Pharmacy provision of sexual and reproductive health commodities to young people: a systematic literature review and synthesis of the evidence Academic research paper on "Health sciences"

Accepted Manuscript

Pharmacy provision of sexual and reproductive health commodities to young people: A systematic literature review and synthesis of the evidence

Lianne Gonsalves, Michelle J. Hindin

PII: S0010-7824(16)30540-6

DOI: doi: 10.1016/j.contraception.2016.12.002

Reference: CON 8854

To appear in:

Contraception

Received date: Revised date: Accepted date:

12 April 2016 11 November 2016 17 December 2016

Please cite this article as: Gonsalves Lianne, Hindin Michelle J., Pharmacy provision of sexual and reproductive health commodities to young people: A systematic literature review and synthesis of the evidence, Contraception (2016), doi: 10.1016/j .contraception .2016.12.002

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Pharmacy provision of sexual and reproductive health commodities to young people: A systematic literature review and synthesis of the evidence

Lianne Gonsalves1 Email: gonsalvesl@who.int

Michelle J. Hindin1 Email: hindinm@who.int

Institutional addresses

1 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

Corresponding Author:

Lianne Gonsalves

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 E-mail: gonsalvesl@who.int Tel: +41795006554

Word Count

Abstract: 233

Manuscript Text: 4104

Abstract

Background: 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 PRISMA protocol, we searched for publications from 2000-2016. To be eligible for inclusion, articles had to address the experiences of young people (aged 25 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: 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 increased 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 best 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.

Keywords: Adolescent, youth, contraception, pharmacy, systematic review

1. Introduction

There are over 1.8 billion young people between the ages of 10-24 in the world today, 90% of whom live in developing countries[1]. Comprising one quarter of the world's total population[2], youth are faced with a number of challenges to their sexual and reproductive health (SRH) and wellbeing. 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[3].

As a result, 16 million girls aged 15-19 and 1 million girls under age 15 give birth every year, and complications during pregnancy and childbirth are the second-leading cause of death for 15-19 year old girls, globally[4]. Additionally, an estimated 3 million girls aged 15 to 19 undergo unsafe abortions each year[4]. 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[5]. Data from 61 low-and middle-income countries (LMICs) estimates that 33 million young women aged 15-24 have an unmet need for contraception[6], 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 healthcare 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 wellbeing of adolescents and young people is receiving increased attention and emphasis in a number of global-level collaborations and strategies developed in recent years, including Family

Planning 2020 (FP2020)[7]; the UN Secretary-General's Global Strategy for Women's Children's and Adolescents' Health[8]; and even some targets from the newly-minted Sustainable Development Goals[9]. 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 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)[10]. We searched for studies that addressed the following research question:

What is the experience of young people (25 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 Jan 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. Figure 1 contains a flow diagram of the study selection process.

2.2 Screening

We first screened articles by title, yielding 350 potential articles. We then dual screened (LG and MJH) the abstracts for relevance, also eliminating articles that did not have an abstract in English, Spanish, Portuguese or French, non-research 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[11], the second on emergency contraception in South Africa[12]); this provided an additional 4 articles for full-text review. We were left with 114 articles which were read in full by LG.

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 STI self-test kits. We were interested in the overall experience of commodity provision to young people in pharmacies, either from the adolescent's or 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, LG abstracted 49 articles (presented in Table 1), using data extraction forms modified from a previous review[13]. 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.

3. Results

Of the forty-five studies identified from the 49 abstracted articles, a majority were from high-income countries, most notably the United States (22 articles, including one 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 (1 article); oral contraception (7 articles); STI self-screening kits (4 articles); and SRH commodities in general (4 articles). Most (n=28) described client (real or simulated) experiences, 17 described the experiences of the pharmacist or pharmacy personnel, while the remaining four provided both pharmacists' and clients' perspectives. Ten of the 49 articles included only adolescent populations (10-19 years), while an additional six 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 ten 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[14-17]. Users cited convenience as a major draw of pharmacies, specifically their longer operating hours (including evenings and weekends) [18-20], accessible locations[14], and ease of commodity access[21, 22]. Five articles cited the speed to obtain SRH commodities, such as oral contraception or ECPs, as a major draw of pharmacy access [16, 17, 21, 23, 24]. 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 [16, 23]. 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[21, 25].

With regards to anonymity and privacy, the evidence was mixed. Some clients reported privacy as one of the advantages of pharmacy provision [14, 15, 17, 22]; 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[18, 26, 27].

3.2 SRH Outcomes and ease of use

Repeated ECP use and risky behaviors

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[28], 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 [29], or compared to traditional clinic access [30]. In particular, two 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[30, 31]. However, two Swiss studies found an increase in repeat use among young women following ECP deregulation [32, 33].

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[30, 31, 34]. Additionally, increased access had no adverse effect on unintended pregnancy and STIs[31, 34].

Appropriate self-screen and product use

When provided the opportunity, young women proved capable of accessing and correctly using emergency contraception without pharmacist assistance [16, 24, 34]. Using 'simulated' over-the-counter conditions, minors (girls under age 18) could self-screen and use ECPs [24], and were no more likely than older women to use the product incorrectly[34].

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 [17, 35-37]. 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 [38]. 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[39, 40]; a second UK study followed a national chlamydia screening program offered opportunistically to young people between 15-24[27]; while a third Dutch study targeted mainly ethnic minority young (15-29) women visiting pharmacies to collect contraception[41]. These studies had mixed results and low rates of kit acceptance - often due to reluctance on the part of the pharmacist to offer the kit[39, 27] - and kit return (between 17-27% of offered kits were returned, as reported by the Dutch and one UK study)[41, 40].

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 young people making poor decisions[19, 22, 42-50]. In two U.S. studies, for example, adolescent girl participants voiced concerns that increased commodity availability might lead to teenagers having sex at an earlier age[22] and engaging in unprotected sex[22, 46].

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 [42, 43, 45, 49]. This notion that ECP availability condones or even encourages promiscuity among younger people persisted for some time after deregulation[45, 49]. 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 [19, 47], or that youth would not be able to take them as directed[48, 50].

Compounding these concerns about effects on health and behavior are additional reservations on the appropriateness of pharmacy personnel themselves to provide expanded SRH services[18, 22, 51-55]. Pharmacists did not always feel that it was their place to prescribe medicine due to time constraints[56], limited availability and privacy to provide quality counselling[18], and feeling that they had not been well trained in adolescent-specific issues[51]. Meanwhile, some clients were concerned about leaving the pharmacy without enough information[20].

Especially variable was the quality of reported interactions with clients around the offering or dispensing of SRH services and commodities[18, 19, 57, 27, 39, 26, 55]. Studies noted pharmacy staff's discomfort[27, 39], even intimidation[19], in approaching clients as a reason that pharmacy

interactions suffered. Several studies cited the pharmacy environment as a sub-optimal setting to provide proper counselling on SRH-related issues[18-20, 51, 27, 55]. In particular, the lack of space and privacy[18, 27], especially when a pharmacy was busy[18, 19], could be hindrances to meaningful pharmacist-client interactions and counselling.

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 and under) access and uptake often less than that of older youth[58, 23, 37, 59, 50, 60]; this was despite implied similar levels of need for the two groups, as indicated by ECP use[31] in an experimental setting. Two studies found that younger youth (especially those 18 and under) were consistently and significantly slower to access ECPs than older youth and adult women[23, 37].

