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Male access to emergency contraception in pharmacies: a mystery shopper survey
Contraception 90 (2014) 413 – 415
Original research article
Male access to emergency contraception in pharmacies: a mystery shopper survey☆,☆☆ David L. Bell a, b,⁎, Elvis J. Camacho a , Andrew B. Velasquez a, b a
Columbia University Medical Center, New York, NY, USA b NewYork-Presbyterian Hospital Received 28 January 2014; revised 16 June 2014; accepted 18 June 2014
Abstract Background: Pharmacy access to emergency contraception (EC) could involve men in pregnancy prevention. The objectives were to assess the availability and cost of EC. Study Design: Male mystery shoppers visited 158 pharmacies in three neighborhoods in New York City. They asked for EC and its cost and noted weekend hours. Results: Twenty-two (73.3%) of 30 pharmacies created barriers to get EC. The cost of EC was higher in the higher-socioeconomic status (SES) neighborhood (pb.001), and the higher-SES neighborhood pharmacies had a greater number of weekend hours (pb.001). Conclusions: Overall, males had a 20% probability of not being able to access EC. The national dialogue should include males. © 2014 Elsevier Inc. All rights reserved. Keywords: Adolescent; Contraceptives; Drug costs; Males; Pharmacies; Pharmacists
1. Introduction Most recent national data suggest that nearly half of pregnancies in the US were unintended [1]. Emergency contraception (EC) provides an important alternative if unprotected sex occurs. Historically, research has focused on women's access to EC. Few studies have addressed males and EC to support timely use by their female partner [2–5]. The Food and Drug Administration has supported over-thecounter access for males to purchase EC, with the same age restrictions as for females, since the initial ruling in 2006[6]. However, actual over-the-counter access is impacted by pharmacist's knowledge, dispensing behaviors, pharmacy hours and out-of-pocket costs [7–9]. This study extends the literature by employing males as “mystery shoppers” seeking EC for their female partner. The
☆
Financial disclosures: None. Contributors: Ben Mather, summer intern, supported pharmacy visits. ⁎ Corresponding author at: The Young Men's Clinic, CCHE, 60 Haven, B3, New York, NY 10032, USA. Tel.: + 1 646 382 3913; fax: + 1 212 304 5209. E-mail address: [email protected] (D.L. Bell). ☆☆
http://dx.doi.org/10.1016/j.contraception.2014.06.032 0010-7824/© 2014 Elsevier Inc. All rights reserved.
objectives of this study were to assess availability of EC, its cost and the weekend business hours of pharmacies in three neighborhoods in New York City.
2. Materials and methods Pharmacies from three New York City neighborhoods — Washington Heights, East Harlem and the Upper East Side were chosen. These neighborhoods differ in racial and ethnic makeup, socioeconomic status (SES) and teenage and young adult pregnancy rates [10–12]. The final pharmacy sample was 158: 87 from Washington Heights, 38 from East Harlem and 33 from the Upper East Side (see Fig. 1). In July 2012, three male research assistants aged 19, 25 and 28 years were matched with a neighborhood based on the racial and ethnic majority of the neighborhood. Each research assistant asked the pharmacist or pharmacy technician to purchase levonorgestrel EC, specifically “Plan B" or the “morning after pill,” for their female partners because the condom broke. The research assistants then asked about the variables (see below) related to using EC.
414
D.L. Bell et al. / Contraception 90 (2014) 413–415 Pharmacies Listed=188 Out of Business/ Not Pharmacies/ Duplicates= 37
Pharmacies Listed & Visited: 151
Pharmacies Added in the Field=7
Pharmacies Visited=158
Washington Heights=87
Available=69
Upper East Side=33
Unavailable=18
East Harlem=38
Available=29
Available=29
Unavailable=9
Unavailable=4
Fig. 1. Pharmacy Sample.
