Changing oral contraceptives from prescription to over-the-counter status: an opinion statement of the Women's Health Practice and Research Network of the American College of Clinical Pharmacy

Physicians' Opinion Regarding Extended Access to Hormonal Contraception in Switzerland

(1) Background: Access to hormonal contraceptives (HC) strongly differs between countries and varies from over the counter (OTC) to prescription-only availability. This study aimed to identify opinions among physicians in Switzerland regarding extended access to HC. (2) Methods: Web-based survey among physicians (gynecologists, general practitioners, and pediatricians) in Switzerland. (3) Results: Hundred sixty-three physicians, mainly gynecologists, participated in this survey and 147 (90%) were included for analysis. A total of 68% (n = 100) answered that prescription-only status could be extended under certain conditions but physicians were concerned about patients' safety (97%, n = 142). Moreover, there was concern about insufficient patient education on HC (93%, n = 136) and that women may forego preventive examinations (80%, n = 118). Participants did not support OTC availability (93%, n = 136). Pharmacists prescribing (including initiation of HC) revealed controversial results, but a combined access model (initial prescription from physician and follow-up prescriptions by pharmacists) found acceptance in 70% (n = 103). (4) Conclusions: Participating physicians stated that prescription-only status for HC could be lifted under certain conditions but also some concerns, e.g., patients' safety or neglection of preventive examinations, were raised. Future research should focus on specific conditions in which extended access to HC could be agreed on.

Knowledge and beliefs about the use/abuse of oral contraceptive pills among males: A mixed-method explanatory sequential study in community pharmacy settings

BACKGROUND

Oral contraceptive pills (OCPs) are considered one of the most important birth control methods globally. However, these pills were designed for female administration rather than males. This study was designed to investigate patterns of OCPs use and abuse among Jordanian males, according to the community pharmacists' observations.

METHOD

A mixed-method explanatory sequential study was conducted using an online self-administered survey, followed by semi-structured in-depth interviews for registered pharmacists, assistant pharmacists and pharmacy interns. The interviews were utilized using a conceptual framework. Inductive thematic analysis and descriptive/regression analyses were completed using Nvivo and SPSS, respectively.

RESULTS

A total of 158 questionnaire responses and 22 interviews were included in our analysis. Around half (48.4%) of the questionnaire responses confirmed that males could use OCPs for hair growth enhancement, muscle gain and acne treatment 12.7%, 31.7% and 4.4%, respectively. Through the interviews, the participating pharmacists highlighted that males use OCPs mostly for bodybuilding purposes, according to recommendations by their coaches at the gym. The most abused OCPs containing estrogen (Ethinyl estradiol) and progestins (Drospirenone or Levonorgestrel).

CONCLUSION

This study provided insight into unexpected uses of OCPs by males in Jordan. Community pharmacists have a crucial role in the management of OCPs use and abuse. However, restricted regulations and monitoring must be released and implemented on the community to limit such practices.

Unforeseen uses of oral contraceptive pills: Exploratory study in Jordanian community pharmacies

Background

The use of oral contraceptive pills (OCPs) as a birth control method is very common worldwide. OCPs have many other labeled non-contraceptive indications, and as a result there is an associated risk of improper use, as with any other medications. This study was designed to assess the unforeseen improper uses of OCPs observed by community pharmacists in Jordan.

Method

A cross-sectional study design was conducted using a self-administered survey. A convenience sample (n = 380) of Jordanian community pharmacists, were recruited through social media resources. The survey included multiple-choice and open-ended questions. Descriptive statistics and correlation analyses were completed using SPSS.

Results

More than half of the recruited pharmacists (55.3%) were female, and the mean age of the participants was 32.58 ± 9.94. The majority of the pharmacists (85%) had good knowledge about the non-contraceptive indications of OCPs. About 53% of them confirmed their exposure to cases of the improper use of OCPs. About 67.5% of the pharmacists who confirmed exposure to such cases, reported the topical use of OCPs for the enhancement of hair growth. Around 15% of those pharmacists stated that OCPs were used to give negative results for addictive drug screening tests. In the event that the pharmacists suspected improper use, more than 90% suggested they would refrain from dispensing the pills.

Conclusion

This study has spotlighted many unforeseen uses of OCPs in Jordan and highlighted the need for restricted national regulations on the monitoring of OCP prescription/selling patterns in Jordan by policymakers. Moreover, there is a need for the establishment of national educational programs for the Jordanian community regarding the safe proper use of OCPs.