Evidence indicated that other sub-populations 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 counselling[47, 56]. Additionally, two studies revealed a reluctance on the part of pharmacists to provide commodities (ECPs) to men[61, 18], 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[18]. 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 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[49].

Pharmacists themselves could be an insurmountable obstacle for young people[44, 45, 58, 26, 40, 15, 49, 62, 61, 60]. 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[58, 26, 56, 15, 62, 61, 60]. Some evidence indicated differences in dispensing practices by sex; two studies found male pharmacists more willing than female pharmacists to provide ECPs to minors[26, 48]. Pharmacists reported using personal comfort and bias to decide whether or not to dispense commodities [39, 27, 48, 19]. Pharmacist biases about the appropriate age to dispense commodities were common [58, 59, 50, 60]. 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[58]. 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[60].

Confusion or misinformation about various SRH commodities and their dispensing guidelines also created unnecessary barriers to quality commodity provision and counselling for young people[57, 63, 48, 49, 62, 19, 61, 60, 18, 26, 15]. 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[49, 61, 62]. Young mystery clients requesting ECPs in France found - in contrast to French regulations - no pharmacies gave information on regular methods of contraception, prevention of STIs, 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[26]. 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[63].

4. Discussion

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 five years after the deregulation of ECPs, there had been no decrease in the use of other methods of contraception or determinants of ECP use [64]; in fact there was an increase in the use of highly effective contraceptive methods, especially among young people[65]. 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[66, 67, 65, 64, 68, 69], 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 counselling. 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 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 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 six 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 counselling, testing, or referrals could make pharmacies lose their fast and discreet appeal that draw in young clients in the first place. A United Kingdom 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 [40, 39]. 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[19, 15, 27]. The proliferation of mobile phones among this age group is also an opportunity to provide young people with needed 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 RCTs 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 tradeoff 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 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.

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.

Conflicts of Interest

The authors declare that they have no conflicts of interest

Funding

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" ) References

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22. Manski R, Kottke M. A Survey of Teenagers' Attitudes Toward Moving Oral Contraceptives Over the Counter. Perspectives On Sexual and Reproductive Health. 2015;47(3). doi:http://dx.doi.org/10.1363/47e3215.

23. Lewington G, Marshall K. Access to emergency hormonal contraception from community pharmacies and family planning clinics. British Journal of Clinical Pharmacology. 2006;61(5):605-8. doi:10.1111/j.1365-2125.2006.02623.x.

24. Raine TR, Ricciotti N, Sokoloff A, Brown BA, Hummel A, Harper CC. An Over-the-Counter Simulation Study of a Single-Tablet Emergency Contraceptive in Young Females. Obstetrics and Gynecology. 2012;119(4):772-9. doi:http://dx.doi.org/10.1097/AOG.0b013e31824c0aed.

25. Landau SC, Tapias MP, McGhee BT. Birth control within reach: a national survey on women's attitudes toward and interest in pharmacy access to hormonal contraception. Contraception. 2006;74(6):463-70. doi:10.1016/j.contraception.2006.07.006.

26. Delotte J, Molinard C, Trastour C, Boucoiran I, Bongain A. Delivery of emergency contraception to minors in French pharmacies. Gynecol Obstet Fertil. 2008;36(1):63-6. doi:10.1016/j.gyobfe.2007.11.001.

27. Dabrera G, Pinson D, Whiteman S. Chlamydia screening by community pharmacists: A qualitative study. Journal of Family Planning and Reproductive Health Care. 2011;37(1):17-21.

28. World Health Organization. Medical eligibility criteria for contraceptive use, 5th edition. Geneva, Switzerland: World Health Organization2015.

29. Raymond EG, Spruyt A, Bley K, Colm J, Gross S. The North Carolina DIAL EC project: increasing access to emergency contraceptive pills by telephone. Contraception. 2004;69(5):367-72.

30. Raine TR, Harper CC, Rocca CH, Fischer R, Padian N. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs. A randomized controlled trial. JAMA. 2005;293(1):54-62.

31. Harper CC, Cheong M, Rocca CH, Darney PD, Raine TR. The effect of increased access to emergency contraception among young adolescents. Obstetrics and Gynecology. 2005;106(3):483-91.

32. Samartzis EP, Merki-Feld GS, Seifert B, Kut E, Imthurn B. 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? European Journal of Contraception and Reproductive Health Care. 2012;17(3):197-204. doi:http://dx.doi.org/10.3109/13625187.2012.661108.

33. Arnet I, Frey Tirri B, Zemp Stutz E, Bitzer J, Hersberger KE. Emergency hormonal contraception in Switzerland: A comparison of the user profile before and three years after deregulation. European Journal of Contraception and Reproductive Health Care. 2009;14(5):349-56. doi:10.3109/13625180903147765.

34. Raymond EG, Chen PL, Dalebout SM. "Actual use" study of emergency contraceptive pills provided in a simulated over-the-counter manner. Obstetrics and Gynecology. 2003;102(1):17-23. doi:10.1016/S0029-7844(03)00377-6.

35. Killick SR, Irving G. A national study examining the effect of making emergency hormonal contraception available without prescription. Human Reproduction. 2004;19(3):553-7. doi:10.1093/humrep/deh128.

36. Lloyd K, Gale E. Provision of emergency hormonal contraception through community pharmacies in a rural area. Journal of Family Planning and Reproductive Health Care. 2005;31(4):297-300.

37. Foster DG, Landau SC, Monastersky N, Chung F, Kim N. Pharmacy access to emergency contraception in California. Perspectives on Sexual and Reproductive Health. 2006;38(1):46-52.

38. Potter JE, White K, Hopkins K, Amastae J, Grossman D. Clinic versus over-the-counter access to oral contraception: Choices women make along the US-Mexico border. Am J Public Health. 2010;100(6):1130-6. doi:10.2105/AJPH.2009.179887.

39. Thomas G, Humphris G, Ozakinci G, O'Brien K, Roberts SA, Hopkins M et al. A qualitative study of pharmacists' views on offering chlamydia screening to women requesting emergency hormonal contraception. BJOG: An International Journal of Obstetrics and Gynaecology. 2010;117(1):109-13. doi:10.1111/j.1471-0528.2009.02362.x.

40. Brabin L, Thomas G, Hopkins M, O'Brien K, Roberts SA. Delivery of chlamydia screening to young women requesting emergency hormonal contraception at pharmacies in Manchester, UK: A prospective study. BMC Women's Health. 2009;9.

41. Van Bergen JEAM, Postma MJ, Peerbooms PGH, Spangenberg AC, Tjen-A-Tak J, Bindels PJE. 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. International Journal of STD and AIDS. 2004;15(12):797-802. doi:10.1258/0956462042563765.

42. Barrett G, Harper R. Health professionals' attitudes to the deregulation of emergency contraception (or the problem of female sexuality). Sociology of Health & Illness. 2000;22(2):197-216.

43. Seston EM, Holden K, Cantrill J. Emergency hormonal contraception: The community pharmacy perspective. J Fam Plann Reprod Health. 2001;27(4):203-8. doi:10.1783/147118901101195768.

44. Blanchard K, Harrison T, Sello M. Pharmacists' knowledge and perceptions of emergency contraceptive pills in Soweto and the Johannesburg Central Business District, South Africa. International Family Planning Perspectives. 2005;31(4):172-8. doi:10.1363/3117205.

45. Bissell P, Savage I, Anderson C. A qualitative study of pharmacists' perspectives on the supply of emergency hormonal contraception via patient group direction in the UK. Contraception. 2006;73(3):265-70. doi:10.1016/j.contraception.2005.07.017.

