Barriers to adolescents' getting emergency contraception through pharmacy access in California: differences by language and region

Access challenges for patients with limited English proficiency: a secret-shopper study of in-person and telehealth behavioral health services in California safety-net clinics

The recent growth of telehealth may be impacting access to care for patients, including those with limited English proficiency (LEP). Using a secret-shopper design, simulated patients contacted 386 safety-net clinics in California in both Spanish and English from February-March 2023. Callers stated that they were new patients seeking medication for depression, and they documented time to an appointment and available visit modalities (telehealth and in-person). Multinomial logistic regression models examined associations between clinic characteristics and available modalities. English-speaking callers were more likely to speak with a live scheduler and to obtain appointment information from a scheduler who could engage with them in their preferred language. Among Spanish-speaking callers who reached a live scheduler, 22% reached someone who did not engage (eg, were hung up on) and, as a result, could not obtain appointment information. The mean estimated time to a prescribing visit was 36 days and did not differ by language. Sixty-four percent of clinics offered both telehealth and in-person visits, 14% only offered in-person visits, and 22% only offered telehealth visits. More attention and resources are needed to support patients with LEP at the point of scheduling and to ensure choice of visit modality for all patient populations.

Validation of the Adolescent Health Quality of Care (AHQOC) index for mystery client studies

The Adolescent Health Quality of Care (AHQOC) index is a tool designed to evaluate the quality of facility-based adolescent sexual and reproductive health (ASRH) services. This descriptive cross-sectional study aimed to validate the AHQOC index in 27 primary and secondary public health facilities located in a rural and an urban local government area (LGA) of Ogun State, Nigeria. To conduct the study, 12 mystery clients (MCs) were recruited and performed 144 visits to the health facilities. The MCs were young males and females who were seeking information on premarital sex, pregnancy prevention, sexually transmitted infections (STIs), and contraception. The validity, and reliability of the AHQOC index were evaluated using exploratory factor analysis, Cronbach's Alpha, and intra-class correlation coefficient tests. The Kaiser-Meyer-Olkin test result for the initial 37-item pool was 0.7169, and the final tool retained 27 items with a Cronbach's Alpha of 0.80. Two subscales of the index had Cronbach's Alpha of 0.76 and 0.85. The intra-rater consistency assessed by the intra-class correlation coefficient was 0.66 (0.10-0.92) p = 0.001 for the urban LGA and 0.72 (0.37-0.91) p = 0.001 for the rural LGA. Positive and statistically significant relationships were observed between the full scales and subscales and the validity item (MC ranking of health worker on proficiency from 1 to 10). The results of this study demonstrate that the validated AHQOC index is a valuable tool for assessing the quality of ASRH services in public health facilities.

Emergency Contraception: Access and Challenges at Times of Uncertainty

BACKGROUND

The UN Commission on Life-Saving Commodities for Women's and Children's Health identified emergency contraceptive pills as 1 of the 13 essential underused, low-cost, and high-impact commodities that could save the lives of millions of women and children worldwide. In the US, 2 emergency contraceptive regimens are currently approved, and their most plausible mechanism of action involves delaying and/or inhibiting ovulation.

AREAS OF UNCERTAINTY

Abortion and contraception are recognized as essential components of reproductive health care. In the US, in the wake of the Dobbs v. Jackson Women's Health Organization Supreme Court decision on June 24, 2022, 26 states began to or are expected to severely restrict abortion. It is anticipated that these restrictions will increase the demand for emergency contraception (EC). Several obstacles to EC access have been described, and these include cost, hurdles to over-the-counter purchase, low awareness, myths about their mechanisms of action, widespread misinformation, and barriers that special populations face in accessing them. The politicization of EC is a major factor limiting access. Improving sex education and health literacy, along with eHealth literacy, are important initiatives to improve EC uptake and access.

DATA SOURCES

PubMed, The Guttmacher Institute, Society of Family Planning, American College of Obstetrician and Gynecologists, the World Health Organization, The United Nations.

THERAPEUTIC ADVANCES

A randomized noninferiority trial showed that the 52 mg levonorgestrel intrauterine device was noninferior to the copper intrauterine device when used as an EC method in the first 5 days after unprotected intercourse. This is a promising and highly effective emergency contraceptive option, particularly for overweight and obese patients, and a contraceptive option with a different bleeding profile than the copper intrauterine device.

CONCLUSIONS

EC represents an important facet of medicine and public health. The 2 medical regimens currently approved in the US are very effective, have virtually no medical contraindications, and novel formulations are actively being investigated to make them more convenient and effective for all patient populations. Barriers to accessing EC, including the widespread presence of contraception deserts, threaten to broaden and accentuate the already existing inequities and disparities in society, at a time when they have reached the dimensions of a public health crisis.