Extended Access to Hormonal Contraception in Pharmacies: A Survey among Swiss Pharmacists

Background: Worldwide the availability to Hormonal Contraceptives (HC) varies from over the counter (OTC) to prescription-only access. In various countries pharmacists are allowed to prescribe HC, although conditions may be different. In Switzerland, HC require a prescription from a physician, although Swiss law allows pharmacists to dispense prescription-only medications in justified exceptional cases without a valid physician’s prescription. This study aimed to identify current dispensing practices for HC in Swiss pharmacies, pharmacists’ knowledge about HC, and their opinion and interest about expanding access to HC. Methods: Web-based survey among Swiss pharmacists. Results: This survey was completed by 397 registered pharmacists and 331 (83%) were included for analysis. The survey showed that 21% of respondents regularly dispense HC without prescription and that a high number of participants are either very interested (57%, n = 189) or rather interested (33%, n = 110) in extended pharmacy access to HC. The majority did not or rather not support physician’s prescription-only status (77%, n = 256) or OTC availability (94%, n = 310). Furthermore, surveyed pharmacists are willing to train for contraception services (90%, n = 299). According to participants, resistance of physicians is the most relevant barrier to this service (88%, n = 292). Conclusion: Surveyed pharmacists are interested in extended access to HC.

Proper Counseling and Dispensing of Isotretinoin Capsule Products by Community Pharmacists in UAE: A Simulated Patient Study

PURPOSE

To evaluate the pharmacist's assessment of patient eligibility for safe use of isotretinoin and the quality of pharmacist's counseling.

PATIENTS AND METHODS

A covert simulated patient (SP) methodology was used in which a trained female researcher, who was 25 years old, played the patient's role through this cross-sectional study by visiting community pharmacies and requesting isotretinoin capsules through a controlled prescription. A data form was used to collect the information following each pharmacy visit by asking about medical/family history and providing comprehensive counseling about the most common adverse effects, proper use instructions, and the importance of adherence to medication. The pharmacists, who did not initiate counseling, were prompted by the SP.

RESULTS

The pharmacists in 400 pharmacies who agreed to participate were visited by the SP. Only 7 (2%) pharmacists provided a complete assessment of patient eligibility for using isotretinoin with comprehensive counseling. Most of the pharmacists (84%) provided incomplete assessment as indicated by the overall score. Only 11 (3%) pharmacists asked the six crucial questions for the assessment of patient eligibility. On prompting, only 6 (2%) pharmacists provided complete counseling about the expected adverse effects. The most frequently provided adverse effect was dry skin, specifically dry lips (71.8%). A minority of 108 (27%) pharmacists provided education about the importance of using contraception during isotretinoin therapy. A complete level of counseling was provided by 125 (31.3%) pharmacists regarding the lab tests that the SP needs to undergo during therapy. Female pharmacists were more likely to provide counseling about the pregnancy test (mean=134, p=0.001).

CONCLUSION

Suboptimal level of the patient's assessment was revealed with poor educational counseling by the community pharmacists. New strategies are needed to improve pharmaceutical care services in the UAE.

Patient Satisfaction and Their Willingness to Pay for a Pharmacist Counseling Session in Hospital and Community Pharmacies in Saudi Healthcare Settings

Objective

Patient satisfaction is an indicator for quality of healthcare service and is sometimes linked to patients’ willingness to pay. Willingness to pay is an economic method for estimating patient’s inclination for a service in monetary terms. This study assessed satisfaction of patients from pharmacist counseling service and estimated their willing to pay for the same.

Methods

A month-long survey was conducted in community and hospital pharmacies located in Khobar, Dammam, and Qatif cities of Saudi Arabia, using Arabic version of Patient Satisfaction Feedback (PSF) questionnaire that measured satisfaction with counseling as well as willingness-to-pay. Convenient sampling method was used, and sample size was calculated based on power analysis. Data was analyzed through SPSS version 23. Chi-square (χ²) test and logistic regression analyses were conducted to report associations between variables and, determinants of satisfaction as well as willingness to pay respectively. The study was approved by concerned ethical committee (IRB-2019-05-020).

Results

Patients (n = 531) with previous counseling experience were more likely to be satisfied [adjusted odds ratio (AOR) 5.2, p < 0.05]. Patients were more willing to pay if, they had an income above SAR 10,000 i.e., USD 2666.5 (AOR 1.78, p < 0.05), were satisfied with counseling time duration (AOR 4.5) and, were able to get counseling without difficulty (AOR 2.1, p < 0.05). Patients were more likely to be satisfied and were willing to pay if, they received required knowledge/information completely (AOR 2.5, 3.7, and p < 0.05) and found pharmacist helpful (AOR 1, 4.5, and p < 0.05). Most patients (43.9%) were satisfied with pharmacist counseling and average satisfaction rating was 7.87 ± 1.99/10.

Conclusion

Patients considered counseling as an important service and were satisfied from it. Less than a third of patients were willing to pay for the service. Knowledge and helpfulness of pharmacist were identified as two major determinants that could not only satisfy and but also promote willingness to pay for the service. A pharmacist with skills in pharmaceutical care and counseling could be useful in promoting the service and making it profitable for pharmacy business.