46. Krishnamurti T, Eggers SL, Fischhoff B. The impact of over-the-counter availability of "Plan B" on teens' contraceptive decision making. Social Science and Medicine. 2008;67(4):618-27. doi:http://dx.doi.org/10.1016/j.socscimed.2008.04.016.

47. Mackin ML, Clark K. Emergency Contraception in Iowa Pharmacies Before and After Over-the-Counter Approval. Public Health Nursing. 2011;28(4):317-24. doi:http://dx.doi.org/10.1111/j.1525-1446.2011.00951.x.

48. Ehrle N, Sarker M. Emergency contraceptive pills: Knowledge and attitudes of pharmacy personnel in Managua, Nicaragua. Int Perspect Sexual Reprodud Health. 2011;37(2):67-74. doi:10.1363/3706711.

49. Maharaj P, Rogan M. Missing opportunities for preventing unwanted pregnancy: A qualitative study of emergency contraception. Journal of Family Planning and Reproductive Health Care. 2011;37(2):89-96. doi:10.1136/jfprhc.2011.0055.

50. Apikoglu-Rabus S, Clark PM, Izzettin FV. Turkish pharmacists' counseling practices and attitudes regarding emergency contraceptive pills. International Journal of Clinical Pharmacy. 2012;34(4):579-86. doi:10.1007/s11096-012-9647-x.

51. Conard LA, Fortenberry JD, Blythe MJ, Orr DP. Pharmacists' attitudes toward and practices with adolescents. Archives of Pediatrics and Adolescent Medicine. 2003;157:361-5.

52. Rafie S, El-Ibiary SY. Student pharmacist perspectives on providing pharmacy-access hormonal contraception services. Journal of the American Pharmacists Association. 2011;51(6):762-5. doi:10.1331/JAPhA.2011.10094.

53. Richman AR, Daley EM, Baldwin J, Kromrey J, O'Rourke K, Perrin K. The role of pharmacists and emergency contraception: Are pharmacists' perceptions of emergency contraception predictive of their dispensing practices? Contraception. 2012;86(4):370-5. doi:10.1016/j.contraception.2012.01.014.

54. Rafie S, El-Ibiary SY. California pharmacy student perceptions of confidence and curricular education to provide direct pharmacy access to hormonal contraception. Pharmacy Education. 2014;14(1):31-6.

55. Fakih S, Batra P, Gatny HH, Kusunoki Y, Barber JS, Farris KB. Young women's perceptions and experiences with contraception supply in community pharmacies. Journal of the American Pharmacists Association. 2015;55(3):255-64. doi:10.1331/JAPhA.2015.14192.

56. Sampson O, Navarro SK, Khan A, Hearst N, Raine TR, Gold M et al. Barriers to adolescents' getting emergency contraception through pharmacy access in California: Differences by language and region. Perspectives on Sexual and Reproductive Health. 2009;41(2):110-8. doi:10.1363/4111009.

57. Ratanajamit C, Chongsuvivatwong V, Geater AF. A randomized controlled educational intervention on emergency contraception among drugstore personnel in Southern Thailand. Journal of American Medical Women's Association. 2002;57(4):196-9, 207.

58. Chin-Quee DS, Cuthbertson C, Janowitz B. Over-the-counter pill provision: Evidence from Jamaica. Studies in Family Planning. 2006;37(2):99-110. doi:10.1111/j.1728-4465.2006.00089.x.

59. Griggs SK, Brown CM. Texas community pharmacists' willingness to participate in pharmacist-initiated emergency contraception. Journal of the American Pharmacists Association. 2007;47(1):48-57. doi:10.1331/1544-3191.47.1.48.Griggs.

60. Hussainy SY, Stewart K, Pham MP. A mystery caller evaluation of emergency contraception supply practices in community pharmacies in Victoria, Australia. Australian Journal of Primary Health. 2015;21(3):310-6. doi:10.1071/PY14006.

61. Wilkinson TA, Vargas G, Fahey N, Suther E, Silverstein M. I'll See What I Can Do: What Adolescents Experience When Requesting Emergency Contraception. Journal of Adolescent Health. 2014;54(1):14-9. doi:http://dx.doi.org/10.1016/j.jadohealth.2013.10.002.

62. Wilkinson TA, Fahey N, Shields C, Suther E, Cabral HJ, Silverstein M. Pharmacy communication to adolescents and their physicians regarding access to emergency contraception. Pediatrics. 2012;129(4):624-9. doi:10.1542/peds.2011-3760.

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64. Moreau C, Trussell J, Bajos N. The determinants and circumstances of use of emergency contraceptive pills in France in the context of direct pharmacy access. Contraception. 2006;74(6):476-82. doi:10.1016/j.contraception.2006.07.008.

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66. Hobbs MK, Hussainy SY, Taft AJ, Stewart K, Amir LH, Shelley JM et al. Pharmacy access to the emergency contraceptive pill (ECP) in Australia: Policy implications of the findings from two national studies. Journal of Sexual Medicine. 2011,'8:138.

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68. Soon JA, Levine M, Osmond BL, Ensom MH, Fielding DW. Effects of making emergency contraception available without a physician's prescription: a population-based study. Canadian Medical Association Journal. 2005;172(7):878-83.

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Figure 1 Study selection flow diagram

Records identified through searching (n=4192)

Titles screened after duplicates removed (n=2S42)

Abstracts sc eligil (n=a ;reened for jility 50}

Full-text articles assessed for eligibility (n=114)

Records excluded (n=2492}

Abstracts excluded (n=240) Not article (no data) (n=B5) Not related to review (n=27) Unlikely to have age data (n=126) Literature review (2) four relevant references extracted and included for full-text review

Full-text articles excluded (n=65) Adult mystery client (9} Notwithin age range(lS) -5H - Not research study/not article (25) Not pharmacy-related (6) Commodity use trends only (6) Not commodity provision (1)

Studies included for thematic analyses (n=49)

Table 1 Description of studies, ordered by publication year

Authors/ Study design and Study Relevant Regulations Results Strengths Limitations

year/country methods population outcomes

Barrett et al. Qualitative (in- PROVIDERS: Attitudes ECPs available Providers expressed concerns Reflexivity and Study takes

2000 depth interviews) n=18 towards over- only through about repeat use in terms of first-hand place prior to

United community the-counter physician promiscuity accounts of deregulation,

Kingdom pharmacists availability of prescription providers' and centers

[42] ECPs beliefs on

n=6 Deregulation hypothetical

general deregulation

practitioners

Wilson et al. Observational CLIENTS: Current Hormonal 29% of males, 13% of females Inclusion of Low response

2000 (school- and mail- n=711 provision of contraception got contraception from males and rate for

United based survey) males and SRH available only pharmacist at last intercourse females postal survey

Kingdom females aged commodities with a component

[20] 13-19 in pharmacies prescription Embarrassment (55%), lack of Assessed views

information (25%), and on pharmacy

confidentiality (27%)are key access versus FP

barriers to pharmacy access clinics and GPs

Seston et al. Qualitative (focus PROVIDERS: Concerns ECPs available Pharmacists' who never Includes ECP provision

2001 group discussions) n=14 about in pharmacies dispensed ECPs expected ECP providers who to youth is

United pharmacists deregulation under 'patient users to be adolescents or had and had not never