Kentucky pharmacists' perceptions regarding provision of hormonal contraception

BACKGROUND

Although Kentucky pharmacists recently gained authority to provide protocol-driven care for 13 conditions, provision of prescription hormonal contraception (HC) services is not currently authorized. A board-approved protocol allowing for provision of nonprescription over-the-counter (OTC) emergency contraception (EC) was recently approved by the Kentucky Board of Pharmacy but has yet to be implemented.

OBJECTIVES

The objectives of this study were (1) to assess Kentucky pharmacists' interest in providing prescription HC and OTC EC services via protocol and (2) to identify perceived benefits/barriers regarding provision of prescription HC.

METHODS

An online questionnaire was disseminated electronically to a convenience sample of Kentucky pharmacists. The questionnaire collected (1) demographic information, (2) opinions regarding provision of prescription HC and OTC EC, and (3) perceived benefits and barriers regarding provision of prescription HC. For analysis, responses were limited to pharmacists in community-based practice. McNemar's test was used to identify statistically significant differences in support by dosage form. In addition, a multivariable logistic regression model was used to examine associations between demographic factors and support for pharmacist provision of prescription HC.

RESULTS

We received 151 responses from community-based pharmacists. Support for provision of prescription HC was highest for oral (61%) and transdermal (54%) forms. We found no statistically significant differences in support among demographic factors other than number of years in practice, with more recent graduates being at higher odds of support. In addition, time, reimbursement, training, and belief in the need for pelvic exams were the most commonly cited barriers to implementation. With regard to OTC EC provision, pharmacists were largely supportive (62%) and confident in their abilities.

CONCLUSIONS

Community-based pharmacists in Kentucky are supportive of provision of oral, vaginal, and transdermal prescription HC as well as OTC EC via protocol. Barriers, including time, reimbursement, training, and belief in the need for pelvic exams, should be addressed to increase support for prescription HC provision.

Perspectives of community pharmacists on conscientious objection to provide pharmacy services: A theory informed qualitative study

BACKGROUND

In recent years, pharmacists have been opting out of certain pharmacy services, particularly, providing contraceptives, for moral reasons. No research has been conducted on the perceptions of community pharmacists toward conscience objection in a secular state with a mostly Muslim population.

OBJECTIVE

This study aimed to provide an in-depth understanding of the factors related to the beliefs of community pharmacists on conscientious objection to provide pharmacy services contrary to their personal beliefs based on the theory of planned behavior.

METHODS

Semistructured interviews were conducted with a purposive sampling of community pharmacists. A hybrid deductive and inductive qualitative analysis approach was used on the data that were recorded and transcribed verbatim. Constructs related to attitude, subjective norm, and perceived behavioral control were explored.

RESULTS

In total, 25 community pharmacists were interviewed. Factors affecting pharmacists' decision to provide pharmacy services when their personal beliefs included the desire to maintain moral integrity, beliefs about consequences for health care service, profit, patient pressure, precedence of professional values, and care for religious sources.

CONCLUSION

Most of the community pharmacists were against the behavior of conscientiously objecting to provide pharmacy services in Turkey because of possible negative consequences on health care. The pharmacists who were willing to act based on their personal beliefs were expecting from various third parties to fulfill certain responsibilities to facilitate to adopt the behavior. This novel study highlights the urgent need for more research and training for community pharmacists serving patients in different socioeconomic contexts in both developed and developing countries.

Accessibility of emergency contraception for adolescents in Quebec community pharmacies

Objective

Access to effective contraceptives, including emergency contraception (EC), is critical to reducing unintended adolescent pregnancy. This study evaluates the accessibility of Ln-EC (levonorgestrel EC) for adolescents in Quebec community pharmacies.

Methods

We conducted an anonymous self-administered electronic survey of Quebec community pharmacists between June 1, 2016 and October 31, 2016. Pharmacists were asked about the availability of Ln-EC in their pharmacy, whether they prescribed Ln-EC, and their experience with adolescents who requested Ln-EC.

Results

Five hundred and ninety-one pharmacists responded, with representation from across the province. Ninety-five per cent had Ln-EC in stock. Most pharmacists (90%) reported being comfortable prescribing Ln-EC, though they were less comfortable prescribing to adolescents than to adults (*P<0.001). Pharmacists also reported that cost and confidentiality are barriers to accessing Ln-EC for some adolescents.