Australian pharmacists: ready for increased non-prescription medicines reclassification

OBJECTIVES

Reclassification of medicines from prescription to non-prescription increases timely access to treatment, promotes self-management of minor ailments and relieves healthcare system burden. Previous research identified that Australia lagged behind the United Kingdom and New Zealand in medicines reclassification. This study aimed to identify Australian pharmacists' opinions on the current state of medicines reclassification; the prescription medicines consumers requested without prescription; the medicines pharmacists believed should and should not be considered for reclassification; and perceived barriers to reclassification.

METHODS

A 2016 national online survey that sought pharmacists' opinions on the state of reclassification, perceived barriers to reclassification and readiness of the profession for further reclassification. Pharmacists' comments were invited through open-ended questions.

KEY FINDINGS

Two hundred and thirty-five valid surveys were completed. Respondents practised in community, hospital, consultant and academic contexts, and the majority were female (58.7%, n = 138). More than two thirds (70.66%, n = 166) of pharmacists reported receiving daily or weekly requests for non-prescription access to prescription medicines. The majority of pharmacists (71.7%) agreed that the Australian pharmacy profession is ready for further medicines reclassification, guided by patient safety, harm minimisation and medication continuance. The most prominent barrier to further reclassification was opposition from other healthcare professionals.

CONCLUSIONS

Australian pharmacists believe that their profession has the capacity to safely and effectively manage a wider range of non-prescription medicines through increased reclassification in the contexts of patient safety and risk mitigation. This study has contributed to the global conversation on non-prescription medicines access, providing momentum for practice and policy change.

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.

Pharmacists’ Perspectives on Prescribing and Expanding Access to Hormonal Contraception in Pharmacies in the United States

Introduction:

Pharmacist prescribing of contraception is becoming increasingly available in selected states. The objective of this study was to assess US community pharmacists’ perspectives on expanding access, barriers, and facilitators since states have begun pharmacist scope of practice expansions for prescribing contraception.

Methods:

A survey study of US community pharmacists’ support for expanded access models, pharmacist prescribing practices and interest, and importance of safety, cost, and professional practice issues for prescribing was conducted.

Results:

Pharmacists are generally supportive of pharmacist prescribing and behind-the-counter models for hormonal contraception and generally opposed to over-the-counter access. A majority (65%) are interested in prescribing hormonal contraception. The top motivation for prescribing contraception is enjoying individual patient contact (94%). Safety concerns (eg, patients not obtaining health screenings) remained most important for pharmacist implementation, followed by cost (eg, lack of payment or reimbursement for pharmacists’ services), and professional practice (eg, pharmacist time constraints and liability) issues.

Conclusion:

This study provides an updated understanding of attitudes toward models of expanded access to hormonal contraception, interest in prescribing, and barriers and facilitators to this service among community pharmacists. Many barriers such as time and reimbursement remain unchanged. This information can inform policy and implementation efforts.

Development of a pharmacist-provided contraceptive service following passage of Oregon House Bill 2879

OBJECTIVES

To describe the development and implementation of a pharmacist-provided contraceptive service in a community pharmacy to increase access to hormonal contraceptives and improve quality measure performance following passage of Oregon House Bill 2879.

SETTING

Community pharmacy embedded within a federally qualified health center (FQHC).

PRACTICE DESCRIPTION

Not applicable.

PRACTICE INNOVATION

Women 18 to 50 years of age without evidence of an effective contraceptive method in the electronic medical record were administratively identified. Women were then contacted by pharmacy staff and educated about the opportunity to receive hormonal contraceptives directly from the pharmacy. Women were seen for contraceptive services through scheduled and walk-in appointments.

EVALUATION

Not applicable.

RESULTS

From November 1, 2017, to March 31, 2018, 23 women were seen for contraceptive services through the community pharmacy. They averaged 27.2 ± 8.6 years of age and all were Hispanic. The pharmacist prescribed hormonal contraceptives to 78.3% of the women (n = 17). Six women were referred to their primary care provider because pregnancy could not be ruled out (n = 5) or the patient requested a method not within the pharmacists' prescriptive authority (n = 1). No patients were referred to their primary care provider for elevated blood pressure readings, contraindicated disease states, or drug interactions.

CONCLUSION

A pharmacist-provided contraceptive service was successfully implemented at a community pharmacy within an FQHC. This service was mostly used by young Hispanic women with unmet contraceptive needs. The expanded access to hormonal contraceptives provided by this service may help the health center to achieve quality measures related to contraceptive use and decrease unintended pregnancies in the future.

Hormonal contraception without a prescription: opinions of pharmacists, general practitioners and gynaecologists in Flanders, Belgium

OBJECTIVE

The accessibility of contraceptives varies greatly from country to country. Because unintended pregnancies have a considerable impact, programmes have been initiated in some countries to make certain contraceptives available without a prescription. We therefore investigated whether or not Flanders, the Dutch-speaking part of Belgium, is ready for such an initiative.

