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By Sue Alford, Consultant; 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. | Q. | How do you feel about adolescents using emergency contraception? | | 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.
| | Q. | In your opinion, how widespread is misinformation about the safety and efficacy of EC among pharmacists? | | 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®.
| | 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.
| | Q. | Do you have any special concerns about serving teens? | | 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.
| | Q. | Do you think that a nationally representative survey of pharmacists would yield different results? | | 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. | * 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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