Kingdom of ECPs; group sexually irresponsible women dispensed ECPs explicitly

[43] Perceived direction' - a who use ECPs on a regular explored;

support and pharmacist basis instead it

training protocol to arises from

needs for determine Pharmacists who did dispense concerns

deregulation eligibility for found that most clients were about who

ECP use women in their 20s who had might abuse

experienced failure of ECP access

contraceptive method

Sucato et al. Observational CLIENTS: Reasons for Reasons included 'easy to get Respondents Low response

2001 (self-administered n=126 going to a to' and 'privacy protection'. were able to rate (36%)

United States survey) females ages pharmacist- If services didn't exist, 20% report on actual

(Washington) 15-21, satisfaction wouldn't know where else to decision and 25% of

[14] received ECPs with care go, 22% would wait and see if experience in sample never

from a provided by they became pregnant obtaining ECPs received the

pharmacist pharmacist from a survey

Clients felt counselling was pharmacy

clear (99%)and were satisfied

with time to ask questions

Ratanajamit et Randomized PROVDIERS: Knowledge of ECPs available Significantly higher knowledge Robust study Youth issues

al. controlled trial n=60 and practice over-the- of ECPs (score of 22.1 vs 18.5), design never

2002 pharmacy in dispensing counter higher levels of provision of explicitly

Thailand Intervention: and ECPs dosing information (45 vs 12 Three month explored,

[57] course to increase drugstore pharmacists providing), but no follow-up study

ECP knowledge personnel statistical difference in medical included

and improve history taking between because

dispensing skills. intervention and control group mystery

Mystery clients clients are

assess outcomes <25

Raymond et al. Longitudinal CLIENTS: Use of ECP ECPs available With ECP access, minors not Study modelled Limited

2003 n=585 product only through significantly more likely than OTC setting generalizabili

United States Study mimics females under physician older women to use products closely ty to women

(various pharmacy access. presenting (simulated) prescription in a contraindicated or self-selecting

settings) Women for an ECP OTC incorrect manner and did not Low loss to ECPs

[34] requesting ECPs prescription conditions have more adverse events or follow-up (only

asked to review at 8 Planned subsequent pregnancy 7%)

ECP package Parenthood

designed for OTC sites and 5

use and were sold pharmacies in

ECPs 5 cities

Conard et al. Cross-sectional PROVIDERS: Pharmacists' ECPs and Pharmacists <45 were more Excellent Limited

2003 (self- n=948 attitudes and other likely to state they dispensed response rate generalizabili

United States administered, chief practices contraception ECPs (70%) ty to other

(Indiana) mail-in survey) pharmacists related to only available cadres of

[51] of active SRH services through Male pharmacists more likely Use of clear pharmacy

licensed for physician to think adolescents asked case studies to workers and

pharmacies in adolescents. prescription questions about prescriptions provide insight beyond the

Indiana Few felt trained in adolescent issues (13%), confidentiality (23%) into prescribing practices state of Indiana

van Bergen et Cohort CLIENTS: Response Prescription CT-positivity detected among Vulnerable Generalizabili

al. (picked up n=446 rates, refills of oral ethnic minority population population ty to other

2004 Chlamydia women (<30 Chlamydia contraceptive where 15% were CT positive, focus: populations,

Netherlands trachomatis years) test results, s can be as compared with 6-10% found multicultural, pharmacies

[41] screening kit at pharmacy and recruited from a survey results ordered remotely and in other Dutch STI clinics low-income

followed up for pharmacy, collected at Higher rates of CT positivity Cross-checked

test results, who were pharmacy, no among youth (13% among 15- urine samples

questionnaire) offered kits GP contact required 19 year olds, and 14% among 20-24 year olds) as compared to older age group (5% among 25-29 year olds) with test results Explored nonparticipatio n

Killick et al. Cross-sectional CLIENTS: Knowledge of ECPs available Most of the users (72%) were Data from 112 Systematic

2004 (questionnaire) n=419 ECP use, for purchase <20. different bias in

United pharmacy planned from a pharmacies questionnaire

Kingdom ECP clients future pharmacist 49% of women in their 20s, distribution

[35] (ages 16-39) contraceptive use for women aged 16+ 20% of women <20 and 31% of those 30+ paid. and response rates

Raymond et al. Cross-sectional CLIENTS: ECP use

2004 (screening data to n=7774 patterns

United States an ECP telephone female

(North counselling and callers, 88%

Carolina) prescription aged <29

[29] service) years, 37% aged <19 years

Raine et al. Randomized CLIENTS: Use patterns,

2005 controlled trial n=2117 risky sexual

United States female clients behaviours

(California) Three arms (clinic (ages 15-24) and

[30] access, pharmacy enrolled from pregnancy/ST

access, and 4 FP clinics Is

advanced

provision to ECPs)

Special 83% adolescent users received Generalizable Only data

program: any 1 prescription (compared with data available was that

woman 84% of users overall) for various obtained as

needing ECPs ethnicities and part of

could call 12% adolescent users received education levels screening

service and be 2 prescriptions (compared process, no

screened. 40 with 11% of users overall) Extended hours ability to

USD fee for of call service follow up

prescriptions 5% adolescent users received provides data with

3 prescriptions (compared on weekend use participants.

with 5% of users overall)

State Women in pharmacy group Explores High

legislation were no more likely to use ECP pharmacy contaminatio

allowing than women in the clinic group provision n across

women to distinct from study arms.

obtain ECPs Women in the pharmacy advance

from group (8.5%) not more likely provision Could not be

pharmacies than women in the clinic group an intent-to-

without to use ECP 2+ times Follow-up rates treat analysis

consulting a equal across as some

physician No significant differences in groups, no participants

sexually risky behavior, difference in were lost to

pregnancy, or STIs by study characteristics follow-up.

group of women lost to follow-up

Blanchard et Quantitative PROVIDERS: Providers' ECP available Fewer than half felt <18s Careful Response

al. (in-person n=34 knowledge for purchase should get ECP access. One screening of bias

2005 questionnaire pharmacy and attitudes in pharmacies third did not offer ECP to <18s pharmacies for

South Africa administered to providers towards without eligibility Recall bias:

[44] pharmacy from 28 providing prescription Fewer than one-third thought (pharmacies reliance on

providers pharmacies ECPs and for free in <18s should get advance ECP visited an pharmacist

public health provision average of four self-report

facilities times before

Concern that ECP access interview

increases risky behavior conducted)

Lloyd et al. Observational CLIENTS: Trends in age All At beginning, about 21% of the Study site in a Limited

2005 (Retrospective n=1412 of ECP users pharmacies in clients were <20. Increased to rural area generalizabili

United pharmacy record Records of study area 46% after two quarters, and ty to other

Kingdom review) pharmacy could provide afterwards clients <20 Data available areas of the

[36] clients ECPs on accounted for 42-45% of from before UK

Pharmacies request (14 consultations program start

submitted and 15 year

monthly returns olds had to By end of study, community

over 24 months demonstrate pharmacies were the largest

competence) provider of ECP

Harper et al. Randomized CLIENTS: Pharmacy use State Use among adolescents <16 Robust study Participants

2005 controlled trial n=964 by age, risky legislation (38%) similar to group aged design with enrolled from

United States female FP sex, STIs and allowing 16-17 (38%), and higher than specific youth clinics,

(California) Three arms (clinic clinic clients, pregnancy women to those aged 18-19 (33%). focus (15-24), making them