Conclusions

This study indicates that availability and pharmacist comfort are not likely to be barriers to Ln-EC use for adolescents. On the other hand, cost and/or confidentiality do represent a barrier for some adolescents. This study lays the groundwork for a national study examining the accessibility of EC for adolescents.

Emergency Contraception Access and Counseling in Urban Pharmacies: A Comparison between States with and without Pharmacist Prescribing

Pharmacists are often the primary source of emergency contraception (EC) access and patient information. This study aims to identify differences in pharmacist-reported EC access and counseling between states which do or do not permit pharmacist-prescribed EC. This prospective, mystery caller study was completed in California (CA), which permits pharmacist-prescribed EC after completion of continuing education, and Georgia (GA), which does not. All community pharmacies that were open to the public in San Diego and San Francisco, CA, and Atlanta, GA were called by researchers who posed as adult females inquiring about EC via a structured script. Primary endpoints were EC availability and counseling. Statistical analyses completed with SPSS. Researchers called 395 pharmacies, 98.2% were reached and included. Regarding levonorgestrel (LNG), CA pharmacists more frequently discussed (CA 90.4% vs. GA 81.2%, p = 0.02), stocked (CA 89.5% vs. GA 67.8%, p < 0.01), and correctly indicated it “will work” or “will work but may be less effective” 4 days after intercourse (CA 67.5% vs. GA 17.5%, p < 0.01). Ulipristal was infrequently discussed (CA 22.6% vs. GA 3.4%, p < 0.01) and rarely stocked (CA 9.6% vs. GA 0.7%, p < 0.01). Pharmacists practicing in states which permit pharmacist-prescribed EC with completion of required continuing education may be associated with improved patient access to oral EC and more accurate patient counseling.

Conscientious Objection: A Talmudic Paradigm Shift

Conscientious objection remains a very heated topic with strong opinions arguing for and against its utilization in contemporary health care. This paper summarizes and analyzes various arguments in the bioethical literature, favoring and opposing conscientious objection, as well as some of the proposed solutions and compromises. I then present a paradigm shifting compromise approach that arises out of very recent Jewish bioethical thought that refocuses the discussion and can minimize the frequency with which conscientious objection is required.

An Evaluation of the Implementation of Pharmacist-Prescribed Hormonal Contraceptives in California

OBJECTIVE

To evaluate the implementation of pharmacist-prescribed hormonal contraceptives in California after a recent expansion of pharmacists' scope of practice.

METHODS

A probability sample of 480 licensed California retail pharmacies (stratified by nonrural or rural location and independent or chain status) was included in a cross-sectional "secret shopper" telephone survey assessing the availability of pharmacist-prescribed hormonal contraceptives and service details. Survey data were analyzed using weighted descriptive statistics, CIs, and Wald tests.

RESULTS

Findings included data from 457 pharmacies (response rate 95.2%). Only 5.1% of pharmacies reported providing pharmacist-prescribed hormonal contraceptives (95% CI 2.9-7.2%). This proportion did not differ significantly between rural and nonrural pharmacies (P=.83) nor between independent and chain pharmacies (P=.40). Five of the 22 pharmacies that were providing pharmacist-prescribed hormonal contraceptives informed secret shoppers that all allowed hormonal methods were available; most of these pharmacies (77.3%) did proactively describe that a health history was required before receiving medications. Only half of pharmacies providing pharmacist-prescribed hormonal contraceptives would do so for minors although this was allowed by law.

CONCLUSION

In the first year after statewide protocol implementation, only a small proportion of retail pharmacies across California has begun offering hormonal contraception services. In the absence of additional supportive legislation regarding reimbursement for pharmacist services, increases in scope of practice regulations to build a larger network of contraceptive providers may not be effective in increasing access to birth control.

Pharmacy-based sexual health services: a systematic review of experiences and attitudes of pharmacy users and pharmacy staff

BACKGROUND

Pharmacies are increasingly providing services related to contraception and STIs. Identifying pharmacy staff' and users' experiences and attitudes relating to sexual health services is critical to understand users' needs and examining how pharmacy staff can most effectively contribute to patient-centred care. This systematic review aimed to examine pharmacy staff and pharmacy users' experiences and attitudes towards the delivery of a large range of sexual health services.

METHODS

Seven electronic databases and the reference lists of all included studies were searched in September 2018. Studies giving insight into pharmacy users' and pharmacy staff's experiences and attitudes towards the delivery of services related to contraception and STIs were included. The Mixed Methods Appraisal Tool was used to assess the quality of included studies and a narrative synthesis applied to analyse evidence.

