It is important for pharmacists to remain up-to-date on the most recent hormonal emergency contraception products and information, as pharmacists remain a major point of access to emergency contraception.

Emergency contraception in Iowa pharmacies before and after over-the-counter approval

OBJECTIVES

To compare availability of emergency contraception in Iowa pharmacies, before and after the U.S. Food and Drug Administration (FDA) approved over-the-counter sales and identify reasons why over-the-counter, emergency contraception might still not be available in some Iowa pharmacies.

DESIGN AND SAMPLE

Secondary analysis of data collected for an existing, descriptive study. A total of 906 pharmacies were identified; 405 (56.8%) pharmacies participated before, and 308 (43.2%) after the FDA policy change.

MEASURES

Data collected via a scripted telephone survey.

RESULTS

After the FDA changed its policy and allowed over-the-counter sales of emergency contraception, the percentage of Iowa pharmacies offering emergency contraception increased from 57.8% to 70%. In the before sampling, 67.5% reported a perceived lack of demand as the primary reason for not carrying emergency contraception 66.7% reported this rationale in the after group. Other reasons included store policy, and moral, religious, or personal reasons. Pharmacists were surprisingly uninformed about the action of emergency contraception; before the FDA approved over-the-counter sales 53% believed the drugs primarily worked by blocking implantation of a fertilized egg. Indeed, even after FDA approved over-the-counter sales, 38% of pharmacists still believed that emergency contraception was comparable to an abortifacient. In addition, before the policy changed, 43.8% of pharmacists accepted emergency contraception as safe for teenagers; this percentage fell to 27.9% after the policy change.

CONCLUSIONS

Significant increases in the carrying of emergency contraception suggest the policy did succeed in increasing access. Despite this, barriers to access exist. Further research should explore why pharmacies might not carry emergency contraception.

Can private pharmacy providers offer comprehensive reproductive health services to users of emergency contraceptives? Evidence from Nairobi, Kenya

OBJECTIVE

To evaluate the provision of reproductive health information and services to users of emergency contraceptives (ECs) by private pharmacists.

METHODS

The study involved intervention (9) and control (8) pharmacies, with baseline and endline assessments of EC provision through the use of mystery clients. Intervention pharmacies received weekly updates on EC, fliers with three key messages on EC, and information, education, and communication materials. Logistic regression models are estimated to predict the provision of reproductive health services to EC clients.

RESULTS

The differences between the control and intervention pharmacies with respect to the provision of additional information on EC and regular family planning services are in the expected direction but statistically insignificant. In contrast, the likelihood of providing information or referral for counseling or testing for sexually transmitted infections or HIV was lower in the intervention than in the control pharmacies but the difference was also not statistically significant.

CONCLUSION

Pharmacy providers in the country face institutional challenges in providing reproductive health services to EC clients.

PRACTICE IMPLICATIONS

The challenges could be addressed through pre-service training, targeted in-service training, sensitization of clients, and point-of-sale materials such as brochures, posters and package inserts.