[31] access, pharmacy aged 15-24, obtain ECPs Adults (aged 20-24) had lower computer- not

access, and recruited from overall use (24%). generated representativ

advanced from four pharmacies randomization, e of those

provision of ECPs) clinics in without Pharmacy access no more researchers who seek

study area consulting a likely than clinic access blinded to services from

physician participants to use ECP, participant non-facility

engage in risky behaviours, get group allocation sources

STIs or be pregnant

Bissell et al. Qualitative (in- PROVIDERS: Pharmacist ECPs made Confidentiality noted as A diversity in Response

2006 depth interviews) n=45 views on available for advantage of pharmacies gender, bias: all

United pharmacists provision of purchase from ethnicity, age of pharmacists

Kingdom participating ECP to young a pharmacist Concern that pharmacy supply pharmacists, were

[45] in program to people for women encouraged 'irresponsible' and socio- participating

supply ECPs aged 16+. In attitudes to contraception. demographics in a special

without some areas Particular concern for younger of areas where program

charge there is an option for obtaining free access to ECPs women without a regular partner and those who chose to have unprotected sex Girls <14 requested ECPs pharmacies were located designed to make ECPs more accessible to young people

Chin-Quee et Qualitative BOTH: Pharmacist Oral Mystery client refused access Use of multiple Sampling

al. (observation, n=78 willingness to contraception by 9 of 15 pharmacists and data sources limits

2006 interview) pharmacists sell OC to available for told she needed prescription. allows for generalizabili

Jamaica interviewed minors (<16 purchase in When MC could buy the pill, triangulation in ty

[58] n=524 years) pharmacies without no report of negative reaction collection of data on Limited data

females (age Access to OCs prescription When asked whether they contraceptive- collected on

not specified) for 16 year would sell to minors (<16), accessing youth self-

who olds 46% of pharmacists said they experience reported

purchased OC would not, 38% said they experiences

interviewed would as only 3% of interviewed

n=14 Age was the most mentioned pill

adolescent factor in pharmacists' customers

mystery decisions to restrict customer were <20

client access to OCs

observations

Landau et al. Cross-sectional CLIENTS: Experiences Certain states Younger women (aged 18-25) Random-digit Majority of

2006 (nationally n=811 with have nearly twice as likely (1.78 OR) dialling to data is not

United States representative females, age hormonal legislation as women 36+ to support obtain a age-

(nationwide) telephone survey) 18-44, at risk contraception allowing pharmacy access to OC, patch nationally disaggregate

[25] of and interest pharmacy and ring representative d and

unintended in pharmacy access to sample therefore not

pregnancy access to ECPs. Uninsured, single, and young extractable

reproductive women more likely to have

health had problems obtaining a Low response

commodities prescription for contraception rate (37%)

Lara et al. Qualitative BOTH: pharmacy Abortion Half of participants knew of Pharmacy staff Youth

2006 (in-person n=100 staff legally drug to 'interrupt a survey followed provision not

Latin America interviews with pharmacies knowledge restricted, but pregnancy'. Increased to 74% by MC explored: MC

(unspecified) pharmacy visited by and provision research during MC encounters evaluation of are aged 18 -

[63] personnel and mystery practices of suggests the same 25, but no

mystery clients clients (aged misoprostol many women 60% said misoprostol was pharmacy comment on

visits to same 15-24, male and other frequently use available in interview; 53% compares staff's any age bias

pharmacies) and female) medical misoprostol said it was available to MCs reported and

abortifacients (often actual behavior Same

n=97 obtained from 6% of those recommending pharmacies

pharmacies pharmacies) misoprostol in interviews and Inclusion of received MC

where a staff to self-induce 17% in MC visit offered dosage male and visits and

member was abortion effective for medical abortion female MC staff surveys,

interviewed allows for but MC did

61% of the staff interviewed assessment of not

reported at least one request pharmacy staff necessarily

for abortifacient, more from interactions interview the

women (71%) than men (31%); with clients of same staff

average age of requester: 22 different sex member as

was surveyed

Lewington et Observational CLIENTS: Differences in ECPs in study Weak but significant inverse Specific focus Small sample

al. (pharmacy record n=203 access community correlation between age and on women age of youth

2006 review) females, aged experience could be time to access ECPs via 20 and under, under age 16

United 13-20, between provided free pharmacy data age-

Kingdom requesting young to women disaggregated,

[23] ECPs from women <20. Women Clients <16 significantly more provides

two family accessing <16 who likely to not have used any needed focus

planning ECPs at family could form of contraception on younger

clinics, and planning demonstrate adolescents (16

community clinics vs competence Clients took significantly less and under)

pharmacies community also had time to access ECPs from

pharmacy access pharmacies (41hrs median at

settings clinic compared to 16hrs at

pharmacy)

Foster et al. Cross-sectional CLIENTS: Previous use Post training, Pharmacy faster and more Questionnaire Operating

2006 (questionnaire) n=426 of ECP, pharmacists convenient than a doctor completed on hours of

United States females, aged information can be site, reducing pharmacies

(California) 13-47, on certified to Interest in getting more SRH barriers to affected time

[37] requesting unprotected provide ECP services from pharmacist participation to obtain ECP

ECPs from 25 intercourse, without a (contraceptives, STI testing)

pharmacies reason for prescription. Demographic Respondent

participating requesting No federal <16s took 27 hours longer to information bias -

in the direct ECP and law in place access ECP than women aged available for all participants

ECP access barriers to providing 30+, clinically and statistically women women who

program obtaining ECP prescription- significant delay accessing ECPs requested

free access. ECP

Peremans et Qualitative PROVIDERS: Health ECP are Pharmacists report many ECPs Asking similar Assessed only

al. (focus group n=33 (4 professionals accessible in sold in weekend and evenings, questions of self-report of

2007 discussion) FGDs) experiences pharmacies reluctance to dispense to men three cadres of behavior - no

Belgium general dealing with free of charge and young girls health workers other way to

[18] practitioners ECP requests to triangulate compare

Concern with privacy in experiences reported

n=24 (3 pharmacy and community for views and

FGDs) counselling young patients Including health behavior to

pharmacists professionals actual

Pharmacists at ease with from both in- performance

n=26 (5 opportunity to help school and out-

FGDs) adolescents, quality of-school

school counselling by pharmacists a settings

physicians concern, often refer to GPs

Griggs et al. Cross-sectional PROVIDERS: Knowledge ECPs only Respondents (57.7%) believed Extensive Minimal

2007 (mail-in survey) n=148 and available by patients receiving ECP should piloting of study youth-related

United States community perceptions prescription be a certain age: mean of instrument data

(Texas) pharmacists of ECP and 17.25 years prior to its

[59] dispensing implementation

Delotte et al. Qualitative CLIENTS: Adolescent ECPs available Over 1/3 were refused ECPs Adolescent MC Low

2008 (adolescent n=53 experience anonymously Of those that provided, 1/3 record actual generalizabili

France mystery client pharmacies obtaining and for free asked for ID, almost half asked rather than ty

[26] requesting ECPs) visited by MC ECPs in through to confirm minor status reported

pharmacies pharmacies to pharmacist

random minors who Fewer than half that provided behaviours

sample of all meet gave information on use or

pharmacies in dispensing side effects. None provided

the city criteria additional SRH counselling

Krishnamurti Mixed-Methods CLIENTS: Peer Federal 45.8% teens 16+ and 44% Focus on high- Social

et al. (interviews and n=30 decision- approval of teens <16 thought their peers risk populations desirability

2008 surveys) interviews making over-the- would have more unprotected (racial and response