RESULTS

Nineteen studies were included. Eleven studies looked at pharmacy staff, four at users and four at both groups. Users found services accessible and convenient and staff found service provision feasible. However, several barriers to service delivery were identified including lack of privacy for delivering services, lack of trained staff available to provide services and subjective judgements being made on who should be provided or offered a service.

DISCUSSION

Barriers to service delivery need to be addressed to allow pharmacies to deliver their full potential. Future research on pharmacy-based gonorrhoea and syphilis screening, and hepatitis B vaccination is needed.

PROSPERO REGISTRATION NUMBER

CRD42018106807.

Contraceptive Desert? Black-White Differences in Characteristics of Nearby Pharmacies

OBJECTIVES

Race differences in contraceptive use and in geographic access to pharmacies are well established. We explore race differences in characteristics of nearby pharmacies that are likely to facilitate (or not) contraceptive purchase.

STUDY DESIGN

We conducted analyses with two geocode-linked datasets: (1) the Relationship Dynamics and Social Life (RDSL) project, a study of a random sample of 1003 women ages 18-19 living in a county in Michigan in 2008-09; and (2) the Community Pharmacy Survey, which collected data on 82 pharmacies in the county in which the RDSL study was conducted.

RESULTS

Although young African-American women tend to live closer to pharmacies than their white counterparts (1.2 miles to the nearest pharmacy for African Americans vs. 2.1 miles for whites), those pharmacies tend to be independent pharmacies (59 vs. 16%) that are open fewer hours per week (64.6 vs. 77.8) and have fewer female pharmacists (17 vs. 50%), fewer patient brochures on contraception (2 vs. 5%), more difficult access to condoms (49% vs. 85% on the shelf instead of behind glass, behind the counter, or not available), and fewer self-check-out options (3 vs. 9%). More African-American than white women live near African-American pharmacists (8 vs. 3%). These race differences are regardless of poverty, measured by the receipt of public assistance.

CONCLUSIONS

Relative to white women, African-American women may face a "contraception desert," wherein they live nearer to pharmacies, but those pharmacies have characteristics that may impede the purchase of contraception.

A systematic review of the use of adolescent mystery clients in assessing the adolescent friendliness of health services in high, middle, and low-income countries

Background: Mystery client methodology is a form of participatory research that provides a unique opportunity to monitor and evaluate the performance of health care providers or health facilities from the perspective of the service user. However, there are no systematic reviews that analyse the use of mystery clients in adolescent sexual and reproductive health (ASRH) research and monitoring and evaluation of programmes.

Objective: To assess the use of adolescent mystery clients in examining health care provider and facility performance in providing ASRH services in high, middle, and low-income countries.

Methods: We carried out a systematic review of published journal articles and reports from the grey literature on this topic from 2000 to 2017 (inclusive). Thirty research evaluations/studies were identified and included in the analysis. We identified common themes through thematic analysis.

Results: The findings reveal that researchers and evaluators used mystery client methodology to observe client-provider relationships, and to reduce observation bias, in government or private health facilities, NGOs, and pharmacies. The mystery clients in the evaluations/studies were young people who played varying roles; in most cases, they were trained for these roles. Most reported good experiences and friendly providers; however, some reported lack of privacy and confidentiality, lack of sufficient written/verbal information, and unfavourable experiences such as sexual harassment and judgmental comments. Female mystery clients were more likely than males to report unfavourable experiences. Generally, the methodology was considered useful in monitoring and evaluating the attitudes of health service providers and ASRH service provision.

Conclusions: The research evaluations/studies in this review highlight the usefulness of mystery clients as a method to gain insight, from an adolescent perspective, on the quality of ASRH services for research and monitoring and evaluation of programmes.

Availability and Accessibility of Emergency Contraception to Adolescent Callers in Pharmacies in Four Southwestern States

PURPOSE

To evaluate the availability and accessibility of emergency contraception (EC) to adolescents in U.S. pharmacies across four Southwestern states, 3 years after the federal Food and Drug Administration (FDA) removed age restrictions for over-the-counter sales of levonorgestrel-only pills.

METHODS

Using a mystery-caller approach, we trained male and female data collectors to phone pharmacies posing as 16-year-olds who wanted to prevent a pregnancy after recent unprotected sex. From April to May 2016, they called 1,475 randomly selected retail pharmacies in Arizona, California, New Mexico, and Utah and completed an online survey about their experience. Caller data were analyzed by state and pharmacy type (i.e., national chains, regional outlets, and individually owned outlets).

