The acceptability of contraception task-sharing among pharmacists in Canada — the ACT-Pharm study

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Original research article

The acceptability of contraception task-sharing among pharmacists in

Canada

— the ACT-Pharm study

☆,☆☆

Wendy V. Norman

a, b,

⁎

, Judith A. Soon

a, b, c

, Dimitra Panagiotoglou

a, d

,

Arianne Albert

a

, Peter J. Zed

a, c, e

a

Contraception Access Research Team-Groupe de recherche sur l’accessibilité à la contraception (CART/GRAC), Women’s Health Research Institute, British Columbia Women’s Hospital and Health Centre, Vancouver, British Columbia (BC), Canada

b

Department of Family Practice, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC, Canada

c

Faculty of Pharmaceutical Sciences, UBC, Vancouver, BC, Canada

d_{School of Population and Public Health, Faculty of Medicine, UBC, Vancouver, BC, Canada} e_{Department of Emergency Medicine, Faculty of Medicine, UBC, Vancouver, BC, Canada}

Received 28 July 2014; revised 16 February 2015; accepted 24 March 2015

Abstract

Background: Access to prescription contraception is often limited by the availability of physicians, particularly in rural areas. Pharmacists are available but are not authorized in Canada to prescribe contraceptives, an innovation proved successful in the United States. It is unknown whether Canadian pharmacists, particularly those in rural areas, are willing to adopt this innovation and what barriers and facilitators they predict. We explored the acceptability and feasibility for independent provision of contraception at pharmacies throughout British Columbia (BC). Methods: This mixed-methods study used validated questionnaires followed by optional structured interviews among all rural, and a sample of urban, community pharmacies in BC. Analyses use descriptive, logistic regression and qualitative thematic evaluation.

Results: Responding community pharmacies represent all geographic health regions of BC and the range of pharmacy business models. Respondents reported a mean of 17 years in practice. Seventy percent of pharmacies reported a private counseling area. Over 80%, including pharmacies in all regions, indicated willingness to prescribe hormonal contraceptives. Factors associated with willingness to prescribe were comfort using a protocol to assess sexual history, confidence about staff availability and public acceptability, and fewer years in practice. Pharmacists requested training in assessment protocols and liability issues prior to implementation.

Interpretation: Pharmacies from all areas throughout BC, responded and report a high degree of acceptability and feasibility for independent prescription of hormonal contraceptives. As pharmacists are often the most accessible health professional in rural areas, pharmacist provision of hormonal contraceptives has potential to improve access to contraception.

Keywords: Pharmacists; Contraception; Task-sharing; Canada; Survey

1. Introduction

Access to prescription contraceptives is an important Canadian problem. One in three women have at least one abortion prior to reaching menopause [1], and Black et al. found that one in six women currently at risk for an unwanted pregnancy did not use any method of contracep-tion at last intercourse[2]. Inability to arrange and attend an appointment with a professional able to prescribe contra-ception, and then to attend a pharmacy to dispense the contraception, contributes to unintended pregnancy [3]. In Canada, hormonal contraceptives are available through prescription from physicians, nurse-practitioners and

☆ _{Conflict of interest: All authors declare that they have no conflict of}

interest in relation to this work.

☆☆ _{Financial declaration: This work was supported by a non-competitive}

grant from the Contraception Access Research Team and received infrastructure support from the Women’s Health Research Institute of British Columbia Women’s Hospital and Health Centre. W.N. is supported as a Scholar of the Michael Smith Foundation for Health Research.

⁎ Corresponding author at: Dept of Family Practice, Faculty of Medicine, 320-5950 University Boulevard, Vancouver, BC V6T 1Z3. Tel.: + 1 604 761 7767; fax: + 1 866 656 5544.