United States around sex counter sale sex with increased ECP access. minorities, bias based on

(Pennsylvania) Structured surveys n=125 and of ECPs to urban area) sensitivity of

[46] were survey contraception women 18+ When asked who should be topics

administered , knowledge able to purchase ECPs without Open-ended

either on paper or females aged of ECPs, a prescription, 18% chose interview guide

electronically and 12-19, from awareness 'anyone aged 12+', 43% chose allowed natural

consisted of a 'at-risk' and use of 'anyone aged 16+' 23% chose conversation

combination of communities ECPs; 'anyone 18+' and 7% said no among

closed and open- prediction of one. participants

ended questions effect of talking about a

increased ECP <16s less likely to know about taboo subject

availability on ECP, more likely to think that

behavior greater availability would

increase unprotected sex

Arnet et al. Pharmacy record CLIENTS: Profile of ECP ECPs Stratification of the study Opportunity to Forms based

2009 review n=729 (380 users just accessible population by age groups assess client use on patient

Switzerland from 2003, after without showed no differences in the of ECPs when recall and

[33] Official 1-page 349 from deregulation prescription in contraceptive methods used deregulation reporting

ECP written 2006) and three pharmacies between groups took place and

assessment form females, aged years later for women three years No age-

is used during 15-49, 16+, provided: Re-use significantly more later disaggregate

consultation and obtaining a pharmacist frequent in Group 2006 d data

helps pharmacists ECPs dispenses, a women aged 18-21 than Retrospective provided on

make the decision counselling Group 2003 (21.3% vs 33.1%, design assured contraceptio

to administer ECPs accessing interview p<0.001). Significant that pharmacies n use during

ECPs from 18 takes place correlation observed between were not biased ECP request

pharmacies in span of time until re-use and by the study period

three cities age (p< 0.01)

Brabin et al. Pharmacy record CLIENTS: Previous ECP ECPs available Only one quarter of women Pharmacy Lack of

2009 review n=2904 use and free, without provided ECPs were offered a records during understandin

United females, age chlamydia prescription in chlamydia screening study allowed g why clients

Kingdom Pharmacists range treatment pharmacies for later did not

[40] offered screening unspecified, for women Using actual (rather than screening of return the

kit with requesting <25. grouped) ages, there was a proportion of test,

questionnaire ECPs Pharmacies significant increase in the kits offered to uncertainty

after completing also offered number of positive tests with clients, and as to whether

the ECP protocol mail-in age. proportion of clients felt

Chlamydia kits accepted obligated to

trachomatis 24/264 returned samples in and returned by accept test

screening total were positive (9.1%) clients kits

Sampson et al. Mixed-methods BOTH: Comfort <18s can Rural pharmacies calls less Study design Did not

2009 (mystery client n=115 providing ECP obtain ECPs successful than urban, Spanish provides assess actual

United States (MC) and pharmacies to without a speakers less successful than opportunity to provision of

(California) interview) called with adolescents; prescription English speakers compare ECPs

[56] mystery ability for from reported vs

MC phone calls to clients adolescent to designated Pharmacist concern with effect actual behavior Cannot

pharmacies in obtain pharmacies. on young girls, whether they determine

English and n=22 method ~1/5 of state were appropriate health MC represented how age

Spanish, posing as pharmacists pharmacies professional to prescribe understudied related to

a 15- or 18-year- and clinical enrolled in adolescent accessing

old needing ECPs providers interviewed this system Those who did dispense cited desire to help young women populations ability

Glasier et al. Qualitative CLIENTS: ability for ECPs available ECP was dispensed in 26 of 40 Random Youth never

2010 (mystery client) n=40 youth to for free, (65%) pharmacies. In 12 (43%) selection of explicitly

United pharmacies obtain ECPs, without a pharmacies where ECP was pharmacies for explored,

Kingdom Young MC visited visited by information prescription offered, MC asked about study inclusion study was

(Scotland) pharmacies with a mystery provided by from future plans for contraceptive included

[15] variety of clients pharmacist, pharmacies to use. Single MC because

scenarios. perceived women aged visited included mystery

attitude, 13+ across A consultation occurred in 35 pharmacies, clients are

privacy of Scotland, pharmacies, 83% in a private completed data below 25. For

consultation through consultation room collection form all intents

space nationwide patient group direction 31 pharmacists (98%) considered to be nonjudgemental; 12 were very pleasant (34%), 18 pleasant (51%) immediately following visits and purposes, this is a study of adults

Potter et al. Cross-sectional CLIENTS: Experience OC available Age positively associated with Study Many factors

2010 (in-person, n=1046 obtaining pills free from FP crossing the border to access participants explain

United States- structured survey) females, 18- and clinics in oral contraception from contain large reluctance to

Mexico border 44 accessing perceived United States. Mexican pharmacies number of cross

[38] OC from a FP advantages Women can traditionally international

clinic in Texas and also buy More US clinic users among understudied border

(n=532) or a disadvantage contraception 18-24 (34% v 23% using Ciudad women:

pharmacy in s of using that in Mexico Juarez pharmacy) Spanish- Minimal age-

Ciudad Juarez source. without speaking, low disaggregate

(n=514) prescription income d data

Thomas et al. Qualitative PROVIDERS: Experience Pharmacies in Pharmacists' decision to offer Discrepancies in Sample was a

2010 (interviews) n=26 providing study area screening was personal rather knowledge pharmacists

United pharmacists screening kits offer free than financial. None willing to versus behavior who opted to

Kingdom completing to clients, ECPs to approach a client in a long- reported in participate in

[39] questionnaire including why women under term relationship questionnaire the screening

many 25 years of could be probed program. This

n=12 pharmacists age. Pharmacists felt ideally placed during the in- group

pharmacists did NOT offer Participating to talk to clients depth interview displayed low

interviewed screening to pharmacies adherence to

eligible also offered Less educated clients would protocol, in

Recruited clients postal not see benefit of screening that many did

from chlamydia NOT offer

pharmacies screening <20s seen as poorly informed screening to

participating and at higher risk because of eligible

in Chlamydia 'promiscuity', more likely to clients

trachomatis take a kit. <16s seen as more

screening reluctant and shy

Dabrera et al. Qualitative (semi- PROVIDERS: Challenges to Nationwide Concerns about privacy Pharmacists Very small

2011 structured n=10 offering chlamydia available. Concerns also interviewed sample size,

United interviews) pharmacists chlamydia screening expressed about offering reflected mix of subject to

Kingdom from screening program screening to less- multiple-site volunteer

[27] pharmacies offers knowledgeable <16s and single-site bias - only 10

registered screening pharmacies in of 17

with opportunistic Perception that screening only the study area pharmacists

Chlamydia ally to young appropriate in relation to approached

trachomatis people (aged other SRH services and that it agreed to

screening 15-24) in was difficult to bring up participate

program pharmacies screening when clients

attended for non-SRH

complaints. Suggestion to use

leaflets or promotions to

encourage screening

Mackin et al. Cross-sectional PROVIDERS: Availability of During data After deregulation, 70% of State-wide Minimal

2011 (telephone survey n=713 ECPs and collection, pharmacies had ECP available study youth-related

United States including closed pharmacies, reasons for ECPs data

(Iowa) and open-ended (surveyed continued approved for Percentage of pharmacists Comparison of