METHOD

We used a mixed-methods approach with a mainly qualitative methodology. The opinions of pharmacists, general practitioners (GPs) and gynaecologists, the three types of health care provider most closely involved in the prescription and delivery of contraception, were examined.

RESULTS

A majority of pharmacists supported the idea. Moreover, a large majority occasionally dispensed hormonal contraception without a prescription. Pharmacists expected negative responses from physicians. Among GPs and gynaecologists, a small majority supported the idea conditionally. A minority either fully supported the idea or found it completely unacceptable.

CONCLUSION

Economic aspects were clearly important in forming an opinion on the topic, although medical arguments were often used when they happened to point in the same direction. Flemish pharmacists were willing to train for and implement a new service that would provide contraceptives without a prescription. The majority of GPs and gynaecologists expressed reservations about such a service and doubted that it would reduce unintended pregnancies. If this service were to be implemented, caution would be needed to avoid giving contraceptive users conflicting information.

Quality of Community Pharmacy Practice in Antibiotic Self-Medication Encounters: A Simulated Patient Study in Upper Egypt

Antibiotic misuse, either by patients or healthcare professionals, is one of the major contributing factors to antimicrobial resistance. In many Middle Eastern countries including Egypt, there are no strict regulations regarding antibiotic dispensing by community pharmacies. In this study, we examined antibiotic dispensing patterns in Egyptian community pharmacies. About 150 community pharmacies were randomly chosen using convenience sampling from the five most populous urban districts of Minia Governorate in Egypt. Two simulated patient (SP) scenarios of viral respiratory tract infection requiring no antibiotic treatment were used to assess the actual antibiotics dispensing practice of. Face-to-face interviews were then conducted to assess the intended dispensing practice. Descriptive statistics were calculated to report the main study outcomes. In 238 visits of both scenarios, 98.3% of service providers dispensed amoxicillin. Although stated otherwise in interviews, most pharmacy providers (63%) dispensed amoxicillin without collecting relevant information from presenting SPs. Findings showed high rates of antibiotic misuse in community pharmacies. Discrepancies between interviews and patient simulation results also suggest a practice‒knowledge gap. Corrective actions, whether legislation, enforcement, education, or awareness campaigns about antibiotic misuse, are urgently needed to improve antibiotic dispensing practices in Egyptian community pharmacies.

Assessing hormonal contraceptive dispensing and counseling provided by community pharmacists in the United Arab Emirates: a simulated patient study

BACKGROUND

Hormonal contraceptive pills have evolved as a common form of contraception worldwide. Pharmacists play a vital role in providing safe and effective access to these medicines. In many developing countries such as the United Arab Emirates (UAE), these medicines are available to the general public without the presentation of a prescription which requires the pharmacist to shoulder responsibility by assessing and educating patients to assure their appropriate use.

OBJECTIVES

To evaluate community pharmacists' current practice of dispensing and counseling on hormonal contraceptives.

METHODS

Simulated patient methodology was used in this study. A single simulated patient visited community pharmacies requesting an oral contraceptive as per a preplanned scenario. Information from the visits were recorded on a data collection form including: pharmacist assessing patient eligibility to take hormonal contraceptives, selecting the appropriate oral contraceptive, providing complete counseling on how to use the pill, adherence, missed dose handlings and side effects of the medication. The Pharmacist was prompted by the simulated patient to provide the information if they did not provide spontaneous counseling. The quality of pharmacists' counseling was rated and consequently coded as complete, incomplete or poor.

RESULTS

A total of 201 community pharmacies were visited. More than 92% of the pharmacists did not ask the simulated patient any question to assess their eligibility to use contraceptives. Twenty three pharmacists (11.4%) selected the proper product. One hundred seventeen (58.2%) of the pharmacists provided spontaneous counseling on how to use the pill, 17 of them had their counsel rated as complete, but none of the pharmacists provided spontaneous counseling regarding adherence or side effects of the medications. On prompting, 10 pharmacists (12%) provided complete counseling regarding how to use oral contraceptives, 14 pharmacists (7.0%) provided complete counseling on adherence and missing dose handling and five pharmacists (2.5%) provided complete counseling about expected side effects.

CONCLUSIONS

Pharmacists' practice regarding hormonal contraceptive dispensing and counseling was suboptimal in this study. Areas needing intervention were related to pharmacist assessment of eligibility for oral contraceptive use, choice of optimal oral contraceptive for patient-specific co-morbidities and provision of adequate counseling regarding proper use, adherence and missed dose handlings.

Over-the-Counter Access to Oral Contraceptives

Making oral contraceptives (OCs) available over the counter (OTC) could help to reduce the high rate of unintended pregnancy in the United States. Surveys show widespread support for OTC access to OCs among US women. Studies indicate that women can accurately use checklists to identify contraindications to OCs. Continuation is as good or better among OTC users compared with women using OCs obtained by prescription. Women and clinicians have expressed concerns related to making OCs available OTC. These concerns can be addressed by existing data or through research required by the Food and Drug Administration as part of the application to make OCs available OTC.