E-mail address:[email protected](W.V. Norman).

http://dx.doi.org/10.1016/j.contraception.2015.03.013

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midwives, but not directly from pharmacists. Geographic distributions of prescribing professions are concentrated in large urban settings, disproportionate to the distribution of women throughout Canada [4]. In rural areas of Canada, women face limited hours and in many cases significant travel to access a health professional able to prescribe contraception. Potential barriers to pharmacist prescription of contra-ception, such as proper patient screening, are surmountable. Pharmacists are trusted health professionals[5]with highly accessible hours and locations. Current Canadian regulations are increasingly expanding pharmacist scope of practice, including independent prescription of a variety of medica-tions [6–8]. Models exist in the United States to allow pharmacists to independently initiate prescription contracep-tion [9]. For example, Gardiner’s Direct Access study

demonstrated effectiveness and acceptability for pharmacists to independently provide hormonal contraceptives using protocols[10]. In British Columbia (BC), registered nurses may acquire certification in contraception management, allowing them to use decision-making tools to independently dispense or administer hormonal contraception [11–13]. These decision-making tools use history and the measure-ment of blood pressure to screen women for suitability for hormonal contraception [14–16]. Pharmacists in Canada have attained certifications to utilize a broad range of decision-making tools for independent provision of pre-scriptions, such as emergency contraceptive pills, immuni-zations and management for asthma, anticoagulants and other conditions[17,6,18]. Evidence has demonstrated that automated office measurement of blood pressure, such as by pharmacists, is accurate, reliable and preferable to physician office manual blood pressure measurement [19]. No evidence currently exists on the willingness among Canadian pharmacists to adopt an innovative practice to independently provide hormonal contraception.

We developed the “Acceptability of Contraception Task-sharing for Pharmacists” (ACT-Pharm) study to answer the question: “Is the independent prescription of hormonal contraception acceptable and feasible at commu-nity pharmacies distributed throughout BC?” We hypothe-sized that every rural area will have pharmacies willing to adopt this innovation. Further, we sought to understand potential facilitators and barriers to implementation of this innovation, as identified by community pharmacies.

2. Methods

For this mixed-methods study, we distributed a validated multiple-choice questionnaire [19] to community pharma-cies and invited participants to volunteer for a semistructured qualitative interview with open-ended questions. The questionnaire and the interview script both addressed all conceptual constructs for successful integration of an innovation into practice, as framed within Roger’s theory of Diffusion of Innovations[21,22]. We have described the

development, review, iterative pilot testing and validation of the survey [20]. Ethics approval was obtained from the University of BC, Children’s and Women’s Research Ethics Board (H12-01569).

We obtained a list of all licensed community pharmacies from the BC College of Pharmacists[23]. Urban pharmacies were defined as those within a Census Metropolitan Area (CMA) according to Statistics Canada [24,25]. Rural pharmacies were defined as not located in a CMA and not sampled during our pilot phase testing (n= 333). Our intention was to understand the potential to increase access to hormonal contraception where hours of physician services are limited. As such, we included all rural pharmacies, and for comparison purposes, a small sample of pharmacies was chosen from urban areas. We grouped a postal-code-ordered list of all urban pharmacies into numbered clusters of six and then, using an online randomization number generator, selected seven random clusters (n= 42) of urban pharmacies. 2.1. Survey distribution

We distributed self-completion questionnaires (Appendix A. ACT-Pharm Questionnaire) on October 18, 2012, with a choice of paper or electronic versions (compliant with the BC Freedom of Information and Protection of Privacy Act

[26]). The survey was open until December 11, 2012. We used Dillman’s “Tailored Design” methods for survey distribution and follow-up [27], including faxed reminder notices to nonresponders at 1, 3 and 5 weeks from the initial invitation and a 2-week visit or telephone reminder by pharmacy student volunteers. Respondents who volunteered to participate in an interview were contacted to arrange a time at their convenience. All interviews were semistruc-tured, asking open-ended questions with key prompts to expand upon the answers (see Appendix B. ACT-Pharm Interview Script). Interviews were recorded and then transcribed by a professional transcriptionist.

2.2. Analysis

All quantitative analyses were performed in R version 2.15.3 [28]. Descriptive statistics (proportion, mean and standard deviation) were used to characterize responder demographics. Bivariate analyses (χ2

tests) and logistic regressions were used to find correlates of willingness to prescribe contraception, and to determine correlates of barriers and facilitators to this innovative practice.

We compared the two key survey questions (willingness to adopt innovations and willingness to prescribe hormonal contraception) between the two groups using χ2 tests of independence. This allowed determination of whether responses of urban and rural pharmacy respondents could be combined for the analyses. We tested internal reliability using a repeated rephrased question on willingness to adopt innovations to obtain a Cohen’s Kappa value.