RESULTS

Of pharmacies contacted, 80.6% had EC available at the time of the call. Availability of EC varied by state (p < .01) and pharmacy type (p < .01), but not by rural/urban location. Even where EC was available, pharmacy personnel often hindered youths' access to EC by mentioning incorrect point-of-sale restrictions, keeping EC in restrictive store locations, or asking personal questions. Individually owned outlets presented significantly more barriers than larger chains. Overall, EC was completely accessible to an adolescent caller in only 28% of pharmacies. Lower EC accessibility was found in states with higher teen pregnancy rates.

CONCLUSIONS

This study found that EC is still not sufficiently available or accessible to adolescents in Southwestern states. Differences in accessibility vary significantly by state and pharmacy type and may be a contributor to teen pregnancy rates.

State of emergency contraception in the U.S., 2018

Emergency contraception is indicated in instances of unprotected sexual intercourse, including reproductive coercion, sexual assault, and contraceptive failure. It plays a role in averting unintended pregnancies due to inconsistent use or non-use of contraception. Options for emergency contraception vary by efficacy as well as accessibility within the U.S. This paper provides an overview of levonorgestrel (Plan B One-Step and generic counterparts), ulipristal acetate (sold as ella), and the copper intrauterine device (IUD, sold as ParaGard), including the mechanisms of action, administration, efficacy, drug interactions, safety, side effects, advantages, and drawbacks. It will also review current misconceptions about emergency contraception and access for subpopulations, including adolescents, immigrants, survivors of sexual assault, rural populations, and military/veteran women. This paper will address barriers such as gaps in knowledge, and financial, health systems, and practice barriers. Continuing areas of research, including the impact of body weight on the efficacy of emergency contraceptive pills and potential interactions between ulipristal acetate and ongoing hormonal contraceptives, are also addressed.

A Youth-Friendly Pharmacy Initiative: Decreasing Unintended Pregnancies Among Disenfranchised Youth

Teens from neighborhoods that have experienced historical and contemporary disinvestment have among the highest rates of teen pregnancy, yet they have less access to resources to reduce unintended pregnancies. In recognition of this, the New York City Department of Health and Mental Hygiene (NYCDOHMH) developed the Youth-Friendly Pharmacy Initiative. Over 7 consecutive months in 2015, educational materials and free NYCDOHMH condoms were placed strategically in independent pharmacies in the South Bronx. Refills were made monthly. Pharmacists were directed to order free refills from the NYCDOHMH after the project ended. To evaluate the feasibility of the study, a survey with teens (15-19 years) at the study midpoint and a 3-month post follow-up assessment were conducted. The retention rate over 7 months was 96.4% (27/28 pharmacies). Forty-three percent (2,068/4,830) of the booklets and 87.9% (43,841/49,850) of the condoms were taken by patrons. The posters and pamphlets were recognized by 63.6% and 27.3% of the teens, respectively. Forty-percent of the teens were aware of the free condoms, and one third had taken the free condoms. In the post assessment, 20% of the sampled pharmacies independently sought out resources for free condom refills. Pharmacies are positive sexual and reproductive health resources for underserved teens.

Evaluating Community Pharmacy Responses About Levonorgestrel Emergency Contraception by Mystery Caller Characteristics

PURPOSE

Since restrictions on nonprescription sales were removed in 2013, levonorgestrel emergency contraception (EC) should be available without a prescription at pharmacies for consumers of all genders and ages. Using mystery callers, we assessed variations in availability of and access to EC.

METHODS

In 2015-2016, three sets of mystery callers (two female physicians, two adolescent females, and two adolescent males) each called all licensed retail pharmacies in five U.S. cities using standardized call scripts. Scripts assessed same-day availability and subsequent access to EC for 17-year-olds. Data on various characteristics of calls were collected and compared by caller type.

RESULTS

Among the 993 pharmacies called, same-day availability for EC was approximately 80%, with no differences by caller types (p = .34). However, 10.7% of calls made by the adolescent male caller and 8.3% made by the adolescent female caller resulted in incorrectly being told they could not obtain EC based on age, compared to only 1.6% of calls made by the physician (p < .01). Pharmacy staff stated correctly that EC was available over-the-counter more often to adolescent male callers (62.0%) than adolescent females (51.6%) or female physicians (57%) (p < .01). Physicians were more likely to be placed on hold, talk to a pharmacist, or be transferred to a pharmacist (p < .01) than adolescents.

CONCLUSIONS

Persistent barriers to accessing EC exist for adolescents despite regulatory changes to make EC available over-the-counter, especially for females. Additional work to remove these barriers is needed to assure timely access for those who require effective pregnancy prevention.

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.