The Columbia University Institutional Review Board approved this research. 2.1. Variables 2.1.1. Availability Levonorgestrel EC was considered “available” if two criteria were met: (1) levonorgestrel EC was “in stock,” and (2) the pharmacist would sell it to the male research assistant at that moment. Conversely, the existence of any barriers to immediate purchase of EC was categorized as “not available.” 2.1.2. Effective time For the effective time of levonorgestrel EC, we dichotomized the responses into two groups: correct and incorrect answers. Correct answers for the efficacy were noted as either 72 hours or 5 days [13,14]. All other responses were categorized as incorrect answers. 2.1.3. Cost The cost was noted in dollars and cents. 2.1.4. Extended hours The extended hour variable was the total number of hours from Saturday 5 p.m. to Monday 9 a.m. that each pharmacy was open. The business hours of the pharmacy were recorded from the available signage.
significance at a pb.05 level. We also used a one-way analysis of variance (ANOVA) for the continuous variables (cost of EC and extended hours) to determine if there was any statistical significance at a pb.05 level. The one-way ANOVA found both variables to be significantly different; therefore, a Tukey post hoc test was used to identify which of the neighborhoods were significantly different to each other.
3. Results Of the 158 pharmacies, 128 (81%) would give EC to the male research assistants, i.e., it was available. (See Table 1 for full account of results.) Of the 30 pharmacies in which males could not access EC, i.e., not available, the majority (n= 22; 73.3%) required the presence of a female or her identification card at the time of purchase and 8 (26.7%) reported not having it in stock. Overall, most pharmacists and/or pharmacy technicians gave the correct time of effectiveness for EC. A few pharmacists gave a range of misinformation regarding the effective timing of EC: 24, 36 and 48 hours. Of note, one pharmacist stated that EC was an abortifacient, and one stated that it was associated with birth defects.
2.2. Analysis
4. Discussion
SPSS was used for data analysis. We used the chi-square test analysis for the categorical variables (availability and efficacy answers) to determine if there was any statistical
Overall, 80% of pharmacies across three different neighborhoods in NYC would make EC available to young men. Although this represents the majority of pharmacies, a
D.L. Bell et al. / Contraception 90 (2014) 413–415
415
Table 1 Availability, correct information on timing, cost and number of extended hours in three NYC neighborhoods
a
Availability , n (%) Correct time a, n (%) Cost b, mean (SD) Extended hours b, mean (SD)
Upper East Side (n=33)
Washington Heights (n=87)
East Harlem (n=38)
p-Value
30 (91) 31 (93.9) $50.58 ($5.59) c 11.88 (9.91) c
69 (79.3) 74 (85) $45.72 ($4.43)* 2.82 (3.79)*
29 (76.3) 34 (89.5) $47.66 ($3.78)* 3.74 (4.20)*
p=.527 p=.389 pb.001/pb.021 pb.001/pb.001
⁎ Indicates statistical significance. a Chi-square. b ANOVA. c Upper East Side was the referent group.
young man has a 1 in 5 chance of not having EC available to them. Of note, the number of pharmacies that did not have EC in stock is consistent with previous studies in NYC and may not reflect a male specific issue [7]. However, it is unknown whether they did not ever stock EC; they were temporarily out of it; or the pharmacist covertly refused to give EC to the male (or females) for “conscience” motives. However, 73% of pharmacies that limited access to EC by requiring the presence of a female or her ID may have reflected an attempt to comply with the federally mandated age restriction. This issue may be a moot point at present. Since the data were collected, EC is available over-thecounter without an age restriction [15]. However, cost and timely access are still important issues that remain today. Most pharmacists in all three neighborhoods gave correct time of effectiveness. Cost of EC and the number of extended hours differed between neighborhoods. Despite being less expensive in the low-income neighborhoods, cost could still be a barrier to purchase for many individuals. Males (and females) in lower-SES neighborhoods also may have less access to EC because fewer pharmacies have extended hours on Saturday and Sunday when unprotected intercourse is most likely to occur. There are several limitations to this study. First, this is a cross-sectional study and did not determine whether those pharmacies that did not have EC in stock, ever stocked EC. Second, due to the lack of funds to actually buy EC at each pharmacy, we solely determined the intention to buy versus the actual purchase as the outcome. Pharmacy stocking decisions, price, store hours and misinformation are of equal importance in the new regulatory scenario with levonorgestrel EC, as well with access to future over-the-counter formulations of EC in light of controversies about the effectiveness of Levonorgestrel EC. In addition, it is important to incorporate males in the national dialogue regarding EC access now and in the future. Future research on pharmacy access to EC by males would need to be approached differently. Age is no longer a mandated restriction. Future research should determine if pharmacists refuse to dispense EC for “conscience” motives by gender. In addition, future research should explore males' knowledge and attitudes of EC and their intentions to accept advance provision of EC with condoms as well as any implications of coercion between males and females related to EC.