Prescription to over-the-counter switches in the United States

As the role of the pharmacist becomes more patient and counseling-centered, the healthcare market is changing to keep pace with more modern needs, such as self-treatment. Self-treatment provides patients the ability to diagnose their own condition and pick an appropriate medication from the pharmacy to treat their symptoms. This process allows a certain freedom for consumers to actively engage in their own health. In order for patients to self-treat, access to over-the-counter (OTC) medication is of prime importance. Many medications that are available as OTC today were previously labeled as prescription medications. As more safety studies and trials are conducted for different drugs, they can be deemed appropriate for use without a prescription. This review study discusses the process of switching of prescription medications to OTC medications in the United States and the implications of switching on patients, practitioners, drug makers, and insurers.

Availability and Accuracy of Information Regarding Nonprescription Emergency Contraception

Background:

Although access to emergency contraception (EC) has increased with nonprescription status and approval of Plan B One-Step without age restrictions, barriers may still remain in patient education. This study assesses product availability and accuracy of information for EC among community pharmacies in Rhode Island, comparing changes from 2009 to 2012.

Methods:

Two female investigators posing as patients seeking EC followed a standardized script over telephone conversations. Investigators assessed EC availability, product use information, and cost at all community (retail) pharmacies in Rhode Island. Data were reported as group results with no identifiers. Chi-square and Fisher exact tests were used to analyze results.

Results:

During spring of 2009 and 2012, 165 and 171 pharmacies were telephoned, respectively. Approximately 90% of pharmacies stocked EC both years. In all, 62% versus 28% ( P < .001) indicated EC should be taken as soon as possible; 82.5% versus 87.7% ( P = .220) provided correct administration information; 67% versus 84% ( P < .001) warned about adverse effects; and 67% versus 53% ( P = .123) provided the correct minimum age for purchase.

Conclusions:

Access to nonprescription EC in Rhode Island is very good. Sites not stocking EC should reassess plans for patients to obtain medication. There is need for reeducation on EC labeling to improve counseling provided over the telephone.

A comparison of patients' and pharmacists' satisfaction with medication counseling provided by community pharmacies: a cross-sectional survey

Background

Medication counseling is a critical component of pharmaceutical care to promote the safe and effective use of medications and to maximize therapeutic outcomes. The assessment of patients’ and pharmacists’ satisfaction with medication counseling services could be one of the vital parameters for predicting the quality of pharmacy services. No study has measured and compared both patients’ and pharmacists’ satisfaction with medication counseling. The objectives of this study were to describe and compare patients’ and pharmacists’ levels of satisfaction with medication counseling services offered by community pharmacists in South Korea.

Methods

This was a descriptive, cross-sectional survey. The online survey was distributed to patients and community pharmacists using a structured questionnaire. The questionnaires consisted of 4 main areas: (1) responders’ characteristics (2) current state of medication counseling methods provided by community pharmacies (3) overall satisfaction with medication counseling (4) demand for the development of medication counseling standards. A comparison between patients and pharmacists was made using either a chi-square test or a Fisher’s exact test.

Results

Between June 13, 2014 and July 15, 2014, a total of 252 patients and 620 pharmacists completed the survey. It was found that 47.3 % of pharmacists and 34.0 % of patients were satisfied with the current medication counseling service. Pharmacists showed a higher degree of satisfaction with the medication counseling service compared to patients (p <0.05). A major reason for patients not being satisfied with the medication counseling from community pharmacists was the insufficient time spent on counseling (51.2 %). The pharmacists’ perception of a major barrier to providing appropriate medication counseling for patients was the lack of time (24.3 %). Moreover, a substantial number of patients (88 %) and pharmacists (73 %) supported the development of medication counseling standards to improve community pharmacist counseling services (p < 0.001).

Conclusions

This study showed that both patients and pharmacists have low levels of satisfaction with the current medication counseling service offered by community pharmacists. This study provides baseline data for the development of national guidelines for medication counseling by pharmacists.

Pills on the World Wide Web: reducing barriers through technology

Oral contraceptive pills are safe, effective, and available without a prescription in most countries. Despite support from the American Congress of Obstetricians and Gynecologists to provide oral contraceptives as an over-the-counter medication, US women are still required to have a prescription to obtain them. Use of online applications and the Internet has made most things easier to obtain in our society and this includes contraceptive methods. Several online ventures are now underway to enable US women to obtain oral contraceptives without visiting a medical provider's office. Women's health care professionals should encourage these novel approaches, as they will improve contraceptive access. As US women experiment with innovative health care models, providers will need to lead, follow, or be left behind.