We performed logistic regression to determine factors related to willingness to prescribe hormonal contraception,

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comparing responses to the two questions — ‘If given legislative authority today I would be interested in prescribing hormonal contraceptives’ and ‘If a pilot project to prescribe hormonal contraceptives was available I would be interested in participating’ — using multivariable regression against a list of 12 variables on pharmacist training, attitudes regarding barriers and comfort levels, as well as compared to self-described willingness to adopt innovations. We then simplified the model using stepwise regression using the Akaike Information Criterion (AIC) as implemented in the‘stepAIC’ function in the MASS package

[29]to calculate adjusted odds ratios.

The qualitative inductive thematic analysis was assisted by use of the program NVivo 10[30]. D.P. read the first four interviews and identified four broad, descriptive categories reflecting the semistructured interview themes: barriers or challenges, benefits or advantages, capacity and pharma-cists’ opinions. A coding scheme of 20 first-level codes was developed under these larger themes and applied to the original four transcripts. The scheme was tested on an additional four transcripts. The themes, codes and findings were discussed with W.N. before coding the remaining transcripts. A second meeting was held between D.P., W.N. and J.S. until agreement on all categories was achieved. The 20 first-level categories collapsed to 16 and 5 second-level codes were added to further define key concepts. All transcripts were then recoded using the final scheme. Thematic quotes aligned closely with survey findings. Typical examples are presented in context with the related quantitative results.

3. Results

Respondents represented all geographic health regions of BC (Table 1). Questionnaires were returned from 146/375 invited pharmacies, including one respondent incorrectly invited (not a community pharmacy). Response rates among rural and urban pharmacies were similar. Half of respondents volunteered for interviews. A regionally representative sample (17 rural, 2 urban) was interviewed.

The χ2 tests compared urban and rural respondents for the proportion of those self-described as a willing adopter of innovation and with a willingness to prescribe hormonal contraception, yielding p values=0.91 and .07, respectively, suggesting that there is no substantial difference between urban and rural respondents. They were combined for further analysis. Internal reliability yielded fairly consistent results with a Cohen’s Kappa=0.61, pb.0001.

3.1. Characteristics of pharmacies

Responding pharmacies represented the range of business models and predominantly were locations with two or fewer pharmacists on duty each day, reflecting the purposive rurality of the sample. The respondent pharmacist was most often the owner or manager and reported a mean 17 (SD 11)

years of experience in community pharmacy. Most were certified in immunizations and first aid, and more than half in cardiopulmonary resuscitation. Participants’ self-character-ization for willingness to adopt innovations and new pharmacy practices in general divided fairly evenly between those willing (Innovation-adopters) and those less willing (Conservative-adopters), with three missing responses. 3.2. Willingness to independently prescribe

hormonal contraception

Respondents’ perception of the advantage of the innova-tion was collected through quesinnova-tions on the perceived advantages for patients, pharmacists and society (Appendix C: Detailed Results 1). Eighty-seven percent of pharmacies felt that this innovation would confer increased access for women and couples to contraception and that it could reduce pressure on the health care system through the prevention of unintended pregnancies. Eighty percent agreed that this would increase collaboration between pharmacists and other health professionals. Most agreed that it would increase job satisfaction for pharmacists. “[This]…also provides the pharmacist with more autonomy. It gives them more—I think on the pharmacist side, gives them more pride in what they’re doing,…as long as there’s appropriate training, a course. I think pharmacists are more than capable.”

Table 1

Characteristics of responding pharmacies in BC, n= 145

Characteristic n (%)

All responders (% among 374 sampled) 145 (38.8) Rural (% among 332 in rural sample) 128 (38.6) Urban (% among 42 in urban sample) 15 (35.7) Unknown rural/urban status 2 Region (% among sample for region)

Vancouver Coastal 15 (31.7) Vancouver Island 38 (48.2) Interior 42 (38.7) Fraser 14 (48.1) Northern 24 (49.5) Unknown region 10 Pharmacy type Banner/chain/franchise pharmacy 93 (64.1) Pharmacy department within a mass-merchandise store 23 (15.9) Independent pharmacy 11 (7.6) Unknown pharmacy type 18 (12.4) Average FTE pharmacists at this pharmacy (SD) 1.9 (0.9) Responding pharmacist

Male 69 (47.6)

Female 58 (40.0)

Not specified 18 (12.4)

Position of respondent

Owner or manager/FT pharmacist 84 (57.9) Full time (not owner or manager) 27 (18.6) Part time or floater 15 (10.3) Mean number of years since graduation of respondent (SD) 16.8 (11.1) Enhanced certifications of respondent

