- Email: [email protected]
Beyond Plan B: A Qualitative Study of Canadian Pharmacists' Emergency Contraception Counselling Practices
WOMEN’S HEALTH
Beyond Plan B: A Qualitative Study of Canadian Pharmacists’ Emergency Contraception Counselling Practices Karen Wong, MD;1 Susan Hum, MSc;2 Lisa McCarthy, PharmD;2,3,4 Sheila Dunn, MD2,4,5 1
Faculty of Medicine, University of Toronto, Toronto, ON
2
Women’s College Research Institute, Women’s College Hospital, Toronto, ON
3
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
4
Department of Family and Community Medicine, University of Toronto, Toronto, ON
5
Dalla Lana School of Public Health, University of Toronto, Toronto, ON
Abstract Objective: Pharmacists are often the front-line health care providers for women seeking emergency contraception (EC). This study explored Ontario pharmacists’ EC counselling practices and their perceived barriers to recommending the most effective EC method, the copper IUD (Cu-IUD). Methods: This qualitative study used one-on-one, semistructured interviews with 20 pharmacists working in pharmacies located within a 1-km radius of a large sexual health clinic that offered postcoital IUDs in downtown Toronto. Results: All pharmacists provided counselling about levonorgestrel (LNG-EC), and all considered it important. Nevertheless, they rarely discussed the Cu-IUD, even in circumstances where LNG-EC could be less effective, such as delayed presentation or for women with BMI >25 kg/m2. Some pharmacists felt conflicted in their dual roles as health care and customer service provider when counselling about and selling EC, and many felt uncomfortable discussing body weight. Pharmacists were not well informed about the Cu-IUD. They identified many pharmacist-specific barriers to counselling about the Cu-IUD for EC, as well as health systems issues around Cu-IUD provision and insertion. Conclusion: Ontario pharmacists embraced their role in EC counselling, yet their discussions rarely included the most effective Cu-IUD option. Educating and training pharmacists about the Cu-IUD and establishing referral pathways for IUD insertion could expand their counselling about this EC option.
Key Words: Emergency contraception, copper intrauterine device, pharmacists, counselling Corresponding Author: Dr. Sheila Dunn, Women’s College Research Institute, Women’s College Hospital, Toronto, ON. [email protected] Competing interests: See Acknowledgements. Received on February 26, 2017 Accepted on April 29, 2017
Copyright ª 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2017;-(-):1e7 https://doi.org/10.1016/j.jogc.2017.04.042
INTRODUCTION
I
n many countries, pharmacists are available to provide patient education and counselling without an appointment. This accessibility is particularly important for timesensitive issues, such as emergency contraception. Currently, there are three approved EC options available in Canada: the 150-mg levonorgestrel pill; the 30-mg ulipristal acetate prescription pill; and the copper intrauterine device, which is the most effective method, with a pregnancy rate of <0.1%.1,2 LNG-EC has been available from pharmacist-supervised areas (“behind-the-counter”) without a prescription since 2001 in Quebec (and 2005 in other provinces) and for self-selection (“over-the-counter”) in most provinces since 2008. At the time of this study, UPA was not available in Canada. Research has raised questions about LNG-EC’s effectiveness for women with a BMI >25 kg/m2.1,3,4 In Canada, the product monograph was changed,5 consistent with a 2014 Health Canada advisory alerting health care providers that LNG-EC may be less effective in women weighing over 75 kg (and BMI >30 kg/m2).6 However, this advisory is contentious, and according to the US Food and Drug Administration and other organizations, the evidence is inconclusive.7e9 -
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Because pharmacists are often the front-line health care providers for women seeking advice about EC, this study sought to explore their attitudes towards and current practices regarding LNG-EC counselling. We also examined their perceived barriers to counselling about the Cu-IUD for EC.
Table 1. Interview guide Interview topic Store details
What are the store hours? How many scripts do you do per day? Where is emergency contraception stocked?
Pharmacist demographics
When were you licensed to practice pharmacy in Ontario? Where did you get your pharmacy degree?
LNG-EC
How often do you counsel women who purchase these products? What do you discuss? Are you aware of the Health Canada warning? Have you ever discussed the issue of weight and LNG-EC with a patient?
Cu-IUD
Do you carry the Cu-IUD? What is your experience with it for EC? Would you ever recommend it for EC? Under what circumstances? What are the challenges to discussing Cu-IUD as EC? Where would you refer a patient to for insertion?
