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Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Avenue Appia 20, 1201, Geneva, Switzerland
Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Avenue Appia 20, 1201, Geneva, Switzerland
We conducted a systematic review of peer-reviewed literature on youth access to, use of and quality of care of sexual and reproductive health (SRH) commodities through pharmacies.
Methods
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, we searched for publications from 2000 to 2016. To be eligible for inclusion, articles had to address the experiences of young people (aged 25 years and below) accessing SRH commodities (e.g., contraception, abortifacients) via pharmacies. The heterogeneity of the studies precluded meta-analysis — instead, we conducted thematic analysis.
Results
A total of 2842 titles were screened, and 49 met the inclusion criteria. Most (n=43) were from high-income countries, and 33 examined emergency hormonal contraception provision. Seventeen focused on experiences of pharmacy personnel in provision, while 28 assessed client experiences. Pharmacy provision of SRH commodities was appealing to and utilized by youth. Increasing access to SRH commodities for youth did not correspond to increases in risky sexual behavior. Both pharmacists and youth had reservations about the ease of access and its impact on sexual behaviors. In settings where regulations allowing pharmacy access were established, some pharmacy personnel created barriers to access or refused access entirely.
Discussion
With training and support, pharmacy personnel can serve as critical SRH resources to young people. Further research is needed to better understand how to capitalize on the potential of pharmacy provision of SRH commodities to young people without sacrificing qualities which make pharmacies so appealing to young people in the first place.
], youth are faced with a number of challenges to their sexual and reproductive health (SRH) and well-being. SRH challenges are not unique to this population and are faced by men and women of all ages. However, even when services are available in a given community, added financial, cultural or social barriers may prevent young users from utilizing them, especially if providers and communities are biased against youth access [
As a result, 16 million girls aged 15–19 years and 1 million girls under age 15 years give birth every year, and complications during pregnancy and childbirth are the second leading cause of death for 15–19-year-old girls globally [
]. Millions of women worldwide have an unmet need for contraception. However, in many regions of the world, adolescents wanting to avoid pregnancy can be up to twice as likely as adult women to have an unmet need for modern contraception [
], demonstrating a need to improve access to and uptake of SRH commodities.
Pharmacy access — that is, making commodities available either over-the-counter (openly accessible at a pharmacy) or behind-the-counter (dispensing contingent on evaluation from a pharmacist) — is one strategy that might help to overcome barriers for young people unwilling or unable to access services from another health care provider. Pharmacy provision allows for more direct access to SRH commodities. To date, there has been very little documentation, for adults or youth, around pharmacy-based distribution of reproductive commodities. Encouragingly, however, the health and well-being of adolescents and young people are receiving increased attention and emphasis in a number of global-level collaborations and strategies developed in recent years, including Family Planning 2020 [
]. It seemed particularly timely, therefore, to identify strategies for best providing needed SRH commodities to a young population. As such, we conducted a systematic review of the peer-reviewed literature to identify any evidence on young people's (aged 25 years or younger) access to, use of and quality of care of SRH commodities in pharmacies.
2. Methods
We conducted this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [
]. We searched for studies that addressed the following research question:
What is the experience of young people (25 years and younger) who access SRH commodities through pharmacies?
2.1 Search strategy
We searched PubMed, Embase, Popline and Scopus databases for relevant publications without language restrictions limitations published between 1 January 2000 and 1 May 2016. We searched for articles published from the year 2000 onwards in light of a noticeable, turn-of-the-century shift in policies worldwide towards increasing SRH commodities' availability through pharmacy provision. The search strategy for each database was developed by mapping keywords associated with the two major components of the research question (“SRH commodities” and “pharmacies”) onto established controlled vocabulary for the selected database (for example, MeSH for PubMed or Emtree for Embase). The search strategies developed for each database are available in Appendix A. We also searched the Cochrane database for existing or related systematic reviews. We screened the references of all articles identified for data extraction. Excluding duplicates, in total, we identified 2842 records for potential inclusion. Fig. 1 contains a flow diagram of the study selection process.
We first screened articles by title, yielding 350 potential articles. We then dual screened (L.G. and M.J.H.) the abstracts for relevance, also eliminating articles that did not have an abstract in English, Spanish, Portuguese or French; nonresearch articles (e.g., commentaries, editorials); and posters/presentations from meetings. Where there was disagreement between the screeners as to whether an article should be included or excluded, we included the article. All articles that either screener was unsure about were discussed in person until an inclusion/exclusion decision was reached. We also screened references from two reviews of the literature (the first on community pharmacy supply of emergency hormonal contraception [
]); this provided an additional four articles for full-text review. We were left with 114 articles which were read in full by L.G.
2.3 Inclusion/exclusion criteria
We included all articles that considered the provision of SRH commodities to young people via pharmacies. All studies focused on or contained data on people aged 25 years or younger; this also meant including broader population-based studies that disaggregated data by age group.