References [1] Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011;84:478–85. [2] Marcell AV, Waks AB, Rutkow L, McKenna R, Rompalo A, Hogan MT. What do we know about males and emergency contraception? A synthesis of the literature. Perspect Sex Reprod Health 2012;44(3):184–93. [3] Nguyen BT, Zaller N. Pharmacy provision of emergency contraception to men: a survey of pharmacist attitudes in Rhode Island. JAPhA 2010;50:17–23. [4] Nguyen BT, Zaller N. Male access to over-the-counter emergency contraception a survey of acceptability and barriers in Providence, Rhode Island. Womens Health Issues 2009;19:365–72. [5] Cohen AC, Bruno M, Grimm M, Chen A. Study of male knowledge and influence on partner emergency contraception (EC) use. Contraception 2012;85:320. [6] U.S. Food and Drug Administration. Plan B: Questions and Answers — August 24, 2006; [cited 2013 April 9, 2013]. Available from: http://www.fda.gov/Drugs/DrugSafety/ PostmarketDrugSafetyInformationforPatientsandProviders/ ucm109783.htm. [7] Legare K, Bakshi S, Keyhani S, Howell EA. Availability of over-thecounter emergency contraception in 2 disparate New York City neighborhoods. AJPH 2012;102:e45–7. [8] Bennett W, Petraitis C, D'Anella A, Marcella S. Pharmacists' knowledge and the difficulty of obtaining emergency contraception. Contraception 2003;68:261–7. [9] Glasier A, Manners R, Loudon JC, Muir A. Community pharmacists providing emergency contraception give little advice about future contraceptive use: a mystery shopper study. Contraception 2010;82:538–42. [10] Olson EC VW, Kerker B, Thorpe L, Frieden TR. Take care East Harlem. New York, NY: New York City Department of Health and Mental Hygiene; 2006 [Report No.: Contract No.: 42]. [11] Olson EC VW, Kerker B, Thorpe L, Frieden TR. Take care East Upper East. New York, NY: New York City Department of Health and Mental Hygiene; 2006 [Report No.: Contract No.: 42]. [12] Olson EC VW, Kerker B, Thorpe L, Frieden TR. Take Care Inwood and Washington Heights. New York, NY: New York City Department of Health and Mental Hygiene; 2006 [Report No.: Contract No.: 42]. [13] von Hertzen H, Piaggio G, Peregoudov A, Ding J, Chen J, Song S, et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet 2002;360:1803–10. [14] Piaggio G, Kapp N, von Hertzen H. Effect on pregnancy rates of the delay in the administration of levonorgestrel for emergency contraception: a combined analysis of four WHO trials. Contraception 2011;84:35–9. [15] Belluck P. Judge strikes down age limits on morning-after pill New York Times [Internet]. 2013 April 5 [cited 2013 Dec 23]; Health: [2 screens]. Available from: http://www.nytimes.com/2013/04/06/health/judge-ordersfda-to-make-morning-after-pill-available-over-the-counter-for-all-ages. html?_r=0.
