Pharmacists' Attitudes and Awareness of Emergency Contraception for Adolescents
By Sue Alford, Director, Public Information Services; Laura Davis, Director,
Initiative for Improved Adolescent Sexual Health Services; and Lindsay Brown,
Intern, Advocates for Youth. Updated, 2007.
Pharmacists can play an important role in efforts to improve access for young women to emergency contraception (EC) and help them obtain EC in a timely manner, before they need it or within 120 hours of unprotected sexual intercourse. Pharmacists can provide EC without a prescription to customers ages 18 and over and they can refer young women under age 18 to health care providers to obtain a prescription. Pharmacists can educate teen clients about emergency contraception by providing educational materials such as brochures and wallet cards as well as inserts with prescriptions. They can offer in-depth counseling on EC use, and some drugstores have private counseling spaces. The American Pharmacists Association recommends that pharmacists 1) help overcome barriers to the use of emergency contraception by educating their patients and other health professionals and 2) develop effective counseling skills and sensitivity to the emotional turmoil that women may be experiencing when they seek emergency birth control pills.[1]
In a survey sponsored by Advocates for
Youth and DC Campaign
to Prevent Teen
Pregnancy, teenage researchers interviewed a sample of Washington, DC, pharmacists
to ascertain their role in filling EC prescriptions and/or referring teenage
customers to area health care providers.[2] The findings
demonstrated that:
- Teens in the District frequently
ask pharmacists for reproductive health advice. Nearly
40 percent of responding pharmacists indicated that
teens asked them sexual health-related questions
daily; another one-third received such questions
from teens several times a week. Eighty-three percent
of surveyed pharmacists had a space for private counseling,
a significant issue for teenage customers. About
78 percent said that within the last year, teens
requested their advice regarding pregnancy prevention.
- A majority of pharmacists receive
prescriptions for emergency contraception from adolescent
customers. In the past year, 72 percent
of pharmacists received prescriptions from teens
for EC. One-third of pharmacists received such
prescriptions at least monthly and ten percent
received them weekly.
- Pharmacists are willing to
disseminate educational information about emergency
contraception. About three-fourths
of pharmacists were willing to distribute pamphlets
about EC to
people purchasing condoms, pregnancy test kits,
and other family planning products. Nearly 80
percent
were willing to hang posters about EC.
- Some pharmacists offer Plan B®, the only dedicated product specifically
marketed as emergency contraceptive pills, while
others (30 percent) repackage regular oral contraceptives. In
the United States, at least 11 regular birth
control pill formulations are available for use
in differing
doses as emergency contraception.
- Many pharmacists do not know
that emergency contraceptive pills are both safe
and effective for adolescents. Over
half of surveyed pharmacists (55 percent) completely
agreed
with the inaccurate statement that repeated use
of emergency contraception poses health risks;
another
ten percent somewhat agreed with this statement.
Not unexpectedly, considering this apparent lack
of knowledge about emergency contraception, 50
percent of pharmacists completely disagreed or
somewhat disagreed
with the statement that emergency contraceptive
pills are safe for adolescents. Fifty percent
of pharmacists
completely agreed with the inaccurate statement
that emergency contraceptive pills cause birth
defects
if taken during pregnancy; another ten percent
somewhat agreed with the inaccurate statement.
Only one-third
of pharmacists completely or somewhat disagreed
with this erroneous statement.*
- Although many pharmacists feel
comfortable providing information to teens, most
lack medically accurate knowledge about the method. Two-thirds
of pharmacists said they felt very or somewhat comfortable
talking with teens about emergency contraception.
Unfortunately, 83 percent of those who felt very
or somewhat comfortable talking with teens about
emergency contraceptive pills also held erroneous
beliefs about the safety of these pills.