Any (e.g., First Aid, CPR, immunizations) 109 (75.2) Mean number of certifications (SD) 2.2 (1.3)

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More than two thirds of pharmacies report appropriate private counseling facilities. Most (60%) report the presence of a private room for counseling, particularly pharmacies in rural areas, and many others report the presence of a private counseling area within the dispensary. Interviews indicated that pharmacists found the proposed innovation to be compatible with their current practice:“I mean, the way it is right now, I’m often asked by doctors to help a patient decide. Like, say they’re having a problem with their contraceptive that they’re on, they’ll ask me to help work out which one would be the best in that situation.”

Overall, pharmacists indicated a high degree of comfort with the complex tasks required for this innovation, with roughly 90% agreeing that they have the skills for assessment, examination, decision making and follow-up. Two thirds indicated that they would be comfortable using a protocol to ask risk assessment questions about the patient’s sexual history. “Oh, yes, yeah, I’m comfortable because I can do counselling and I can explain to the customers too, right, how to use and all this. So yeah, I am comfortable to do this for sure.”

Respondents did not agree that either cost considerations for start-up of this innovation or resistance from the public would be a barrier to implementation, although 80% were concerned that lack of compensation for this new cognitive task could be a barrier, and about half had concerns over potential liability. “Yeah,…so I think that the remuneration needs to be sufficient to enable pharmacists to, or to incentivize pharmacists to, work this into their daily operation.” Overall 69% would participate in a pilot project to implement independent pharmacist prescription of hormonal contraception.

The majority of respondents indicated that task-sharing of hormonal contraception prescription by pharmacists would be an important service to provide:“…where I work…there is no female doctor in town. So having the option of a female pharmacist would probably be good for a lot of patients.”

All respondents indicated a reasonable knowledge of the contraindications, compliance considerations, and the rec-ognition and management of routine and rare side effects regarding each of the range of prescription contraceptives, with the most confidence in their knowledge of oral contraceptives, somewhat less with respect to transdermal patches and vaginal rings. During interviews, the most common theme was a desire for specific training:“I would

certainly need a spruce up in terms of info. I feel that I’m rather savvy with [my hormonal contraception knowledge], but when I’m taking the responsibility to prescribe, I would want more recent training.”

Pharmacists were very interested to prescribe hormonal contraceptives, with over 80% agreeing with the statement“If given the legislative authority today, I would be interested in prescribing hormonal contraceptives in my pharmacy prac-tice.” (Appendix D: Detailed Results 2). Support for this innovation was evident among both urban and rural areas and represented a broad geographic distribution in every health region throughout the province:“I think it’s really a good idea. I think we should be more involved…we’re way too far under-utilized in what we could do in the heart of healthcare. …We’re not just dispensing machines. We’re actually functioning as what a pharmacist should function as… certainly I would upgrade in a second if that was a direction that the government was allowing us to go.”

3.3. Factors correlated with a willingness to prescribe hormonal contraception

Logistic regression associated several factors with a willingness to independently prescribe hormonal contracep-tion (Table 2). After model simplification, the odds ratios suggest that feeling comfortable to ask questions assessing a sexual history increases the odds of being willing to independently prescribe contraception by about 13 times; being an Innovation-adopter increases the odds by about 10 times; for every decrease of 1-year experience in practice, the odds of being willing to prescribe increases by about 9%; feeling that lack of staff is not an important barrier to the innovation increases the odds by about 7 times and feeling that resistance from the public is not an important barrier increases the odds by about 6 times.

Similarly for regressions assessing factors correlated with the willingness among community pharmacists to be involved in a pilot project, we found a number of correlates (Table 3). We ascertained that being an Innovation-adopter increases the odds of being willing to participate in a pilot program by about 8 times, feeling comfortable using a protocol to assess the degree of risk due to sexual history factors increases the odds by about 6 times and feeling that liability concerns were not an important barrier to imple-mentation increases the odds of being willing to participate

Table 2

Logistic regression results for willingness to prescribe

Associated factor Willingness to prescribe, OR (95% CI) Significance Comfort taking a sexual history assessment using a protocola _{13.3 (3.7}_–58.7) _p_b.001

Self-defined Innovation adopter 10.0 (2.5–50) pb.01

No concern over lack of staff 7.1 (1.6–33.3) pb.05

No concern there may be resistance from the public 5.6 (1.2–33.3) pb.05 Years in practice as a community pharmacist 0.92 (0.86–0.98) pb.05 Shown are odds ratios (95% confidence interval) and p values from likelihood ratio tests.