A Survey of Teenagers' Attitudes Toward Moving Oral Contraceptives Over the Counter

CONTEXT

Evidence suggests that over-the-counter access to oral contraceptives may help expand use among adult women. Teenagers may particularly benefit from this approach, as they experience disproportionately high rates of unintended pregnancy and face unique challenges accessing contraceptives. However, limited research has explored teenagers' attitudes toward over-the-counter access.

METHODS

In 2014, a sample of 348 females aged 14-17, recruited via Facebook advertisements, participated in an online survey assessing teenagers' attitudes toward over-the-counter access and their understanding of how to use oral contraceptives after reading a prototype over-the-counter product label. Differences by participants' characteristics were assessed in bivariate analyses (Pearson chi-square and Fisher's exact tests for categorical measures, and independent t tests and one-way analyses of variance for continuous measures).

RESULTS

Seventy-three percent of participants supported over-the-counter access, and 61% reported that they would likely use oral contraceptives available through this approach. Few subgroup differences were found. Notably, sexually experienced participants were significantly more likely than others both to support this approach (85% vs. 63%) and to be interested in obtaining oral contraceptives this way (77% vs. 48%). Participants understood an average of 7.1 of eight key concepts that the prototype product label was intended to convey; no significant differences were found among subgroups.

CONCLUSIONS

Over-the-counter access may be a promising approach for providing oral contraceptives to teenagers. Additional research is needed to evaluate whether teenagers can screen themselves for contraindications to oral contraceptive use and correctly use oral contraceptives obtained over the counter.

Views and attitudes of oral contraceptive users towards their availability without a prescription in the Republic of Ireland

Background:

Previous studies show that provision of oral contraceptive pill (OCs) without a prescription is safe, feasible and effective and that users are interested in obtaining contraception in this way, especially if a pharmacist screening is involved. A recent national survey conducted in the Republic of Ireland has highlighted that unintended pregnancy resulting from the failure of OCs could be linked to poor compliance due to costs and difficulty of access.

Objective:

To evaluate views and attitudes of OC users towards the availability of OCs without a prescription in the Republic of Ireland.

Methods:

A cross sectional survey was conducted using an opportunistic sample of OC users aged 18 to 50 years. Sixty community pharmacists were recruited nationwide. Data were collected using self-completed questionnaires. The questionnaires comprised information on: demographic data, need of the service, views on the availability of OCs without prescription, advantages and concerns around the service, role of pharmacists and cost implications for private and public patients.

Results:

A total of 488 eligible OC users completed the survey. The majority of the respondents (71.7%;n = 350/488) reported to have missed a pill for reasons connected to the OCs prescription status and 55.5% (n = 268/488) of the respondents reported to have felt distressed on at least one occasion because they could not renew their OC prescription. A total of 87.9% (n = 429/488) of the respondents said they were in favour of OCs being available without prescription and 92% (n = 448/488) said they were likely to obtain OCs without prescription if available. Convenience and ease of access were indicated as the main advantages of availing of OCs without prescription, while safety was the biggest concern reported. Over 88% (n = 430/488) of the respondents indicated that pharmacists would be able to safely supply OCs without prescription. Private patients expected to save an average of 27.3% on their OC if obtained without prescription.

Conclusions:

OC users in the Republic of Ireland are in favour of OCs being available without prescription and are willing to obtain it this way, providing that pharmacists supply them according to protocols that facilitate the safety and the efficacy of the supply. An easier and more convenient access to OCs could also reduce the likelihood of missed pills and bring considerable savings to users.

Young women's perceptions and experiences with contraception supply in community pharmacies

BACKGROUND

Unintended pregnancy is a major public health problem in the United States.Correct contraceptive use can reduce the rate of unintended pregnancy. Community pharmacies are well positioned to provide contraceptives and advice about contraception.

OBJECTIVES

To determine young women's perceptions and experiences with contraception supply in community pharmacies and to identify whether pharmacy characteristics predicted very positive experiences.

DESIGN

This study comprised two cross-sectional surveys including an online women's pharmacy perceptions and experiences (PPE) survey and a faxed/observed survey of community pharmacies.

SETTING

One county in Michigan.

PARTICIPANTS

Young women and community pharmacies.

MAIN OUTCOME MEASURE

The two surveys were merged to explore pharmacy characteristics that may impact women's perceptions and experiences with community pharmacies. Multiple logistic regression analysis was used to explore relationships between pharmacy characteristics and positive outcomes.

RESULTS

The response rate for the PPE survey was 54% (n = 343/637). Data from all community pharmacies in the county was retrieved via fax (n = 41/94, 43.6%) or observation (n = 53/94, 56.4%). Women were included in this analysis if they indicated a regular pharmacy (one they go to most often) in the county of interest (n = 210). More than 50% of women (n = 125/210) visited a pharmacy more than once per month. Sixty percent of women were currently using something to prevent pregnancy (n = 124/210, 60.8%). Thirty-five percent of women had a positive experience (n = 73/210, 34.8%). In the multiple logistic regression, women who visited a chain pharmacy had almost 65% lower odds of an overall positive experience with their regular pharmacy compared with women who visited a grocery or mass merchandise pharmacy (odds ratio 0.35 [95% CI 0.16], P = 0.75).