Similar Findings in Other Surveys
It is
important to note that Advocates and DC Campaign intended
to "take the pulse"—or
offer a snapshot—of emergency contraceptive services
in District pharmacies rather than to provide firm, scientific
findings. Nevertheless, the findings mirror those
in some other studies. For example, the Academy for Educational
Development conducted a similar survey of pharmacists in
New York City to ascertain knowledge and attitudes regarding
EC and whether pharmacies would be appropriate sites for
outreach to adolescents. The self-administered, mail-return
survey consisted of 35 items. Researchers conducted follow-up
by telephone and through personal visits. The majority
of pharmacists (81 percent) stated that they thought emergency
contraceptive pills were safe for adolescents, and 77 percent
were willing to disseminate information about emergencycontraception
in a variety of ways. Nevertheless, many pharmacists in
this sample also demonstrated confusion about the safety
of emergency contraceptive pills: 56 percent incorrectly
believed that these pills could cause birth defects if
taken during pregnancy; 64 percent agreed with the incorrect
statement that repeated use of the pills can pose health
risks.[3]
An opinion poll conducted among licensed pharmacists in New Jersey and Oregon
by Peter D. Hart Research Associates sheds further light on pharmacists' knowledge
of and feelings about emergency contraception. Pharmacists' actual knowledge
of EC was inconsistent and in some cases, erroneous. Despite scientific evidence
to the contrary, 59 percent of pharmacists in each state believed that emergency
contraception is not safe for most women who have been advised not to take
regular birth control pills. A majority of pharmacists did not know the specific
time frame within which EC is most effective and underestimated the effectiveness
of EC in preventing unintended pregnancy. Twenty-nine percent of pharmacists
in New Jersey and forty-four percent in Oregon said that they had not filled
a prescription for emergency contraceptive pills in the previous year.[4]
Several innovative efforts across the country seek to raise awareness of
EC and increase its availability in pharmacies. In Washington State, for
example,
under collaborative drug therapy agreements, pharmacists are able to prescribe
and provide EC to women without a doctor's prior prescription. Evaluation
shows that, after 22 months of EC service provision in 130 pharmacies, pharmacists
have dispensed over 25,000 cycles of EC. Women receiving EC via a pharmacist
are satisfied with the quality of care and value the increased accessibility.
Pharmacy records reveal that most women receive EC within 24 hours of unprotected
sexual intercourse—when the method is most effective. With this successful
program continuing, women in the state continue to obtain EC directly from
pharmacists.[5]
In California, the Pharmacy Access Partnership, a coalition of public health
advocates in eight counties, is working to ensure that women may obtain EC
without a prescription. Under the program, community clinics provide women
who might want the drug with a referral to a participating pharmacy. Before
receiving a prescription, each woman must complete an encounter form and
receive counseling from the pharmacist. The pharmacy notifies the referring
clinic when the prescription is filled. This pilot effort, funded by a $2.2
million grant from the David and Lucile Packard Foundation, should provide
important lessons for other state efforts.[6]
In the fall of 2000, the Office of Population Research at Princeton University
and the Reproductive Health Technologies Project in Washington, DC, partnered
to conduct a study of pharmacists enrolled on the Emergency Contraception Hotline
and Web site.[7] Two college-aged women made "mystery
calls" to all 151 pharmacies listed as of July 1, 2000. The majority
of calls (85 percent), resulted in success, meaning that the caller was told
she
could obtain ECPs directly from the pharmacy without a prescription.
As with the original quality assurance study, there were some gaps in service.
Of the 23 calls resulting in failure:
- Eleven claimed that pharmacists able
to prescribe ECPs were not available at the time
- Five claimed not to offer EC
- Four said they did not have a pharmacist
on staff able to prescribe ECPs
- One told the caller she had to see a
clinician first.
Researchers shared these results with all pharmacists
listed on the Hotline with recommendations for assuring
quality service where appropriate.
Interview with Two Pharmacists
Ms. Lindsay Brown, Advocates' intern,
interviewed pharmacists Beverly Schaefer from Seattle WA, and Tom Croce
from Philadelphia PA, to explore some
key issues related to providing EC. In particular, Lindsay was interested
in the extent of misinformation about emergency contraception
among pharmacists
and ways to reach pharmacists with accurate information.
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Q.
|
How do you feel about adolescents using
emergency contraception?
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|
A. |
Shaefer. I recently spoke with
a woman who did a study of 13- to 17-year-old adolescents
and EC in Wales. She found that many of the kids
did not have the means to get information on contraception.
The teens didn't want to go to a family planning
clinic because they were not planning families.
They wanted to be able to go into a condom store
to get what they needed to prevent a pregnancy.
A drug store or pharmacy is the next best thing
to a condom store.
I like to hire as many recent graduates from pharmacy school as possible
to work in the pharmacy. They are closer in age to the young customers
and help these young women to feel comfortable rather than intimidated
when asking about personal issues. When I give EC prescriptions to
adolescent customers, I do so without blinking an eye or making the
experience any more traumatic. I am very glad that they are taking
responsibility by obtaining an EC prescription. For adolescent customers,
I always make sure they know about all of their birth control options.