Original research article
Male access to emergency contraception in pharmacies: a mystery shopper survey☆,☆☆ David L. Bell a, b,⁎, Elvis J. Camacho a , Andrew B. Velasquez a, b a
Columbia University Medical Center, New York, NY, USA b NewYork-Presbyterian Hospital Received 28 January 2014; revised 16 June 2014; accepted 18 June 2014
Abstract Background: Pharmacy access to emergency contraception (EC) could involve men in pregnancy prevention. The objectives were to assess the availability and cost of EC. Study Design: Male mystery shoppers visited 158 pharmacies in three neighborhoods in New York City. They asked for EC and its cost and noted weekend hours. Results: Twenty-two (73.3%) of 30 pharmacies created barriers to get EC. The cost of EC was higher in the higher-socioeconomic status (SES) neighborhood (pb.001), and the higher-SES neighborhood pharmacies had a greater number of weekend hours (pb.001). Conclusions: Overall, males had a 20% probability of not being able to access EC. The national dialogue should include males. © 2014 Elsevier Inc. All rights reserved. Keywords: Adolescent; Contraceptives; Drug costs; Males; Pharmacies; Pharmacists
1. Introduction Most recent national data suggest that nearly half of pregnancies in the US were unintended [1]. Emergency contraception (EC) provides an important alternative if unprotected sex occurs. Historically, research has focused on women's access to EC. Few studies have addressed males and EC to support timely use by their female partner [2–5]. The Food and Drug Administration has supported over-thecounter access for males to purchase EC, with the same age restrictions as for females, since the initial ruling in 2006[6]. However, actual over-the-counter access is impacted by pharmacist's knowledge, dispensing behaviors, pharmacy hours and out-of-pocket costs [7–9]. This study extends the literature by employing males as “mystery shoppers” seeking EC for their female partner. The
☆
Financial disclosures: None. Contributors: Ben Mather, summer intern, supported pharmacy visits. ⁎ Corresponding author at: The Young Men's Clinic, CCHE, 60 Haven, B3, New York, NY 10032, USA. Tel.: + 1 646 382 3913; fax: + 1 212 304 5209. E-mail address: [email protected] (D.L. Bell). ☆☆
http://dx.doi.org/10.1016/j.contraception.2014.06.032 0010-7824/© 2014 Elsevier Inc. All rights reserved.
objectives of this study were to assess availability of EC, its cost and the weekend business hours of pharmacies in three neighborhoods in New York City.
2. Materials and methods Pharmacies from three New York City neighborhoods — Washington Heights, East Harlem and the Upper East Side were chosen. These neighborhoods differ in racial and ethnic makeup, socioeconomic status (SES) and teenage and young adult pregnancy rates [10–12]. The final pharmacy sample was 158: 87 from Washington Heights, 38 from East Harlem and 33 from the Upper East Side (see Fig. 1). In July 2012, three male research assistants aged 19, 25 and 28 years were matched with a neighborhood based on the racial and ethnic majority of the neighborhood. Each research assistant asked the pharmacist or pharmacy technician to purchase levonorgestrel EC, specifically “Plan B" or the “morning after pill,” for their female partners because the condom broke. The research assistants then asked about the variables (see below) related to using EC.
414
D.L. Bell et al. / Contraception 90 (2014) 413–415 Pharmacies Listed=188 Out of Business/ Not Pharmacies/ Duplicates= 37
Pharmacies Listed & Visited: 151
Pharmacies Added in the Field=7
Pharmacies Visited=158
Washington Heights=87
Available=69
Upper East Side=33
Unavailable=18
East Harlem=38
Available=29
Available=29
Unavailable=9
Unavailable=4
Fig. 1. Pharmacy Sample.