SRH commodities included contraceptive methods, abortifacients and sexually transmitted infection (STI) self-test kits. We were interested in the overall experience of commodity provision to young people in pharmacies from either the young person's or the provider's perspectives. We excluded all studies that only reported on changes in prevalence of pharmacy provision (i.e., population-based trend data) or any other studies that did not provide information on young people's experiences acquiring the commodities.
Ultimately, L.G. abstracted 49 articles (presented in Table 1) using data extraction forms modified from a previous review [
Detailed methodology for systematic reviews of interventions to improve the sexual and reproductive health of young people in low- and middle-income countries.
]. The included studies employed qualitative and quantitative, experimental and observational designs, and were equally heterogeneous in the outcomes measured. As a result, meta-analysis was not possible — instead, we used thematic analysis to synthesize results across the diverse data available. Additionally, given the variety of study methods used, there was no one (or even two) scoring system that could be used to evaluate quality; instead, Table 1 also includes detailed notes on each study's strengths and weaknesses.
Table 1Description of studies, ordered by publication year
Clients: n=126 females ages 15–21, received ECPs from a pharmacist
Reasons for going to a pharmacist; satisfaction with care provided by pharmacist
Pharmacies evaluated are part of state program to train pharmacists on ECP prescribing and dispensing, and make ECP available for purchase by women without prescription.
Reasons included “easy to get to” and “privacy protection.” If services didn't exist, 20% wouldn't know where else to go, 22% would wait and see if they became pregnant.
Clients felt counseling was clear (99%) and were satisfied with time to ask questions (95%)
Respondents were able to report on actual decision-making and experience in obtaining ECPs from a pharmacy
Intervention: course to increase ECP knowledge and improve dispensing skills. Mystery clients assess outcomes
Providers: n=60 pharmacy and drugstore personnel
Knowledge of and practice in dispensing ECPs
ECPs available over-the-counter
Significantly higher knowledge of ECPs (score of 22.1 vs. 18.5), higher levels of provision of dosing information (45 vs. 12 pharmacists providing), but no statistical difference in medical history taking between intervention and control group
Robust study design
3-month follow-up
Youth issues never explicitly explored, study included because mystery clients are <25
Raymond et al. 2003 United States (various settings)
Study mimics pharmacy access. Women requesting ECPs asked to review ECP package designed for OTC use and were then sold ECPs
Clients: n=585 females presenting for an ECP prescription at 8 Planned Parenthood sites and 5 pharmacies in 5 cities
Use of ECP product under (simulated) over-the-counter conditions
ECPs available only through physician prescription
With ECP access, minors not significantly more likely than older women to use products in a contraindicated or incorrect manner and did not have more adverse events or subsequent pregnancy
Study modeled OTC setting closely.
Low loss to follow-up (only 7%)
Limited generalizability to women self-selecting ECPs
Effectiveness and cost-effectiveness of a pharmacy-based screening programme for chlamydia trachomatis in a high-risk health centre population in Amsterdam using mailed home-collected urine samples.
Cohort (picked up Chlamydia trachomatis screening kit at pharmacy and followed up for test results, questionnaire)
Clients: n=446 women (<30 years) recruited from a pharmacy, who were offered kits
Response rates, chlamydia test results, survey results
Prescription refills of oral contraceptives can be ordered remotely and collected at pharmacy, no GP contact required
CT-positivity detected among ethnic minority population where 15% were CT positive, as compared with 6%–10% found in other Dutch STI clinics.
Higher rates of CT positivity among youth (13% among 15–19-year-olds, and 14% among 20–24-year-olds) as compared to older age group (5% among 25–29-year-olds)
Vulnerable population focus: multicultural, low income.
Observational (retrospective pharmacy record review)
Pharmacies submitted monthly returns over 24 months
Clients: n=1412 Records of pharmacy clients
Trends in age of ECP users
All pharmacies in study area could provide ECPs on request (14 and 15 year olds had to demonstrate competence)
At beginning, about 21% of the clients were <20. Increased to 46% after two quarters, and afterwards clients<20 accounted for 42%–45% of consultations.
By end of study, community pharmacies were the largest provider of ECP
Three arms (clinic access, pharmacy access, and advanced provision of ECPs)
Clients: n=964 female FP clinic clients, aged 15–24, recruited from four clinics in study area
Pharmacy use by age, risky sex, STIs and pregnancy
State legislation allowing women to obtain ECPs from pharmacies without consulting a physician
ECP use among adolescents<16 (38%) similar to group aged 16–17 (38%), and higher than those aged 18–19 (33%). Adults (aged 20–24) had lower overall use (24%).