That is the main difference for me in my communication with teen and
adult customers.
Croce. Personally and professionally, I do not
have a problem with adolescents getting emergency contraception without
parental consent. I would rather that they come to a pharmacy and
get EC, then take the chance of getting pregnant.
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|
Q.
|
In your opinion, how widespread is misinformation
about the safety and efficacy of EC among pharmacists?
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|
A. |
Schaefer. I think it is pretty
high. When I go to national meetings for pharmacists
I hear all of the misconceptions. I think that
the biggest misconception about EC is that it will
interrupt a pregnancy or cause an abortion.
Croce. I think it is more of a lack of information
then misinformation. Many pharmacists that I have talked to do not
have a clue what EC is. The number is unfortunately very high. Some
pharmacists have no idea that there are specific drugs on the market
to prevent pregnancy. They may know about oral contraceptives being
used but probably do not know about Plan B®.
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|
Q.
|
In your opinion, what are some of the
ways we could reach pharmacists with more accurate
information about EC and adolescents?
|
|
A. |
Schaefer. My idea would be
to appear at all pharmacy schools in front of the
senior class and tell them about EC. This would
give them an opportunity to think about it and
what they know and do not know on the subject.
It would get it [EC] into their minds.
Croce. They could be reached in a variety of ways.
One way is that state and local agents could provide educational
information. If you wanted to educate Washington DC, pharmacists
you would approach DC Pharmacy Association and give them information
for a newsletter or other bulletin. Postgraduate pharmacists in most
states have to enroll in continuing education classes. The drug companies
that produce emergency contraception could set up programs or classes.
This is the easiest way to get the awareness raised. An organization
could also mass mail the information to local pharmacies. It is hard
to educate pharmacists about EC when they are not getting prescriptions
or questions about them, like I heard many pharmacists say.
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|
Q.
|
Do you have any special concerns about
serving teens?
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|
A. |
Schaefer. One girl came back
to get EC many times in a row. My biggest fear
was that she was in an abusive relationship. I
guess being in an abusive relationship is a fear
[I have] for many customers, but especially for
adolescents. I am also concerned that they do not
know about other birth control options. I often
want to be their mother! I feel that it is my job
to help them make good choices.
Croce. No, I do not personally.
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|
Q.
|
Do you think that a nationally representative
survey of pharmacists would yield different results?
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|
A. |
Schaefer. I do not think that
doing a wider survey would produce different results
unfortunately. I do think that doing the survey
in places that have new systems in places or are
making strides would be interesting. California
would definitely be a place I would like to see
a survey done.
Croce. I do not think it would hurt. I do not,
however, think that the results would change that dramatically. Pharmacists,
like the general public, do not have a great awareness about EC or
what it is.
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* Emergency contraceptive pills
are safe for adolescents and do not pose health risks to
women, regardless of age. EC does not affect an established
pregnancy, and numerous studies for risk of birth defects
during regular use of oral contraceptives found no increased
risk. There are no known risks for repeated use of EC.
Moreover, research does not link providing EC with increased
sexual risk-taking.
References:
-
American Pharmacists Association. Emergency Contraception: The Pharmacists' Role, Update 2004 [APhA Special Report: A Continuing Education Program for Pharmacists]. Washington, DC: Author, 2004.
-
DC Campaign
to Prevent Teen Pregnancy and Advocates for Youth. Survey
of Pharmacists' Awareness of and Attitudes toward Emergency
Contraception in the District of Columbia. Washington,
DC: Advocates for Youth, 2000.
-
Simkin L,
Radosh A. Description of the Pharmacy Survey Conducted
for Emergency Contraception and Adolescents. New
York: Academy for Educational Development, 2000.
-
Peter D.
Hart Research Associates. A Survey Among the General
Public and Licensed Pharmacists in New Jersey and Oregon.
Washington, DC: The Author, 2000.
-
Consortium for
Emergency Contraception. Medical and Service Delivery
Guidelines. Seattle, WA: Program for Appropriate
Technology in Health, [n.d.].
-
_____.
California pilot program tests distributing emergency
contraception without a prescription. Kaiser Daily
Reproductive Health Report, April 11, 2001.
- Reproductive Health
Technologies Project. Emergency Contraception 2000:
The Year in Review. Washington, DC: The Project,
2001.
Updated January 2008
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