The Columbia University Institutional Review Board approved this research. 2.1. Variables 2.1.1. Availability Levonorgestrel EC was considered “available” if two criteria were met: (1) levonorgestrel EC was “in stock,” and (2) the pharmacist would sell it to the male research assistant at that moment. Conversely, the existence of any barriers to immediate purchase of EC was categorized as “not available.” 2.1.2. Effective time For the effective time of levonorgestrel EC, we dichotomized the responses into two groups: correct and incorrect answers. Correct answers for the efficacy were noted as either 72 hours or 5 days [13,14]. All other responses were categorized as incorrect answers. 2.1.3. Cost The cost was noted in dollars and cents. 2.1.4. Extended hours The extended hour variable was the total number of hours from Saturday 5 p.m. to Monday 9 a.m. that each pharmacy was open. The business hours of the pharmacy were recorded from the available signage.
significance at a pb.05 level. We also used a one-way analysis of variance (ANOVA) for the continuous variables (cost of EC and extended hours) to determine if there was any statistical significance at a pb.05 level. The one-way ANOVA found both variables to be significantly different; therefore, a Tukey post hoc test was used to identify which of the neighborhoods were significantly different to each other.
3. Results Of the 158 pharmacies, 128 (81%) would give EC to the male research assistants, i.e., it was available. (See Table 1 for full account of results.) Of the 30 pharmacies in which males could not access EC, i.e., not available, the majority (n= 22; 73.3%) required the presence of a female or her identification card at the time of purchase and 8 (26.7%) reported not having it in stock. Overall, most pharmacists and/or pharmacy technicians gave the correct time of effectiveness for EC. A few pharmacists gave a range of misinformation regarding the effective timing of EC: 24, 36 and 48 hours. Of note, one pharmacist stated that EC was an abortifacient, and one stated that it was associated with birth defects.
2.2. Analysis
4. Discussion
SPSS was used for data analysis. We used the chi-square test analysis for the categorical variables (availability and efficacy answers) to determine if there was any statistical
Overall, 80% of pharmacies across three different neighborhoods in NYC would make EC available to young men. Although this represents the majority of pharmacies, a
D.L. Bell et al. / Contraception 90 (2014) 413–415
415
Table 1 Availability, correct information on timing, cost and number of extended hours in three NYC neighborhoods
a
Availability , n (%) Correct time a, n (%) Cost b, mean (SD) Extended hours b, mean (SD)
Upper East Side (n=33)
Washington Heights (n=87)
East Harlem (n=38)
p-Value
30 (91) 31 (93.9) $50.58 ($5.59) c 11.88 (9.91) c
69 (79.3) 74 (85) $45.72 ($4.43)* 2.82 (3.79)*
29 (76.3) 34 (89.5) $47.66 ($3.78)* 3.74 (4.20)*
p=.527 p=.389 pb.001/pb.021 pb.001/pb.001
⁎ Indicates statistical significance. a Chi-square. b ANOVA. c Upper East Side was the referent group.
young man has a 1 in 5 chance of not having EC available to them. Of note, the number of pharmacies that did not have EC in stock is consistent with previous studies in NYC and may not reflect a male specific issue [7]. However, it is unknown whether they did not ever stock EC; they were temporarily out of it; or the pharmacist covertly refused to give EC to the male (or females) for “conscience” motives. However, 73% of pharmacies that limited access to EC by requiring the presence of a female or her ID may have reflected an attempt to comply with the federally mandated age restriction. This issue may be a moot point at present. Since the data were collected, EC is available over-thecounter without an age restriction [15]. However, cost and timely access are still important issues that remain today. Most pharmacists in all three neighborhoods gave correct time of effectiveness. Cost of EC and the number of extended hours differed between neighborhoods. Despite being less expensive in the low-income neighborhoods, cost could still be a barrier to purchase for many individuals. Males (and females) in lower-SES neighborhoods also may have less access to EC because fewer pharmacies have extended hours on Saturday and Sunday when unprotected intercourse is most likely to occur. There are several limitations to this study. First, this is a cross-sectional study and did not determine whether those pharmacies that did not have EC in stock, ever stocked EC. Second, due to the lack of funds to actually buy EC at each pharmacy, we solely determined the intention to buy versus the actual purchase as the outcome. Pharmacy stocking decisions, price, store hours and misinformation are of equal importance in the new regulatory scenario with levonorgestrel EC, as well with access to future over-the-counter formulations of EC in light of controversies about the effectiveness of Levonorgestrel EC. In addition, it is important to incorporate males in the national dialogue regarding EC access now and in the future. Future research on pharmacy access to EC by males would need to be approached differently. Age is no longer a mandated restriction. Future research should determine if pharmacists refuse to dispense EC for “conscience” motives by gender. In addition, future research should explore males' knowledge and attitudes of EC and their intentions to accept advance provision of EC with condoms as well as any implications of coercion between males and females related to EC.