Pharmacy access no more likely than clinic access participants to use ECP, engage in risky behaviors, get STIs or be pregnant
Robust study design with specific youth focus (15–24), computer-generated randomization, researchers blinded to participant group allocation
Participants enrolled from clinics, making them not representative of those who seek services from non-facility sources
Providers: n=45 pharmacists participating in program to supply ECPs without charge
Pharmacist views on provision of ECP to young people
ECPs made available for purchase from a pharmacist for women aged 16+. In some areas there is an option for obtaining free access to ECPs
Confidentiality noted as advantage of pharmacies.
Concern that pharmacy supply encouraged “irresponsible” attitudes to contraception. Particular concern for younger women without a regular partner and those who chose to have unprotected sex.
Girls<14 requested ECPs
A diversity in gender, ethnicity, age of pharmacists, and socio-demographics of areas where pharmacies were located
Response bias: all pharmacists were participating in a special program designed to make ECPs more accessible to young people
Structured surveys were administered either on paper or electronically and consisted of a combination of closed and open-ended questions
Clients: n=30 interviews
n=125 survey
females aged 12–19, from “at-risk” communities
Peer decision-making around sex and contraception, knowledge of ECPs, awareness and use of ECPs; prediction of effect of increased ECP availability on behavior
Federal approval of over-the-counter sale of ECPs to women 18+
45.8% teens 16+ and 44% teens <16 thought their peers would have more unprotected sex with increased ECP access.
When asked who should be able to purchase ECPs without a prescription, 18% chose “anyone aged 12+,” 43% chose “anyone aged 16+,” 23% chose “anyone 18+” and 7% said no one.
<16s less likely to know about ECP, more likely to think that greater availability would increase unprotected sex
Focus on high-risk populations (racial minorities, urban area).
Open-ended interview guide allowed natural conversation among participants talking about a taboo subject
Social desirability and response bias based on sensitivity of topics
Official 1-page ECP written assessment form is used during consultation and helps pharmacists make the decision to administer ECPs
Clients: n=729 (380 from 2003, 349 from 2006) females, aged 15–49, obtaining ECPs accessing ECPs from 18 pharmacies in 3 cities
Profile of ECP users just after deregulation and three years later
ECPs accessible without prescription in pharmacies for women 16+, provided: a pharmacist dispenses, a counseling interview takes place
Stratification of the study population by age groups showed no differences in the contraceptive methods used between groups.
Reuse significantly more frequent in group 2006 women aged 18–21 than group 2003 (21.3% vs. 33.1%, p<.001). Significant correlation observed between span of time until reuse and age (p<.01)
Opportunity to assess client use of ECPs when deregulation took place and three years later.
Retrospective design assured that pharmacies were not biased by the study
Forms based on patient recall and reporting.
No age-disaggregated data provided on contraception use during ECP request period
Pharmacists offered screening kit with questionnaire after completing the ECP protocol
Clients: n=2904 females, age range unspecified, requesting ECPs
Previous ECP use and chlamydia treatment
ECPs available free, without prescription in pharmacies for women <25. Pharmacies also offered mail-in Chlamydia trachomatis screening
Only one quarter of women provided ECPs were offered screening.
Using actual (rather than grouped) ages, there was a significant increase in the number of positive tests with age.
24/264 returned samples in total were positive (9.1%)
Pharmacy records during study allowed for later screening of proportion of kits offered to clients, and proportion of kits accepted and returned by clients
Lack of understanding why clients did not return the test, uncertainty as to whether clients felt obligated to accept test kits
Recruited from pharmacies participating in Chlamydia trachomatis screening
Experience providing screening kits to clients, including why many pharmacists did NOT offer screening to eligible clients
Pharmacies in study area offer free ECPs to women under 25 years of age. Participating pharmacies also offered postal chlamydia trachomatis screening
Pharmacists' decision to offer screening was personal rather than financial. None willing to approach a client in a long-term relationship.
Pharmacists felt ideally placed to talk to clients.
Less educated clients would not see benefit of screening
<20s seen as poorly informed and at higher risk because of “promiscuity,” more likely to take a kit. <16s seen as more reluctant and shy
Discrepancies in knowledge vs. behavior reported in questionnaire could be probed during the in-depth interview
Sample was pharmacists who opted to participate in the screening program. This group displayed low adherence to protocol, in that many did NOT offer screening to eligible clients
Providers: n=10 pharmacists from pharmacies registered with Chlamydia trachomatis screening program
Challenges to offering chlamydia screening
Nationwide chlamydia trachomatis screening program offers screening opportunistically to young people (aged 15–24) in pharmacies
Concerns about privacy available. Concerns also expressed about offering screening to less-knowledgeable <16s.