METHODS
We conducted semistructured, one-on-one interviews with 20 pharmacists who worked in community pharmacies in downtown Toronto. These pharmacies had extended hours and were located within a 1-km radius of three universities and a large sexual health clinic that offered postcoital IUDs. Our sampling strategy focused on pharmacists practicing in these locations because we believed that their proximity to the sexual health clinic and universities might provide them with more EC counselling opportunities than their peers working in outlying areas. Eligible participants were Ontario-licensed pharmacists who worked within the recruitment area. We used multiple recruitment strategies: contacting pharmacy managers or owners; directly approaching pharmacists in stores; and a snowball sampling technique for additional participants. Sampling continued until thematic saturation was achieved. We developed a 13-question interview guide based on an earlier survey that examined pharmacists’ perceived barriers to providing LNG-EC (Table 1).10 The interview guide was pilot tested with two pharmacists employed outside the recruitment area and was revised to improve comprehension and flow. The study was approved by the Women’s College Hospital Research Ethics Board (#2014-0111-E). K.W., an Ontario-registered pharmacist who attended medical school at the time of this study, conducted all the interviews either in person or by telephone between March and August 2015. Interviews lasted approximately 20 minutes. They were recorded and transcribed verbatim when participants consented to audio recording; otherwise, field notes were taken during and after the interview. Data Analysis
K.W. and S.D. reviewed the data after 10 interviews by using a modified constant comparative approach and modified the
ABBREVIATIONS Cu-IUD
copper IUD
EC
emergency contraception
LNG-EC levonorgestrel pill UPA
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ulipristal acetate
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Examples of questions
interview guide to explore emerging themes. Once all interviews were completed, three researchers (K.W., S.D., S.H.) independently conducted an inductive content analysis of the data through multiple readings of the notes and transcripts.11 Themes were identified and were then compared and discussed in multiple team meetings with all authors. Descriptive statistics were calculated using Microsoft Excel (Microsoft Corporation, Redmond, WA). RESULTS
We conducted 20 interviews, with 11 female (55%) and nine male (45%) pharmacists. Their mean (±SD) age and years of clinical experience were 30.7 ± 8.5 (minimum 23, maximum 59 years) and 7.6 ± 8.9 years (minimum 1, maximum 23 years), respectively. All but four pharmacists were trained at the University of Toronto. They worked in pharmacies with mean weekly store hours of 88.5 ± 27.8 (minimum 40, maximum 168 hours). Table 2 describes the pharmacists’ demographics, the pharmacies’ characteristics, and the EC products they carried. Most pharmacies stocked LNG-EC in the pharmacistsupervised area (85%), and the brand product, Plan B (94%), was stocked twice as often as generics (47%). In 70% of pharmacies, generic LNG-EC was available from “self-selection” shelves. Current LNG-EC Counselling Practices
Our pharmacists all strongly believed that EC counselling was important, and they liked LNG-EC in the pharmacist-
Beyond Plan B: A Qualitative Study of Canadian Pharmacists' Emergency Contraception Counselling Practices
Table 2. Pharmacists’ demographics and pharmacy characteristics Age group (years)
Training location
Years of experience
Weekly store hours
Product stocked in pharmacist-supervised area
Product available for self-selection
M
<25
Toronto
<5
86
Generic, Plan B
Generic
M
25e34
Toronto
<5
40
Plan B
None
M
25e34
Toronto
<5
47.5
None
Plan B
F
25e34
Toronto
<5
60
None
Plan B
M
25e34
Toronto
<5
78
Generic, Plan B
None
F
25e34
Toronto
<5
81
Plan B
Plan B
F
25e34
IPG
<5
81
Plan B
Plan B
F
25e34
Toronto
<5
84.5
Generic, Plan B
Generic
M
25e34
Toronto
<5
98
Generic, Plan B
Generic
F
25e34
Toronto
<5
109
Plan B
None
M
25e34
Toronto
<5
112
Plan B
None
M
25e34
Toronto
<5
112
Plan B
None
M
25e34
IPG
<5
168
Not specified
Not specified
M
25e34
Toronto
5e9
85
Plan B
Plan B
F
25e34
IPG
5e9
98
Generic, Plan B
Generic
F
25e34
Toronto
10e19
112
Generic
Generic
F
35e44
IPG
5e9
83.5
Plan B
Plan B
F
35e44
Toronto
10e19
92
Generic, Plan B
Generic
F
35e44
Toronto
20e29
57.5
Plan B
Generic
F
55e64
Toronto
30
84.5
Generic, Plan B
Generic
Sex
M: male; F: female; IPG: international pharmacy graduate, including India, Iran, Japan, and United Kingdom in this study.