Pharmacy provision of sexual and reproductive health commodities to young people: a systematic literature review and synthesis of the evidence

BACKGROUND

We conducted a systematic review of peer-reviewed literature on youth access to, use of and quality of care of sexual and reproductive health (SRH) commodities through pharmacies.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, we searched for publications from 2000 to 2016. To be eligible for inclusion, articles had to address the experiences of young people (aged 25 years and below) accessing SRH commodities (e.g., contraception, abortifacients) via pharmacies. The heterogeneity of the studies precluded meta-analysis - instead, we conducted thematic analysis.

RESULTS

A total of 2842 titles were screened, and 49 met the inclusion criteria. Most (n=43) were from high-income countries, and 33 examined emergency hormonal contraception provision. Seventeen focused on experiences of pharmacy personnel in provision, while 28 assessed client experiences. Pharmacy provision of SRH commodities was appealing to and utilized by youth. Increasing access to SRH commodities for youth did not correspond to increases in risky sexual behavior. Both pharmacists and youth had reservations about the ease of access and its impact on sexual behaviors. In settings where regulations allowing pharmacy access were established, some pharmacy personnel created barriers to access or refused access entirely.

DISCUSSION

With training and support, pharmacy personnel can serve as critical SRH resources to young people. Further research is needed to better understand how to capitalize on the potential of pharmacy provision of SRH commodities to young people without sacrificing qualities which make pharmacies so appealing to young people in the first place.

Improving adolescent knowledge of emergency contraception: challenges and solutions

Globally, unintended adolescent pregnancies pose a significant burden. One of the most important tools that can help prevent unintended pregnancy is the timely use of emergency contraception (EC), which in turn will decrease the need for abortions and complications related to adolescent pregnancies. Indications for the use of EC include unprotected sexual intercourse, contraceptive failure, or sexual assault. Use of EC is recommended within 120 hours, though is most effective if used as soon as possible after unprotected sex. To use EC, adolescents need to be equipped with knowledge about the various EC methods, and how and where EC can be accessed. Great variability in the knowledge and use of EC around the world exists, which is a major barrier to its use. The aims of this paper were to 1) provide a brief overview of EC, 2) discuss key social determinants affecting knowledge and use of EC, and 3) explore best practices for overcoming the barriers of lack of knowledge, use, and access of EC.

STD and Abortion Prevalence in Adolescent Mothers With Histories of Childhood Protection Involvement

CONTEXT

Early sexual debut and unprotected sexual activity place adolescents at risk of adverse sexual health outcomes. Adolescents involved with child protective services (CPS) may be a particularly vulnerable population.

METHODS

California birth records for 86,946 adolescents who became first-time mothers in 2008-2010 were probabilistically linked to statewide CPS records from 1998 and later. The prevalence of STDs at birth and of abortion history were explored by preconception CPS involvement. Generalized linear models, adjusted for health, socioeconomic and demographic characteristics, were used to assess correlates of current STDs and history of abortion.

RESULTS

At the time they gave birth, 1% of adolescents had a documented STD, and 5% reported a previous abortion. After adjustment for other characteristics, CPS involvement was associated with a significantly elevated prevalence both of STDs (relative risk, 1.2) and of previous abortion (1.4). Other characteristics also were associated with both outcomes, but not always in the same direction. For example, delaying prenatal care until after the first trimester or getting none at all was associated with an increased prevalence of STDs (1.3), but a reduced prevalence of abortion (0.8-0.9); having public insurance coverage for the birth was associated with a reduced STD prevalence (0.9) and an elevated abortion history prevalence (1.2).

CONCLUSIONS

To assess whether adolescents with a history of CPS involvement need targeted sexual health interventions, further research is needed on the mechanisms that underlie associations between CPS involvement and adverse sexual health outcomes.

Emergency Contraception Pill Awareness and Knowledge in Uninsured Adolescents: High Rates of Misconceptions Concerning Indications for Use, Side Effects, and Access

STUDY OBJECTIVE

To determine the awareness of, access to, and knowledge of the proper use of emergency contraception pills (ECPs) among uninsured adolescents.

DESIGN

Anonymous surveys were used to assess awareness of, knowledge of, and access to ECPs.

SETTING

From 2010 to 2012 at mobile primary care clinic in the San Francisco Bay Area.

PARTICIPANTS

Patients were uninsured adolescents aged 13 to 25; 40% of the participants were currently or had been homeless in the past year. Ethnicity was 50% Asian, 22% Hispanic, 17% Pacific Islanders, 5.5% white, and 5.5% other/mixed ethnicity.

INTERVENTIONS

Post survey completion, patients received one-on-one 15-minute dedicated ECP education.

MAIN OUTCOME MEASURES

Awareness of, knowledge of, and access to ECPs.