Perception that screening only appropriate in relation to other SRH services and that it was difficult to bring up screening when clients attended for non-SRH complaints. Suggestion to use leaflets or promotions to encourage screening
Pharmacists interviewed reflected mix of multiple-site and single-site pharmacies in the study area
Very small sample size, subject to volunteer bias — only 10 of 17 pharmacists approached agreed to participate
Providers: n=30 retail pharmacists (n=20), health workers from NGO-operated FP clinics (n=2), nurses from public general clinics (n=6), nurses from public FP clinics (n=2)
Health workers' views and experiences supplying ECPs
ECPs available without a doctor's prescription. Accessible in public health facilities at no cost and are sold in commercial pharmacies
Providers in private facilities report that requests for ECP on the rise among young women.
Concern of ECP promoting sexual promiscuity among young people. Private sector (pharmacists) only stock dedicated ECPs because the product is more expensive so people need to “think twice”
Providers reported refusing to supply ECPs because unsure about age at which a client can purchase EC products without a guardian's consent
In-depth perspectives of public sector health providers, commercial pharmacists, and specialized FP providers
Study provides opportunity to explore lingering barriers to ECP provision
Limited youth-related data
Lack of privacy, frequent interruptions, and suspicion towards the research.
Cross-sectional (self-administered, web-based or paper survey)
Providers: n=502 pharmacy students
recruited from all California schools of pharmacy
Willingness to provide contraception to minors
ECPs available without prescription in pharmacies to women 18+. State regulation allows trained pharmacists to sell ECPs to all women.
Student pharmacists indicated interest (96.2%) in providing hormonal contraception (pill, patch, and ring) under statewide protocol to both minors and adults (53.3%), adults only (40.6%), or minors only (6.2%)
Opportunity to assess views of new pharmacy practitioners
Comprehensive coverage of all schools of pharmacy in state
Limited youth-related data, as questionnaire contained only one question about willingness to provide to minors
Clients: n=531 females, aged 14–19, who had engaged in unprotected intercourse when they were aware of ECPs
Access to ECPs, barriers to use, satisfaction with access experience
ECPs available without prescription in pharmacies to women 18+ nationwide (17+ by study end) 9 states allow access without age limits
Participants obtaining ECPs without prescription more likely to use within 24h of unprotected sex than those who obtaining with prescription (OR: 2.17, p<.05).
Minors who obtained in pharmacist access states more likely to report satisfaction with their experience (OR: 3.05 p<.05)
Ability to compare experiences of adolescents in states with and without pharmacy access
recruited from a professional networking website/online forum for pharmacists
Counseling practices and attitudes regarding ECP
ECPs are meant to be dispensed with a physician's prescription. In practice, customers can purchase products directly from community pharmacies
Only 52%–57% of pharmacists had positive attitude towards: “teenagers and youngsters can take responsibility for the use of ECPs”; “ECPs give women increased sexual safety”; and “ECPs increase women's control of reproduction”.
58% of pharmacists agreed ECP should be limited for sale to 18+. 52% agreed that teenagers can responsibly use ECP
Comparisons between pharmacist practices based on sex and age of pharmacists
Insight into practice when policy does not permit dispensing without a prescription
Recall/social desirability bias — self-completed survey on sensitive topic
Limited focus on youth as study asked ECP dispensing in general
The role of pharmacists and emergency contraception: are pharmacists' perceptions of emergency contraception predictive of their dispensing practices?.
Six years after deregulation of emergency contraception in Switzerland: has free access induced changes in the profile of clients attending an emergency pharmacy in Zurich?.
Mixed methods (pharmacy record review, structured questionnaire, mystery client)
MC evaluations conducted at three pharmacies, using trained adolescent women
Clients: n=741 consultations
n=99 females client intercept questionnaire
n=19 pharmacy visits by MC
Data on consultations, client satisfaction with pharmacy experience
Special program in select pharmacies to supply oral contraceptives without prescription to eligible women 16+, following pharmacist training
Over 40% of consultations were with 20–24-year-olds (largest proportion), 22.5% were with<19s.
A majority of adolescent mystery clients rated counter staff as helpful, no one felt uncomfortable at the counter, all were happy with the privacy, most were happy with the wait time.
Overall, majority of MCs were satisfied by experience.
Combination of pharmacy consultation data, client intercept interviews, and mystery client visits offers ability to contextualize provision data with reported contraceptive-accessing experiences
MC data is the only extractable data — other data not presented with age disaggregation.
Mystery client telephone call, posing as 17 year old needing ECP and asking about availability of ECP
Clients: n=943 every commercial pharmacy in five US cities, called by mystery client
Experiences of adolescents attempting to obtain ECPs from pharmacies
ECPs approved for sale without prescription in pharmacies to women 17+ nationwide
80% of pharmacies had ECP available on the day the call was made, 57% of available pharmacies provided correct information to the caller regarding ECP access.
Pharmacy staff used ethics-laden terminology to explain policies on dispensing ECP.
Pharmacy staff attempting to help the caller by clarifying regulations often created barriers
Comprehensive sampling of commercial pharmacies.