supervised areas. “I think Schedule 2 [behind-the-counter] makes sense. I think there is some importance to us being able to educate and counsel. I mean a lot of peopledif it’s Schedule 3 [self-selection]dpeople may take it and it may not be effective because they’re not taking it correctly at the appropriate time” [Participant 5]. Many pharmacists described having quick conversations with patients: “[A] brief counsel, I mean I tend to just do it with everyone. Even if they say, oh I’ve taken it” [Participant 17]. They commonly asked whether LNG-EC had been used previously, and the time frame since unprotected intercourse; then they described how to take it properly and the possible side effects. The extent of counselling was driven by patients’ queries. “The degree of information I provide is usually dependent on how much they want to know and whether or not they have any questions for me” [Participant 20]. One pharmacist reported that “Sometimes I’ve counselled someone a little too often, and then I want to talk to them about another form of birth control” [Participant 2]. Oral contraceptives were often recommended, or repeat EC users were referred to a sexual health clinic.
Many pharmacists did not believe that patient counselling created a barrier to EC access. However, some pharmacists felt conflicted in their dual roles as a health care professional and a customer service provider. They felt pressured by patients to provide faster service, rather than detailed counselling. “So a lot of times, it’s get in and get out for them. It’s less like, I want to talk to you about it” [Participant 8]. Most pharmacists were comfortable and believed that patients also felt comfortable in discussing EC. However, a few pharmacists acknowledged that some women might feel uncomfortable under two situations. “They’re usually receptive to talking about it, but I don’t know if they’d be receptive to a male pharmacist” [Participant 2]. Another pharmacist noted, “It’s tough because of the privacy issues in community pharmacies . people will start to get uncomfortable if other patients are waiting for their prescriptions to be filled” [Participant 12]. Our pharmacists rarely discussed the Cu-IUD, except “I’ve encountered several cases where people who have passed the 72-hour window for Plan B, and I mentioned one option would be using the Cu-IUD” [Participant 4].
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However, this occurrence was rare because pharmacists reported that most patients asked for and purchased LNGEC within 24 hours after unprotected intercourse. Whether women exceeded the 72-hour window or the weight threshold for LNG-EC effectiveness, most pharmacists still recommended it because “It’s better than nothing” [Participant 6]. These patients were then advised to follow up with a physician for a possible pregnancy. Discussing LNG-EC and Body Weight
Most of our pharmacists were aware of Health Canada’s weight advisory, but many had yet to counsel overweight women requesting LNG-EC. “I’ve never encountered that situation where that judgment call was required. Although, young women who’ve asked have been very noticeably under the weight category” [Participant 1]. Two pharmacists had each counselled one overweight woman about the Cu-IUD, but neither woman was interested. Pharmacists described weight as “a difficult subject to talk about” [Participant 4]. They struggled with, “Do you ask them? Because some customers might take weight as a touchy topic they don’t want to discuss” [Participant 16]. Pharmacists did not want to ask directly about weight, and judging a person’s weight by appearance was difficult. To overcome this dilemma, two pharmacists described distributing a copy of Health Canada’s weight advisory to patients who appeared overweight, and another incorporated a scripted phrase into his counselling. Barriers to Counselling About the Cu-IUD for EC
Barriers to pharmacists’ counselling on the Cu-IUD for EC included limited knowledge and misperceptions about IUDs, as well as health systems issues around IUD provision and insertion. A major factor influencing both pharmacists’ and patients’ consideration of the Cu-IUD was the widespread brand recognition of Plan B. “People come a lot asking for Plan B. They’re not asking for ‘emergency contraception’. They’ve had years of marketing and people trust it.” [Participant 6]. So much so, that pharmacists reported that many women refused a generic LNG-EC when it was offered to them. Contrary to Plan B, patients were largely unaware of the Cu-IUD for either EC or regular contraception. “No one comes in to ask for the copper IUD. The women that I talk to, they don’t even know copper IUDs exist” [Participant 4]. Because patients did not ask about Cu-IUDs, one pharmacist admitted, “I’m not the most [informed] . you