RESULTS

Of the study population of 439, 30% of the participants were 13-16 years old and 70% were 17-25 years old (mean age 17.8 years); 66% were women. Young women (86%) reported higher rates of "hearing about emergency contraception" than did young men (70%) (P < .0001). Many incorrectly identified or were uncertain if ECPs were an abortion pill (40%) or could be used as regular birth control (40%) or to prevent sexually transmitted infections (19%). Only 40% of women and 43% of men aged 17 and older correctly answered that they could obtain EC over the counter; 72% did not know that males could receive EC for use by their partner; 12% incorrectly selected that infertility was a side effect; 44% were under the false impression that EC had to be taken within 1 day of unprotected sex.

CONCLUSIONS

Uninsured adolescents have high rates of ECP awareness but low ECP knowledge. These adolescents need more ECP education to alleviate misconceptions and increase practical knowledge, specifically, education about male access, side effects, over-the-counter availability for young men and women, and the 120-hour window of use.

The achievement of public health services in pharmacy practice: A literature review

BACKGROUND

It is known that pharmacists are currently contributing to public health; however, the extent of this contribution as reported in the literature has not been examined. Investigating the ways that pharmacists are currently participating in public health is critical for the profession of pharmacy, pharmacy educators, and the public health community.

OBJECTIVES

The purpose of this study was to determine the reported contributions of pharmacy to each of the ten essential services of public health, and which of the five core competencies of public health were most frequently utilized in those contributions.

METHODS

A PubMed search was used to extract references that included both the words pharmacy and services in the title or abstract, and the words public health in any part of the document. A total of 247 references were extracted and categorized into the essential services and core competencies.

RESULTS

The essential services Inform, Educate, and Empower, and Link to/Provide Care were more frequently represented in the literature, and the core competency of Health Policy and Administration was most frequently utilized.

CONCLUSION

To further contribute to and integrate their contributions within population health, pharmacists must consider ways to strategically contribute to the essential services of public health and seek to increase competency in public health.

"But I wasn't told to": lack of education and workplace policy as barriers in the provision of family planning information

Access to family planning has been identified as critical to public health. Improving the linkage between medical and social services could result in improved access to care for those most at risk of unintended pregnancy. This study used a survey based on Alfred Bandura's social cognitive theory (1986) to increase the understanding of the barriers social workers confront in the provision of family planning information to clients. Although moral disagreement with family planning presented a barrier for some, workplace policy, participation in family planning trainings, and working in an urban setting were of greater value in understanding barriers.

A mystery caller evaluation of emergency contraception supply practices in community pharmacies in Victoria, Australia

The aim of this study was to determine supply practices of Victorian community pharmacies in relation to the emergency contraceptive pill (ECP), following release of an updated guideline by the Pharmaceutical Society of Australia. Telephone call scripts were developed for three scenarios in which the ECP was requested: outside the licensed 72-h time frame (Scenario 1); by a woman under 16 years (Scenario 2); and for future use (Scenario 3). From 1222 pharmacies, 515 were randomly selected and allocated into three groups: 177 to Scenario 1 and 169 to each of Scenarios 2 and 3. Pharmacists’ responses were categorised as ‘yes’, ‘no’ or ‘ambiguous’ and descriptive statistics were calculated. The results are as follows. Scenario 1: over half (55.4%; 92/166) declined supply and most referred to the doctor, citing the time frame or the ECP as no longer being effective reasons. Decreased effectiveness was readily discussed among those willing to supply. Scenario 2: more than half (53.9%, 89/165) agreed to supply, assessing the request against eligibility criteria outlined in the guideline; however, 5.6% (5/89) were only willing if the woman obtained a doctor’s prescription or recommendation. Scenario 3: less than half (40.5%; 66/163) declined supply, mainly due to no therapeutic need. Only four respondents willing to give the ECP knew that supply was bona fide. In conclusion, pharmacists’ practices are variable and not always in line with the recommendations of the Pharmaceutical Society of Australia guideline. Pharmacists’ awareness of the guideline needs to be raised so women can unobtrusively access the ECP.

"I'll see what I can do": What adolescents experience when requesting emergency contraception

PURPOSE

To understand the experiences of adolescent females when they try to obtain emergency contraception (EC) from pharmacies.

METHODS

Female callers, posing as 17-year-old adolescents, used standardized scripts to telephone 943 pharmacies in five United States cities. Two investigators independently coded qualitative data from these calls. Codes were discussed and a thematic analysis was conducted. Investigator, expert, and informant triangulation were used to ensure data credibility.