[47] questions) 405 before non- sale without who agreed that ECP is safe for stocking 21% of

and 308 after availability prescription in teens actually decreased practices and pharmacies

policy change pharmacies to significantly, from 43.8% pharmacist declined to

allowing sales women 18+ before to 27.9% after beliefs before participate in

of ECPsto deregulation and after policy study,

women 18+) change response bias

Ehrle et al. Cross-sectional PROVIDERS: Knowledge of ECPs not Majority of participants (85%) Selected Results not

2011 (researcher- n=93 and attitudes available believed that females <16 pharmacies generalizable

Nicaragua administered pharmacy towards ECPs through could not safely take ECPs visited up to to rest of the

[48] semi-structured personnel public health three times country

survey) services, but Concern selling ECPs because during study in

random are available adolescents could abuse it order to obtain Recall and

sample of all with or face-to-face social

licensed, without 13% would sell to a minor interviews with desirability

operating prescription in without parental consent. Men eligible bias based on

pharmacies in private more willing than women to participants topic

the city pharmacies provide to minors sensitivity

Maharaj et al. Qualitative PROVIDERS: Health ECPs available Providers in private facilities In-depth Limited

2011 (in-depth n=30 workers' without a report that requests for ECP perspectives of youth-related

South Africa interviews) retail views and doctor's on the rise among young public sector data

[49] pharmacists experiences prescription. women. health

(n=20), supplying Accessible in providers, Lack of

health ECPs public health Concern of ECP promoting commercial privacy,

workers from facilities at no sexual promiscuity among pharmacists, frequent

NGO- cost and are young people. Private sector and specialized interruptions,

operated FP sold in (pharmacists) only stock FP providers and suspicion

clinics (n=2), commercial dedicated ECPs because the towards the

nurses from pharmacies product is more expensive so Study provides research

public clinics people need to 'think twice' opportunity to

(n=6), nurses explore Social

from public Providers reported refusing to lingering desirability

FP clinics supply ECPs because unsure barriers to ECP and recall

(n=2) about age at which a client can purchase EC products without a guardian's consent provision bias

Rafie et al. Cross-sectional PROVIDERS: Willingness to ECPs available Student pharmacists indicated Opportunity to Limited

2011 (self- n=502 provide without interest (96.2%) in providing assess views of youth-related

United States administered, pharmacy contraception prescription in hormonal contraception (pill, new pharmacy data, as

(California) web-based or students to minors pharmacies to patch, and ring) under state- practitioners questionnaire

[52] paper survey) women 18+. wide protocol to both minors contained

recruited State and adults (53.3%), adults only Comprehensive only one

from all regulation (40.6%), or minors only (6.2%) coverage of all question

California allows trained schools of about

schools of pharmacists pharmacy in willingness to

pharmacy to sell ECPs to all women. state provide to minors

Rubin et al. Cross-sectional CLIENTS: Access to ECPs available Participants obtaining ECPs Ability to Not able to

2011 (self- n=531 ECPs, barriers without without prescription more compare calculate a

United States administered, females, aged to use, prescription in likely to use within 24 hrs of experiences of response rate

(nationwide) web-based 14-19, who satisfaction pharmacies to unprotected sex than those adolescents in

[16] survey) had engaged with access women 18+ who obtaining with states with and Response

in experience (17+ by study prescription (OR: 2.17, p<.05) without bias

unprotected end). pharmacy

intercourse 9 states allow Minors who obtained in access Social

when they access pharmacist access states more desirability

were aware without age likely to report satisfaction bias

of ECPs limits with their experience (OR: 3.05 p<.05)

Apikoglu- Cross-sectional PROVIDERS: Counselling

Rabus et al. (self- n=667 practices and

2012 administered, pharmacists attitudes

Turkey web-based regarding ECP

[50] survey) recruited from a professional networking website/onlin e forum for pharmacists

Raine et al. Longitudinal CLIENTS: ECP use,

2012 n=345 pregnancy,

United States Pharmacy females, aged and adverse

(various) availability of ECPs 11-17, events

[24] simulated, eligible participants read study product label and self-determined whether to use the product (and how) requesting ECPs

ECPs are Only 52-57% of pharmacists Comparisons Recall/social

meant to be had positive attitude towards: between desirability

dispensed 'teenagers and youngsters can pharmacist bias - self-

with a take responsibility for the use practices based completed

physician's of ECPs'; 'ECPs give women on sex and age survey on

prescription. increased sexual safety'; and of pharmacists sensitive

In practice, 'ECPs increase women's topic

customers can control of reproduction' Insight into

purchase practice when Limited focus

products 58% of pharmacists agreed policy does not on youth as

directly from ECP should be limited for sale permit study asked

community to 18+. 52% agreed that dispensing ECP

pharmacies teenagers can responsibly use without a dispensing in

ECP prescription general

ECPs 96.7% (298) of participants Participant self- Response

approved for who received product used it screen on ECP bias -

sale without by the 1-week follow-up. 274 offers detailed recruitment

prescription in (92.9%) correctly used it <72 data on label from FP

pharmacies to hrs after unprotected sex comprehension clinics, means

women 17+ and access recruiting

nationwide Neither age nor previous use competency for care-seeking

during data of emergency contraception young youth

collection. associated with correct use adolescents

simulates 1 in 5 participants who used Special focus on

access for study product reported including young

women 11+ additional ECP use within the adolescents in

follow-up period sample

Richman et al. Cross-sectional PROVIDERS: Knowledge

2012 (self- n=272 and attitudes

United States administered, practicing around ECP

(Florida) mail-in survey) pharmacists dispensing as

[53] random sample of registered pharmacists in the state of Florida well as actual dispensing experience

Wilkinson et Qualitative CLIENTS: Accuracy of

al. (mystery caller) n=943 information

2012 every provided to

United States Mystery client commercial adolescents

(various) telephone calls to pharmacy in and

[62] pharmacies posing five US cities, physicians of

as 17-year-old in called by adolescents

need of ECP or the mystery when

physician of a 17- client requesting

year-old patient in ECPs

need of ECP

ECPs Reported comfort in Randomly Selection bias

approved for dispensing ECPs varied: 67% selected sample - only English-

sale without reported comfort dispensing of pharmacies speaking

prescription in to adult women; 42% to men, pharmacists

pharmacies to 39% to adolescents Survey

women 18+ instrument was Low

nationwide. pilot tested for generalizabili

State face validity. ty

conscience Construct

clauses allows validity and Limited

for refusal to reliability also youth-related

dispense established data

ECPs Average estimated time for Comprehensive Calls made

approved for medication to be available sampling of only during

sale without significantly higher for commercial normal

prescription in adolescents than physicians pharmacies business

pharmacies to (45 vs 39 hrs, p<.0001) hours.

women 17+ Adolescent vs. Cannot know

nationwide Adolescent callers placed on physician MC how

hold more (54% vs 26%, calls separated evening/wee

p<.0001) and less likely to talk by at least two kend calls

to pharmacist (3% vs 12%, weeks would have

p<.0001) than physicians been answered

19% adolescent callers told

they could not obtain ECP at

all (vs. 3% in physician calls,

p<.0001)