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in a pilot program by about 3 times. These findings were typified in interviews by comments such as this: “And the bottom line is, if you wanted to try something tomorrow, just let us know and we’ll be ready to roll.”

4. Discussion

Our mixed-methods study has demonstrated that inde-pendent prescribing of hormonal contraception is highly acceptable and feasible to implement at a selection of community pharmacies widely distributed throughout BC. Responses were received by 39% of pharmacies, yet every region and subregion in the province were represented, indicating that expanding the scope of practice for pharmacists in this way has potential to increase access to prescription contraception for women in all areas.

Our findings among Canadian pharmacists support those found among similar models for pharmacist task-sharing in contraception provision in the United States[9,10,31]. Similarly, BC implemented a registered nurse contraception task-sharing model in 2009 [11]. However, contraception management certified nurses have indicated that limited availability of contraceptive stock at their place of employment, and of hours for provision of this service, can curtail their ability to provide appropriate access to contraceptives [32,33]. Conversely, independent pharmacist provision offers availability of a full range of contraceptive options and of extended service hours.

The model implemented by Guilbert et al. in Quebec[34]

overcomes some of these concerns and has demonstrated the willingness of pharmacists to work with certified nurses to implement a system of nonphysician access to hormonal contraception [35–37]. Once the certified nurse has utilized decision-making tools to determine an appropriate contraceptive for a woman, she then presents a written“direction” from the nurse to a collaborating pharmacist who will dispense any among the full range of contraceptives. In contrast, we propose a model where a contraception-certified pharmacist could directly utilize the decision-making tools to provide an appropriate contraceptive in a single visit. Our study has shown that selected pharmacists find this one-stop process of access to contraception directly at the pharmacy to be feasible and acceptable at both urban and rural sites and in all health regions of BC.

Our response rate of 39% was lower than the 85% we had achieved in our previous survey among physicians in BC[38]

but still improved over that achieved in the most recent

comparable pharmacist study by Marra et al.[39]. Moreover, in this study, we aimed to understand if the proposed innovation could be available particularly in small towns and rural areas where there are fewer options and shorter hours at the only current facilities for access to hormonal contraception. Our survey respondents represent all regions of the province and are overrepresentative of the smallest pharmacies such as those present in areas where the fewest contraception service options are present. Soon et al. have demonstrated stigma associated with accessing sexual health services in such rural settings in BC

[40]. Pharmacies in small towns have the potential to offer longer, more convenient hours including evenings and weekends, and to offer less potential for stigmatization for young and vulnerable women, than has been shown to be the case for currently available options in rural settings.

Similarly, as most respondents represented pharmacies with two or fewer pharmacists, we are encouraged that this new innovation has potential not only to diffuse within large organizations where organizational policy may promote adherence but also to be seen as acceptable and feasible by those within smaller and independent organizations.

Future studies should examine acceptability of the model for contraception provision directly from pharmacists, among women and girls. These concepts have been demonstrated as acceptable with respect to similar noncontraceptive services by pharmacists[41,42]. Additional research should be undertaken to demonstrate effectiveness through pilot implementation.

5. Conclusion

A selection of over a third of pharmacies, representing all areas of BC and all community pharmacy business models, indicates that task-sharing to independently prescribe hor-monal contraception is both highly acceptable and feasible. As pharmacists are often the most accessible health professional, pharmacist provision of hormonal contraceptives carries the potential to improve timely access to contraception.

Supplementary data to this article can be found online at

http://dx.doi.org/10.1016/j.contraception.2015.03.013. References

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Logistic regression results for pharmacists willing to participate in pilot to independently prescribe contraception

Associated Factor Willingness to prescribe, OR (95% CI) Significance Self-defined Innovation adopter 8.33 (3.23–25.0) pb.001 Comfort taking a sexual history assessment using a protocola _{6.4 (2.5}_–17.9) _p_b.001

No liability concerns 3.33 (1.28–9.09) pb.05

Shown are odds ratios (95% CI) and p values from the likelihood ratio tests.

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