CONCLUSION

Young women visit community pharmacies and use contraceptives frequently. Interventions need to be developed and implemented to improve young women's perceptions and experiences with contraception at community pharmacies.

Potential public sector cost-savings from over-the-counter access to oral contraceptives

OBJECTIVE

This study estimates how making oral contraceptive pills (OCPs) available without a prescription may affect contraceptive use, unintended pregnancies and associated contraceptive and pregnancy costs among low-income women.

STUDY DESIGN

Based on published figures, we estimate two scenarios [low over-the-counter (OTC) use and high OTC use] of the proportion of low-income women likely to switch to an OTC pill and predict adoption of OCPs according to the out-of-pocket costs per pill pack. We then estimate cost-savings of each scenario by comparing the total public sector cost of providing OCPs OTC and medical care for unintended pregnancy.

RESULTS

Twenty-one percent of low-income women at risk for unintended pregnancy are very likely to use OCPs if they were available without a prescription. Women's use of OTC OCPs varies widely by the out-of-pocket pill pack cost. In a scenario assuming no out-of-pocket costs for the over-the counter pill, an additional 11-21% of low-income women will use the pill, resulting in a 20-36% decrease in the number of women using no method or a method less effective than the pill, and a 7-25% decrease in the number of unintended pregnancies, depending on the level of use and any effect on contraceptive failure rates.

CONCLUSIONS

If out-of-pocket costs for such pills are low, OTC access could have a significant effect on use of effective contraceptives and unintended pregnancy. Public health plans may reduce expenditures on pregnancy and contraceptive healthcare services by covering oral contraceptives as an OTC product.

IMPLICATIONS

Interest in OTC access to oral contraceptives is high. Removing the prescription barrier, particularly if pill packs are available at low or zero out-of-pocket cost, could increase the use of effective methods of contraception and reduce unintended pregnancy and healthcare costs for contraceptive and pregnancy care.

Impact of a passive social marketing intervention in community pharmacies on oral contraceptive and condom sales: a quasi-experimental study

Background

Almost 50% of pregnancies in the United States are unwanted or mistimed. Notably, just over one-half of unintended pregnancies occurred when birth control was being used, suggesting inappropriate or poor use or contraceptive failure. About two-thirds of all women who are of reproductive age use contraceptives, and oral hormonal contraceptives remain the most common contraceptive method. Often, contraceptive products are obtained in community pharmacies. The purpose of this study was to determine whether a pharmacy-based intervention would impact sales of contraceptive products in pharmacies.

Methods

This study was conducted in Iowa and used a quasi-experimental design including 55 community pharmacies (independent and grocery) in 12 counties as the intervention and 32 grocery pharmacies in 10 counties as a comparison group. The passive intervention was focused towards 18–30 year old women who visited community pharmacies and prompted those of childbearing age to “plan your pregnancy” and “consider using birth control”. The intervention was delivered via educational tri-fold brochures, posters and ‘shelf talkers.’ Data sources for evaluation were contraceptive sales from intervention and comparison pharmacies, and a mixed negative binomial regression was used with study group*time interactions to examine the impact of the intervention on oral contraceptive and condom sales. Data from 2009 were considered baseline sales.

Results

From 2009 to 2011, condom sales decreased over time and oral contraceptives sales showed no change. Overall, the units sold were significantly higher in grocery pharmacies than in independent pharmacies for both contraceptive types. In the negative binomial regression for condoms, there was an overall significant interaction between the study group and time variables (p = 0.003), indicating an effect of the intervention, and there was a significant slowing in the drop of sales at time 3 in comparison with time 1 (p < 0.001). There was a statistically significant association between pharmacy type and study group, where the independent intervention pharmacies had a higher proportion of stores with increases in condom sales compared to grocery pharmacies in the intervention or comparison group.

Conclusions

A passive community pharmacy-based public health intervention appeared to reduce the decrease in condom sales from baseline, particularly in independent pharmacies, but it did not impact oral contraceptive sales.

Physician attitudes toward over the counter availability for oral contraceptives

To assess physician attitude towards making oral contraceptives available over the counter in the United States (US). We assessed physician attitudes towards a transition from prescription only to over-the-counter availability (rx-OTC) for oral contraceptive pills by disseminating an electronic survey directed primarily to residents training in Obstetrics and Gynecology (OBGYN) and Family Practice in the US. An overwhelming majority of 638 respondents (71 %) were against an rx-OTC switch for combined oral contraceptives and among this subset of respondents the primary concern was safety (92.3 %). Overall, respondents were evenly divided on the issue of an rx-OTC switch for progestin-only-pills but of those who opposed, 73.2 % cited safety as their primary concern. For progestin-only-pills female respondents were more likely to support OTC availability. Most OBGYN and Family Practice residents opposed to OTC availability for oral contraceptives cite safety as their primary concern. Considering the abundant evidence as to the overall safety of oral contraceptives, especially progestin-only-pills, there appears to be a knowledge deficit among OBGYN and Family Practice residents regarding the safety of oral contraceptives.