RESULTS

Four major themes emerged. First, ethical terms (personal or religious) were used to explain institutional pharmacy policies on EC availability. Second, there was confusion about the dispensing regulations regarding EC, given recent changes in United States policies. Third, pharmacy staff often introduced false barriers to EC access. In some cases, pharmacy staff used these barriers as justification for refusing to dispense EC; however, in other cases, pharmacy staff helped the adolescents overcome these false barriers. Finally, the degree of confidentiality in providing EC was unpredictable, with some pharmacies guaranteeing strict confidentiality and others explicitly telling adolescents, incorrectly, that their parents had to be informed.

CONCLUSIONS

Adolescents requesting EC from pharmacies are often explained pharmacy policies in ethics-laden terms, and confidentiality is not always guaranteed. They are told of false barriers to EC access, and there is confusion concerning the evolving policies regarding EC dispensing. It is important for clinicians, pharmacy staff and others to be aware of these experiences as they work to help improve adolescents' access to EC.

Pharmacy communication to adolescents and their physicians regarding access to emergency contraception

OBJECTIVE

Emergency contraception (EC) is an effective pregnancy prevention strategy. EC is available without a prescription to those aged 17 years or older. The objective of this study was to assess the accuracy of information provided to adolescents and their physicians when they telephone pharmacies to inquire about EC.

METHODS

By using standardized scripts, female callers telephoned 943 pharmacies in 5 US cities posing as 17-year-old adolescents or as physicians calling on behalf of their 17-year-old patients. McNemar tests were used to compare outcomes between adolescent and physician callers.

RESULTS

Seven hundred fifty-nine pharmacies (80%) indicated to adolescent callers, and 766 (81%) to physician callers, that EC was available on the day of the call. However, 145 pharmacies (19%) incorrectly told the adolescent callers that it would be impossible to obtain EC under any circumstances, compared with 23 pharmacies (3%) for physician callers. Pharmacies conveyed the correct age to dispense EC without a prescription in 431 adolescent calls (57%) and 466 physician calls (61%). Compared with physician callers, adolescent callers were put on hold more often (54% vs 26%) and spoke to self-identified pharmacists less often (3% vs 12%, P < .0001). When EC was not available, 36% and 33% of pharmacies called by adolescents and physicians respectively offered no additional suggestions on how to obtain it.

CONCLUSIONS

Most pharmacies report having EC in stock. However, misinformation regarding who can take EC, and at what age it is available without a prescription, is common. Such misinformation may create barriers to timely access.

Cultural adaptation among Hispanic women as related to awareness and acquisition of emergency contraception

BACKGROUND

The study was conducted to examine the relationship between cultural adaptation (acculturation), contraceptive use, personal history of induced abortion, and emergency contraceptive (EC) awareness and acquisition among a sample of young sexually active Hispanic women.

STUDY DESIGN

A total of 959 Hispanic women between 16 and 24 years of age (mean±SD 20.71±2.42 years) completed a survey containing questions on EC acquisition and awareness, acculturation, contraceptive used at last intercourse and history of induced abortion. Data were analyzed using logistic regression analyses.

RESULTS

Acculturation (p=.017), income (p=.024) and education (p<.001) were positively associated with awareness of EC. Additionally, acculturation (p=.003) and a history of an induced abortion (p=.026) were positively associated with acquisition of EC.

CONCLUSIONS

Educational programs should make an effort to include Hispanic women with lower acculturation levels as increasing their knowledge about EC use and its mechanism of action may greatly reduce the number of unplanned pregnancies in this population.

The impact of race and ethnicity on care in the pediatric emergency department

PURPOSE OF REVIEW

To review healthcare disparities encountered by pediatric patients in the emergency department. The discussion focuses on recent research that is relevant to the field of pediatric emergency medicine.

RECENT FINDINGS

The majority of recent research focuses on healthcare disparities affecting black and Hispanic children and adolescents. Disparities are identified in the areas of emergency department utilization, the provision of effective interpreter services, and the epidemiology and management of specific illnesses, including asthma, adolescent sexual health, and mental health. The findings suggest that disparities persist after controlling for socioeconomic factors and that the effect on healthcare outcomes is measurable. Interventions to mitigate healthcare disparities have shown mixed results. There is some evidence that disparity reduction is possible.

SUMMARY

Recent research demonstrates that healthcare disparities exist in several areas affecting the delivery of quality pediatric emergency care. These disparities are shaped by a complex interaction of social, cultural, behavioral, educational, and financial factors. More research is needed to increase the body of knowledge as to why disparities exist. The success of this future research may require an interdisciplinary approach incorporating experts from multiple scientific fields.