Investigator, expert and informant triangulation were all used to ensure credibility of the data analysis
In-depth discussions with pharmacy staff not possible due to study design
Cross-sectional (self-administered survey with both closed and open-ended questions)
Clients: n=488 females, aged 18–50, presenting a prescription for oral contraception for personal use
Attitudes and views on making oral contraceptives available without prescription
Oral contraception available with prescription
Main reason for having missed a pill for youth (18–25) was for prescription running out (50.3%). 32.8% reported inability to renew a prescription as a reason for missing a pill.
Youth in favor of making hormonal contraception available without a prescription (85.6%) and likely to obtain hormonal contraception without a prescription (89.7%)
Pharmacies were located in both rural and urban areas.
Participants were existing OC users, and could therefore comment on related personal experiences
Selection bias — participants were only current OC users
Mystery client telephone calls to pharmacies including one scenario where a woman under 16 years requested ECPs
Clients: n=168 pharmacies contacted by mystery caller
Pharmacist decisions to provide ECPs or not, justifications for decisions
ECPs available without prescription in pharmacies without age restriction (if competence can be demonstrated)
41.8% (69/165) declined ECP supply.
Reasons pharmacists were unwilling to supply: - woman was <16; or - woman was under another specified age Other justifications included: - uncertainty of the safety of the ECP or limited data regarding its use in 14–16 year olds
Telephone scripts narrow on specific component of ECP provision by pharmacists: assessing pharmacists' persistent myths/misconceptions around ECP provision.
Random sample of pharmacies selected
Hawthorne effect from participants receiving mystery client calls soon after being alerted to the study.
Calls (during normal business hours) may have affected the number of referrals
Cross-sectional (self-administered, web-based survey, following review of a mock-up label for over-the-counter oral contraceptives)
Clients: n=348 female, aged 14–17
recruited via Facebook advertisements
Teenagers' attitudes towards over-the-counter access to oral contraceptives
Hormonal contraception available only with prescription
Nearly 80% supported pharmacy access to oral contraceptives, 73% supported OTC access to contraceptives (60.9% indicating they would likely use the service).
Greatest perceived advantages of increased access: fewer teen pregnancies (44.5%), easier for teens to get OC (22.4%), and more confidential (13.5%).
Greatest perceived disadvantages of increased access: teenagers might not use condoms to protect against STDs (21.6%), need a doctor to decide if oral contraceptives are safe for teens (18.7%), teens might have sex at a younger age (18.%), teens might use oral contraceptives incorrectly (15.8%)
Focus on younger adolescents (14–17).
Participants asked to distinguish between OTC access and behind-the-counter access.
Study provides data both on younger adolescents' interest and ability to access OC in a pharmacy
Convenience sample impacts generalizability
Selection bias — having to actively select (via online clicks) to participate in the survey
Of the 45 studies identified from the 49 abstracted articles, a majority were from high-income countries, most notably the United States (22 articles, including 1 that spanned the US–Mexico border) and the United Kingdom (12 articles). Only six articles were from low- and middle-income countries. Emergency contraceptive pills (ECPs) were the subject of 33 of the 49 articles; the remaining 16 included provision of misoprostol as an abortifacient (one article), oral contraception (seven articles), STI self-screening kits (four articles) and SRH commodities in general (four articles). Most (n=28) described client (real or simulated) experiences, 17 described the experiences of the pharmacist or pharmacy personnel, while the remaining 4 provided both pharmacists' and clients' perspectives. Ten of the 49 articles included only adolescent populations (10–19 years), while an additional 6 focused specifically on youth (10–25 years). The remaining studies included a broader age range of clients but contained enough age-disaggregated data that we could report on some adolescent- or youth-related findings. The use of mystery clients to assess client experience in pharmacies was a popular methodology and featured in 10 articles. Below, we summarize our findings into thematic areas.
3.1 The appeal of pharmacies for reaching young people
Young people expressed satisfaction with their experience accessing SRH commodities from pharmacies [
]. Young people accessed emergency contraception (ECP) faster, with fewer hours elapsing from the time of unprotected sex, when ECPs were available over-the-counter or without a prescription as compared to clinic or prescription access [
]. Corroborating these findings, having to obtain a prescription for a needed SRH commodity was cited as an obstacle to access for young women in two studies [
]; however, clients and providers also noted a lack of privacy — particularly when running through commodity‐dispensing protocols or other screening procedures — as a key concern [
Over one quarter of the included articles assessed the relationship between pharmacy availability of SRH commodities on a variety of SRH outcomes. While updated evidence-based recommendations dismiss the notion that repeat use of ECPs is detrimental to women's health [
], concerns about repeat use were common at the time of data collection for a number of studies. In two studies, easing access to ECPs did not result in repeat use among young women when compared to older women [
]. In particular, 2 articles from a randomized controlled trial of 15–24-year-olds as well as a 15–19-year-old subpopulation found that young women with access to ECPs through pharmacies were no more likely to use them than those who obtained their ECPs through traditional family planning clinics [
Six years after deregulation of emergency contraception in Switzerland: has free access induced changes in the profile of clients attending an emergency pharmacy in Zurich?.