Samartzis et Pharmacy record CLIENTS: Profiles of

al. review n=1500 (750 ECP users

2012 in 2004, 750 following

Switzerland Retrospective in 2009) deregulation

[32] analysis of one- females, aged

page patient 15-49,

assessment forms requesting

and protocol ECPs

Parsons et al. Mixed methods CLIENTS: Data on

2013 (pharmacy record n=741 consultations,

United review, structured consultations client

Kingdom questionnaire, satisfaction

(London) mystery client) n=99 with

[17] females client pharmacy

MC evaluations intercept experience

conducted at questionnaire

three pharmacies,

using trained n=19

adolescent pharmacy

women visits by MC

ECPs available Most ECP users who had never Ability to assess Generalizabili

for free visited a gynecologist were profiles of ECP ty-

without <21 users over time recruitment

prescription - shortly after took place in

for all women Number of repeat ECP users deregulation of only one

15+, following rose between 2004 and 2009 ECPs and five pharmacy

a medical years later

history and a For <20s, condom rupture

pregnancy reported significantly more

test frequently as reason for ECP use

Special Over 40% of consultations Combination of MC data is

program in were with 20-24 year-olds pharmacy the only

select (largest proportion), 22.5% consultation extractable

pharmacies to were with <19s data, client data - other

supply oral intercept data not

contraceptive A majority of adolescent interviews, and presented

s without mystery clients rated counter mystery client with age

prescription staff as helpful, no one felt visits offers disaggregatio

to eligible uncomfortable at the counter, ability to n

women 16+, all were happy with the contextualize

following privacy, most were happy with provision data Small sample

pharmacist the wait time with reported size for

training contraceptive- mystery

Overall, majority of MCs were accessing client

satisfied by experience experiences exercise

Both et al Qualitative BOTH: youth

2014 (observations, n=36 (survey) experiences

Ethiopia survey, females and accessing

[19] interviews) males, aged ECPs,

18-29 attitudes and

beliefs of

n=41 policymakers

(interviews) and providers

males and around ECP

females access

(aged 15-29),

stakeholders,

healthcare

providers

Observations

of ECP

dispensing

Rafie et al. Cross-sectional PROVIDERS: Confidence

2014 (self- n=502 ordering HC

United States administered, pharmacy for minors

(California) web-based or students

[54] paper survey)

recruited

from all

California

schools of

pharmacy

ECPs available Pharmacists worried about Combination of Survey data

in private side effects (e.g. infertility or observation, not age

sector cancer), concerned that young questionnaire, disaggregate

pharmacies people think only of pregnancy and interviews d, making

and drug and not preventing HIV/AIDS offer the only some of

stores without opportunity to the

prescription Sundays and Mondays were contextualize qualitative

popular for ECP selling, along observed and data usable

with holidays reported behavior Limited

Providers intimidated to generalizabili

counsel youth who want to be Detailed ty

in and out quickly observations and surveys of Recall bias

Nearly all young people both young men given the

ensured visit was discreet. and women sensitivity of

Secrecy and shame identified accessing ECPs the topic

as key to young people's in pharmacies

experiences of sexuality

ECPs for sale 68.7% of pharmacy students Opportunity to Limited

without claimed to be moderately to assess views of youth-related

prescription in extremely confident ordering new pharmacy data

pharmacies to HC for minors practitioners

women 18+.

Agreement Comprehensive

allows trained coverage of all

pharmacists schools of

to sell ECPs to pharmacy in

all women state

Wilkinson et Qualitative CLIENTS: Experiences

al. (mystery client) n=943 of

2014 every adolescents

United States Mystery client commercial attempting to

(various) telephone call, pharmacy in obtain ECPs

[61] posing as 17 year five US cities, from

old needing ECP called by pharmacies

and asking about mystery

availability of ECP client

Barlassina et Cross-sectional CLIENTS: Attitudes and

al. (self-administered n=488 views on

2015 survey with both females, aged making oral

Republic of closed and open- 18-50, contraceptive

Ireland ended questions) presenting a s available

[21] prescription for oral contraceptio n for personal use without prescription

ECPs 80% of pharmacies had ECP Comprehensive In-depth

approved for available on the day the call sampling of discussions

sale without was made, 57% of available commercial with

prescription in pharmacies provided correct pharmacies pharmacy

pharmacies to information to the caller staff not

women 17+ regarding ECP access Investigator, possible due

nationwide expert and to study

Pharmacy staff used ethics- informant design

laden terminology to explain triangulation

policies on dispensing ECP were all used to

ensure

Pharmacy staff attempting to credibility of the

help the caller by clarifying data analysis

regulations often created

barriers

Oral Main reason for having missed Pharmacies Selection bias

contraception a pill for youth (18-25) was for were located in -participants

available with prescription running out both rural and were only

prescription (50.3%). 32.8% reported urban areas current OC

inability to renew a users

prescription as a reason for Participants

missing a pill were existing Target

OC users, and sample size

Youth in favour of making could therefore was not

hormonal contraception comment on reached

available without a related personal

prescription (85.6%) and likely experiences

to obtain hormonal

contraception without a

prescription (89.7%)

Fakih et al. Cross-sectional BOTH: Young

2015 (self-administered n=343 women's

United States survey) female, aged perceptions

(Michigan) 23-24 and

[55] n=94 all community pharmacies in the selected county experiences with contraception supply

Hussainy et al. Qualitative CLIENTS: Pharmacist

2015 (mystery client) n=168 decisions to

Australia pharmacies provide ECPs

[60] Mystery client contacted by or not,

telephone calls to mystery justifications

pharmacies caller for decisions

including one

scenario where a

woman under 16

years requested

ECPs Young women in this study did Linking client Very narrow

approved for not feel as comfortable talking survey data age range

sale without about contraceptives with with pharmacy (23-24), not a

prescription pharmacists as with others survey data random

and age limit allowed for an sample, fairly

nationwide. Overall, 51.3% of young examination of homogenous

Hormonal women had a positive attitude a woman's participants

contraception toward pharmacy purchase of experience in demographic

requires contraception the specific s limiting

prescription pharmacy she generalizabili

visited ty

ECPs available 41.8% (69/165) declined ECP Telephone Hawthorne

without supply. scripts narrow effect from

prescription in on specific participants

pharmacies Reasons pharmacists were component of receiving

without age unwilling to supply: ECP provision mystery

restriction (if - woman was <16; or by pharmacists: client calls

competence - woman was under another assessing soon after

can be specified age pharmacists' being alerted

demonstrated Other justifications included: persistent to the study

) - uncertainty of the safety of myths/misconc

the ECP or limited data eptions around Calls (during

regarding its use in 14-16 year ECP provision normal

olds business

Random sample hours) may

of pharmacies have affected

selected the number

of referrals

Manski et al. Cross-sectional CLIENTS: Teenagers'

2015 (self- n=348 attitudes

United States administered, female, aged towards over-

(nationwide) web-based survey, 14-17 the-counter

[22] following review access to oral

of a mock-up label recruited via contraceptive

for over-the- Facebook s

counter oral advertisemen

contraceptives) ts

Hormonal Nearly 80% supported Focus on Convenience

contraception pharmacy access to oral younger sample

available only contraceptives, 73% supported adolescents (14- impacts

with OTC access to contraceptives 17) generalizabili

prescription (60.9% indicating they would ty

likely use the service) Participants

asked to Selection bias

Greatest advantages of distinguish - having to

increased access: fewer teen between OTC actively

pregnancies (44.5%), easier for access and select (via

teens to get OC (22.4%), and behind-the- online clicks)

more confidential (13.5%) counter access to participate

in the survey

Greatest disadvantages of Study provides

increased access: teenagers data both on

might not use condoms to younger

protect against STDs (21.6%), adolescents'

need a doctor to decide if oral interest and

contraceptives are safe for ability to access

teens (18.7%), teens might OC in a

have sex at a younger age pharmacy

(18.%), teens might use oral

contraceptives incorrectly

(15.8%)