Use of simulated patients to evaluate combined oral contraceptive dispensing practices of community pharmacists

BACKGROUND

Combined oral contraceptive (COC) use is the most commonly used reversible method of birth control. The incorrect use of COCs is frequent and one of the most common causes of unintended pregnancies. Community pharmacists (CPs) are in a strategic position to improve COC use because they are the last health professional to interact with patients before drug use.

OBJECTIVE

To evaluate the COC dispensing practices of CPs in a developing country.

METHOD

A cross-sectional study was conducted in community pharmacies of Assis and Ourinhos microregions, Brazil, between June 1, 2012, and October 30, 2012. Four simulated patients (SPs) (with counseled audio recording) visited community pharmacies with a prescription for Ciclo 21(®) (a COC containing ethinyl estradiol 30 mcg + levonorgestrel 15 mcg). The audio recording of every SP visit was listened to independently by 3 researchers to evaluate the COC dispensing practice. The percentage of CPs who performed a screening for safe use of COCs (i.e., taking of patients' medical and family history, and measuring of blood pressure) and provided counseling, as well as the quality of the screening and counseling, were evaluated.

RESULTS

Of the 185 CPs contacted, 41 (22.2%) agreed to participate in the study and finished the study protocol. Only 3 CPs asked the SP a question (1 question asked by each professional), and all of the questions were closed-ended, viz., "do you smoke?" (n = 2) and "what is your age?" (n = 1). None of the CPs measured the patient's blood pressure. Six CPs provided counseling when dispensing COCs (drug dosing, 5 CPs; possible adverse effects, 2 CPs), and one CP provided counseling regarding both aspects.

CONCLUSION

The CPs evaluated did not dispense COC appropriately and could influence in the occurrence of negatives therapeutic outcomes such as adverse effects and treatment failure.

Barriers to contraception and interest in over-the-counter access among low-income women: a qualitative study

CONTEXT

Barriers to contraceptive access encourage nonuse and gaps in use, which contribute to the high prevalence of unintended pregnancy in the United States. One strategy to improve access to oral contraceptives is to make them available without a prescription.

METHODS

From March 2007 to January 2009, focus group discussions and in-depth interviews were conducted with 45 low-income women in the Boston area to explore how they obtain contraceptives and their opinions about making oral contraceptives available over the counter. Transcripts of the discussions and interviews were deductively and inductively coded. Data were analyzed thematically, and illustrative quotes were extracted.

RESULTS

Overall, participants reported ease in obtaining contraceptives, which were available at multiple accessible locations throughout Boston. However, various barriers-unaffordable copays and clinic visits, the time required for clinic visits, restrictions on the number of packs of prescription contraceptives (e.g., the ring, the pill) purchased monthly and the limited time frame in which to purchase them-deterred consistent use of preferred methods. Most participants supported over-the-counter access to oral contraceptives; however, they raised concerns about cost, as well as the safety of such access for minors, first-time users and women with medical conditions.

CONCLUSION

Women's concerns about over-the-counter access to contraceptives must be addressed if this approach is to improve use and potentially help reduce the unintended pregnancy rate.

Contraindications to progestin-only oral contraceptive pills among reproductive-aged women

BACKGROUND

Progestin-only oral contraceptive pills (POPs) have fewer contraindications to use compared to combined pills. However, the overall prevalence of contraindications to POPs among reproductive-aged women has not been assessed.

STUDY DESIGN

We collected information on contraindications to POPs in two studies: (1) the Self-Screening Study, a sample of 1267 reproductive-aged women in the general population in El Paso, TX, and (2) the Prospective Study of OC Users, a sample of current oral contraceptive (OC) users who obtained their pills in El Paso clinics (n=532) or over the counter (OTC) in Mexican pharmacies (n=514). In the Self-Screening Study, we also compared women's self-assessment of contraindications using a checklist to a clinician's evaluation.

RESULTS

Only 1.6% of women in the Self-Screening Study were identified as having at least one contraindication to POPs. The sensitivity of the checklist for identifying women with at least one contraindication was 75.0% [95% confidence interval (CI): 50.6%-90.4%], and the specificity was 99.4% (95% CI: 98.8%-99.7%). In total, 0.6% of women in the Prospective Study of OC Users reported having any contraindication to POPs. There were no significant differences between clinic and OTC users.

CONCLUSION

The prevalence of contraindications to POPs was very low in these samples. POPs may be the best choice for the first OTC oral contraceptive in the United States.