Evidence from three articles found that increasing access to ECPs through pharmacies did not result in a rise in sexually risky behaviors such as age at first sex, number of partners, or frequency and consistency of condom use [
Importantly, based on pharmacy-level surveys and questionnaires, those under 25 years of age comprised a substantial proportion of total users in settings where pharmacies provided access to SRH commodities such as ECPs and oral contraception [
]. The only example where this was not the case was in a study that took place at the United States–Mexico border, which found that older women were more likely than younger women to cross the border to access oral contraception over-the-counter at a pharmacy [
]. However, these results likely reflect the complex dynamics associated with international border crossings for younger women.
It is worth noting that three studies explored opportunities for expanding youth-targeted SRH services, namely, through provision of self-test, mail-in STI (chlamydia) screening. One UK study offered chlamydia screening to young women requesting ECPs at pharmacies [
Effectiveness and cost-effectiveness of a pharmacy-based screening programme for chlamydia trachomatis in a high-risk health centre population in Amsterdam using mailed home-collected urine samples.
Effectiveness and cost-effectiveness of a pharmacy-based screening programme for chlamydia trachomatis in a high-risk health centre population in Amsterdam using mailed home-collected urine samples.
3.3 Reservations around increased access to SRH commodities
As detailed above, lowering barriers to SRH commodity access does not translate to increases in sexually risky behavior. Yet, a persistent reservation expressed by both pharmacy personnel and clients was that increased access was unsafe for young people and would result in poor decision-making [
]. In two US studies, for example, adolescent girl participants voiced concerns that increased commodity availability might lead to teenagers having sex at an earlier age [
Similarly, reservations by pharmacy personnel and other health care providers (including general practitioners and nurses) could be largely categorized in two ways. First, they believed that increasing availability of SRH commodities (ECPs, in particular) could result in “risky and promiscuous” behavior among youth [
]. A second key reservation of pharmacists and other health care providers centered around a general concern that SRH commodities (ECPs, in particular) were not safe for youth [
Compounding these concerns about effects on health and behavior are additional reservations on the appropriateness of pharmacy personnel themselves to provide expanded SRH services [
The role of pharmacists and emergency contraception: are pharmacists' perceptions of emergency contraception predictive of their dispensing practices?.
], in approaching clients as a reason that pharmacy interactions suffered. Several studies cited the pharmacy environment as a suboptimal setting to provide proper counseling on SRH-related issues [
], could be hindrances to meaningful pharmacist–client interactions and counseling.
3.4 Pharmacy access in theory is not pharmacy access in practice
Even when made available through pharmacies, SRH commodity access was not uniform across age groups, with adolescents' (ages 19 years and under) access and uptake often less than that of older youth [
] in an experimental setting. Two studies found that younger youth (especially those 18 years and under) were consistently and significantly slower to access ECPs than older youth and adult women [
Evidence indicated that other subpopulations of youth may face additional challenges to access; two studies from the United States underlined added barriers encountered by rural communities and certain minority groups (particularly those for whom language is a barrier) from pharmacies which may opt not to stock desired commodities or from pharmacists who may not be able to provide proper screening or counseling [
], in one case out of concern that they may not be well informed about their partner's health history or may take advantage of ECP access for use after rape [
]. Finally, in settings where SRH commodities are not subsidized or covered by insurance, commodity cost may serve as yet another barrier for youth. One South African study found that many pharmacists opted to only stock dedicated ECP products because they were significantly more expensive than cut-up combined oral contraceptives, and would therefore discourage overuse by young people [
]. Six studies using mystery clients found that, anywhere between 20% and 65% of the time, youth clients could not obtain the selected SRH commodity (ECPs or oral contraception) despite regulations allowing access [
]. Some evidence indicated differences in dispensing practices by sex; two studies found male pharmacists more willing than female pharmacists to provide ECPs to minors [
]. A study from Jamaica, where certain oral contraceptives were legally available without prescription in pharmacies, found that an adolescent mystery client was refused contraception in 60% of pharmacy visits [
]. An Australian study using telephone scripts found that, following a revision of the national ECP‐dispensing protocol clarifying that there was no reason for ECPs to be restricted on the basis of age, pharmacists still declined dispensing ECPs over 40% of the time when the caller was under the age of 16 [
Confusion or misinformation about various SRH commodities and their dispensing guidelines also created unnecessary barriers to quality commodity provision and counseling for young people [
]. Studies in the United States and South Africa revealed that uncertainty as to when young people were legally entitled to access ECPs resulted in pharmacists incorrectly denying access to eligible youth [
]. Young mystery clients requesting ECPs in France found — in contrast to French regulations — no pharmacies gave information on regular methods of contraception, on prevention of STIs or follow-up medical care or communicated any other place for full contraception education; additionally, fewer than half the pharmacies that dispensed ECPs dispensed it with information on how to use it or side effects [
]. A study on pharmacy provision of abortifacients in a Latin American city found that only 17% of pharmacists who correctly recommended misoprostol as an abortifacient to young mystery clients recommended a dosage potentially effective for causing a medical abortion [
The evidence from this review suggests that pharmacies have qualities which make them convenient points of SRH commodity access for young clients. Between 2000 and 2016, the period covered by this review, there was a clear and steady shift towards legal policies and regulations becoming more favorable to over-the-counter or pharmacist access of SRH commodities for youth. Contrary to both young client and pharmacist concerns, there has been no corresponding increase in sexually risky behavior or adverse health outcomes. A population-based study in France found that 5 years after the deregulation of ECPs, there had been no decrease in the use of other methods of contraception or determinants of ECP use [
]. There is, however, clear evidence that increasing access to SRH commodities through pharmacies can result in improved access, with trends of SRH commodity use (ECP use, in particular) being especially high among youth [
Impact on contraceptive practice of making emergency hormonal contraception available over the counter in Great Britain: repeated cross sectional surveys.