References [1] Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011;84:478–85. [2] Marcell AV, Waks AB, Rutkow L, McKenna R, Rompalo A, Hogan MT. What do we know about males and emergency contraception? A synthesis of the literature. Perspect Sex Reprod Health 2012;44(3):184–93. [3] Nguyen BT, Zaller N. Pharmacy provision of emergency contraception to men: a survey of pharmacist attitudes in Rhode Island. JAPhA 2010;50:17–23. [4] Nguyen BT, Zaller N. Male access to over-the-counter emergency contraception a survey of acceptability and barriers in Providence, Rhode Island. Womens Health Issues 2009;19:365–72. [5] Cohen AC, Bruno M, Grimm M, Chen A. Study of male knowledge and influence on partner emergency contraception (EC) use. Contraception 2012;85:320. [6] U.S. Food and Drug Administration. Plan B: Questions and Answers — August 24, 2006; [cited 2013 April 9, 2013]. Available from: http://www.fda.gov/Drugs/DrugSafety/ PostmarketDrugSafetyInformationforPatientsandProviders/ ucm109783.htm. [7] Legare K, Bakshi S, Keyhani S, Howell EA. Availability of over-thecounter emergency contraception in 2 disparate New York City neighborhoods. AJPH 2012;102:e45–7. [8] Bennett W, Petraitis C, D'Anella A, Marcella S. Pharmacists' knowledge and the difficulty of obtaining emergency contraception. Contraception 2003;68:261–7. [9] Glasier A, Manners R, Loudon JC, Muir A. Community pharmacists providing emergency contraception give little advice about future contraceptive use: a mystery shopper study. Contraception 2010;82:538–42. [10] Olson EC VW, Kerker B, Thorpe L, Frieden TR. Take care East Harlem. New York, NY: New York City Department of Health and Mental Hygiene; 2006 [Report No.: Contract No.: 42]. [11] Olson EC VW, Kerker B, Thorpe L, Frieden TR. Take care East Upper East. New York, NY: New York City Department of Health and Mental Hygiene; 2006 [Report No.: Contract No.: 42]. [12] Olson EC VW, Kerker B, Thorpe L, Frieden TR. Take Care Inwood and Washington Heights. New York, NY: New York City Department of Health and Mental Hygiene; 2006 [Report No.: Contract No.: 42]. [13] von Hertzen H, Piaggio G, Peregoudov A, Ding J, Chen J, Song S, et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet 2002;360:1803–10. [14] Piaggio G, Kapp N, von Hertzen H. Effect on pregnancy rates of the delay in the administration of levonorgestrel for emergency contraception: a combined analysis of four WHO trials. Contraception 2011;84:35–9. [15] Belluck P. Judge strikes down age limits on morning-after pill New York Times [Internet]. 2013 April 5 [cited 2013 Dec 23]; Health: [2 screens]. Available from: http://www.nytimes.com/2013/04/06/health/judge-ordersfda-to-make-morning-after-pill-available-over-the-counter-for-all-ages. html?_r=0.