], a population that faces added barriers to obtaining accurate, high-quality SRH information and services.
Despite the convergence of a number of encouraging factors facilitating access to SRH commodities through pharmacies — youth expressed and demonstrated willingness to use pharmacies, increasing numbers of policies supporting youth access and no evidence of adverse effects as a result of pharmacy access — there is still much to be improved in the access experience itself. Lingering and persistent concerns about commodity provision are often rooted in pharmacy personnel's personal biases, distrust of their young clients' judgment, or general discomfort with providing SRH commodities and any accompanying counseling. As a result, young clients can receive subpar, incorrect or no information on their commodity of choice; can encounter arbitrary and unnecessary barriers to access; or can be denied access entirely.
As the positive impetus towards increasing access continues, and policymakers and medical communities become more comfortable with and confident in the ability of pharmacists to be a valuable SRH resource to young people worldwide, we must strengthen the quality and coverage of the commodity-accessing experience. Pharmacy personnel have enormous potential to become trusted sources of SRH commodities for the young people in their communities but only if provided with adequate training and support.
Many earlier studies taking place before a given country deregulated ECPs assessed smaller programs that often required pharmacy personnel to undergo special training in order to be certified to dispense. As SRH commodities become more readily available through pharmacies, pharmacy personnel should have access to pre-service and in-service training to ensure that they have accurate understandings of appropriate use, dosing and side effects of the SRH products they dispense.
On the other side of the counter is the young client. More efforts are needed to ensure that existing programs can achieve full coverage to all populations of young people — including younger adolescents, those living in rural areas and minorities — who face added barriers which might delay or prevent their ability to access a commodity even when legally permitted. Additionally, more research is needed in low- and middle-income settings — only 6 of the 49 studies in this review took place in LMICs. It is also telling that 33 of the 49 articles presented focused on the provision of ECPs. This demonstrates a dearth of documented exploration of the other SRH commodities that young people access through pharmacies, such as other methods of contraception; misoprostol for medical abortions; or related SRH services, including STI self-testing kits.
It is critically important to improve our understanding of how young people engage with existing pharmacy-provision services. There is a fine line between capitalizing on the potential of pharmacies and losing youth engagement; well-intentioned efforts to incorporate compulsory counseling, testing or referrals could make pharmacies lose their fast and discreet appeal that draw in young clients in the first place. A UK study from this review provides a positive example of improving the pharmacy as an SRH resource without losing youth engagement; pharmacies offer chlamydia screening kits to young women already requesting ECPs, bundling commodities with services needed following a discreet SRH event (unintended unprotected sex) but minimizing added time in the pharmacy, as the kits can be used at home [
]. Strategies for discretely making youth aware of their pharmacy as an SRH resource are also worth exploring; a few articles mentioned provision of leaflets (discretely slipped in a shopping bag) as an option [
]. The proliferation of mobile phones among this age group is also an opportunity to provide young people with SRH information or resources when needed, at their convenience, and with respect to their privacy.
This review has a number of limitations. First, as this is one of the first systematic reviews of pharmacy provision of SRH commodities, we aimed for broad inclusion criteria to allow for a full description of what is known about young people's experiences in pharmacies and providers' experiences providing commodities to young people. Many of the included studies have weak designs (if randomized clinical trials are the “gold standard”), and few studies included interventions or statistical analyses. However, our aim was to describe these experiences rather than draw on statistical inference and generalizability. The trade-off with a broad approach is that we could not use a single methodology to assess quality; most studies were descriptive in nature, and standard scoring methodology was difficult to apply consistently. Instead, key limitations (and strengths) of the studies are described in Table 1. Future research should consider refining our review and assessing quality. This limitation notwithstanding, the review does indicate the context for pharmacy provision of SRH commodities for young people.
We also had to exclude a number of studies (or components of studies) that included young people as part of a broader age range of participants but did not disaggregate data by age group. Additionally, some included studies are only technically youth relevant (for example, studies featuring mystery clients 25 years and under in age) but have no primary or even secondary focus on youth access. A number of studies reported on trends in pharmacy use but did not provide information on the direct experiences of youth or providers. The breadth of studies uncovered reflects a key strength of this review; our search strategy did not include age-related search terms; therefore, we were able to screen a wide range of SRH commodity-pharmacy articles which may not have explicitly addressed youth in the title or abstract but which contained relevant data in the text. We also conducted a global search for studies, and although many came from high-income settings and focused on ECPs, we were able to identify several that included lower-income settings and a range of commodities.
5. Conclusion
Pharmacies have been demonstrated to be a resource young people are willing to use if permitted; however, there is a need for additional study in this field to understand how to most effectively harness pharmacies to improve young people's access to SRH commodities. The pharmacy makes for an excellent SRH resource to young clients but should take care not to exactly replicate the health facility experience — to do so would risk pharmacies losing the unique qualities that make them so appealing to youth in the first place. Instead, pharmacists and pharmacy personnel should be recognized as important complements to the role that physicians and other medical practitioners play in the delivery of SRH services. For young people especially, seeking commodities from pharmacies may be their only option. It is important that future research consider adolescents and young people specifically, as they represent a population most in need of alternate forms of access to SRH information, services and commodities. It is also important that pharmacy personnel are provided with clear information on the guidelines for provision and do not serve as an unnecessary barrier to access.
Conflicts of interest
The authors declare that they have no conflicts of interest.
Acknowledgments
We appreciate the contributions of Sara Cottler who assisted with the search strategy development and Dr. Amanda Kalamar, who assisted with the title screening and results outline review. The manuscript represents the view of the named authors only.
Appendix A. Search strategy
Our search strategy included papers published in any language and had a lower date limit of 1 January 2000 and an upper date limit of 1 May 2016.
The following search strategy was used for PubMed: “(“Contraception”[Mesh:noexp] OR “Contraception, Barrier” [Mesh] OR “Contraception, Postcoital”[Mesh] OR “Natural Family Planning Methods”[Mesh] OR “Ovulation Inhibition”[Mesh] OR “Contraceptive Devices”[Mesh] OR “Contraceptive Agents”[Mesh] OR “Abortion, Induced”[Mesh:noexp] OR “Abortifacient Agents”[Mesh] OR (“misoprostol”[MeSH] AND “Abortifacient Agents”[Mesh]) OR (“Mifepristone”[Mesh] AND “Abortifacient Agents”[Mesh])) AND (“Community Pharmacy Services”[Mesh] OR “Legislation, Pharmacy”[Mesh] OR “Education, Pharmacy”[Mesh] OR “Pharmacies”[Mesh]).
The following search strategy was used for Embase: (‘contraception’/exp. NOT (‘female sterilization’/exp. OR ‘male sterilization’/exp) OR ‘family planning’/exp. OR ‘contraceptive device’/exp. OR ‘contraceptive agent’/exp. OR ‘abortive agent’/exp. OR ‘induced abortion’/exp) AND (‘pharmacy’/exp. OR ‘pharmacist’/exp. OR ‘pharmacist attitude’/exp. OR ‘hospital department’/exp).
The following keyword search strategy was used for Popline: (Fertility Control Postconception, Abortion, RU486, Misoprostol, Contraceptive Agents Female, Contraceptive Agents Male, Contraceptive Agents Progestin, Contraceptive Agents Postcoital, Contraceptive Methods, Emergency Contraception, Female Contraception, Male Contraception) AND Administration and Dosage, Pharmacy Distribution, Pharmacies, Pharmacists.
The following search strategy was used for Scopus: KEY (“Contraception” OR “Contraception, Barrier” OR “Contraception, Postcoital” OR “Natural Family Planning Methods” OR “Ovulation Inhibition” OR “Contraceptive Devices” OR “Contraceptive Agents” OR “Abortion, Induced” OR “Abortifacient Agents” OR “misoprostol” OR “mifepristone” OR “family planning” OR “contraceptive agent” OR “contraceptive device” OR “induced abortion” OR “abortive agent” OR “emergency contraception”) AND KEY(“Pharmacy” OR “Pharmacists” OR “Pharmacies” OR “Chemist” OR “Apothecary”).
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Impact on contraceptive practice of making emergency hormonal contraception available over the counter in Great Britain: repeated cross sectional surveys.
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