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don’t see it, you don’t really know much about it. It’s not something I talk about on a regular basis” [Participant 6]. Although most pharmacists were aware of the Cu-IUD for EC from their pharmacy education, most did not know the following: it is a nonprescription device; it comes in varying lengths and widths, copper content, and price; and specialized training is required to insert it. Many pharmacists had assumed incorrectly that all family doctors or general practitioners in walk-in clinics are trained to insert IUDs. Many pharmacists also had negative views about Cu-IUDs. Some considered them too risky to recommend. “Just comparing the copper IUD with the oral EC, it seems like there are a lot more side effects to it, and it just has to do with how it’s inserted and infections can happen, perforations can happen” [Participant 19]. Another pharmacist had additional concerns: “In the past I’ve seen women who have got scarring, and then weren’t able to have kids afterwards. I’ve seen a couple of accidental pregnancies with it” [Participant 2]. Another barrier to recommending the Cu-IUD was cost. Some pharmacists cited the expense of one brand of CuIUD ($216) compared with LNG-EC ($40); and many were unaware of lower-cost Cu-IUDs ($75). Because of the perceived higher cost and lack of patient demand, many pharmacies did not keep Cu-IUDs in-stock. When needed, it would be ordered for next day delivery. “It’s a bit of a Catch 22dif they don’t want it, and they don’t feel comfortable with it, you’re not going to stock it. And if you don’t stock it, you’re never going to recommend it” [Participant 6]. Logistically, another reason why “it’s a little harder to do emergency IUD is because you still have to find someone to do the insertion” [Participant 16]. Only a few of our pharmacists knew of trained IUD providers nearby, and although some were aware of local sexual health clinics, gynecologists, or family doctors who had previously prescribed IUDs, most pharmacists did not know where women could get an IUD inserted. Overall, pharmacists felt that the Cu-IUD for EC was inconvenient, “You know, taking two tablets is infinitely more convenient than going to the doctor and having someone insert it” [Participant 3]. It was also logistically challenging for such a time-sensitive issue. To overcome potential time delays, one pharmacist suggested that a collaborative care approach from the pharmacy to an IUD provider would be helpful. “I think providing the
Beyond Plan B: A Qualitative Study of Canadian Pharmacists' Emergency Contraception Counselling Practices
information around the patient to make the decision is good. And then maybe if there was an easier way or a quicker way for them to get the attention from a physician in order to get this, then that would be a great way” [Participant 17]. DISCUSSION
Our pharmacists felt strongly about the importance of EC counselling, and they supported having LNG-EC stocked behind-the-counter, although it is regulated for over-thecounter purchase.12 They did not believe that counselling imposed an unnecessary barrier to EC access, as suggested in one study.13 However, our pharmacists’ EC counselling did not typically include the more effective Cu-IUD, a pattern that is consistent among other health care professionals. The Cu-IUD had never been recommended for EC by 85% of physicians and advanced practice clinicians working in a California family planning clinic,14 and only 36% of reproductive health specialists working in academic centres in the United States provided emergency Cu-IUD in their practices.15 One barrier to comprehensive EC counselling by our pharmacists was their limited knowledge or experience with the Cu-IUD, and they wanted more information about different brands and costs of this device, practice algorithms, and names of area-trained IUD providers. A Canadian study showed that when pharmacists were more educated about Cu-IUDs, they were more likely to recommend them.16 A UK study also demonstrated that educating community pharmacists increased referral and uptake of the Cu-IUD for EC.17 Similarly, women may consider the Cu-IUD if they are better informed. Survey studies have shown that roughly 10% of women who sought EC were interested in the CuIUD when it was proposed.18,19 Furthermore, two studies demonstrated that when women seeking EC received structured counselling about the Cu-IUD as part of their EC care or were offered intrauterine contraceptive implants (with EC pills), roughly 10% chose a device, especially when same-day insertion was offered.20,21 Although the percentage of women who chose the Cu-IUD or another IUD in these two studies was small, all EC seekers should be offered this option.20 It could improve the uptake of the Cu-IUD for EC and provide women with reliable, ongoing contraception, especially repeat LNG-EC users. Current guidelines recommend that health care providers discuss a plan for ongoing contraception with women who
use EC pills, including “quick start” of hormonal contraception after LNG EC.1 Notably, Quebec Bill 41 authorizes pharmacists to dispense hormonal contraception after EC.22 However, only a few of our pharmacists reported discussing regular contraceptive options or referred frequent LNG-EC users to a sexual health clinic. A Scottish pilot study demonstrated that the uptake of effective contraception was significantly increased when pharmacists supplied women with 1 month of progestogen-only pills or offered rapid access to a sexual health clinic to discuss contraceptive options after purchasing EC.23 There were many systemic barriers to recommending the Cu-IUD for EC. Pharmacies seldom had Cu-IUDs in stock, and the brand most often prescribed or ordered was expensive ($216). With no established networks or referral pathways for emergency IUD insertion, most pharmacists would have difficulty referring a woman for this service. In other settings, lack of trained IUD providers and the need for two clinic visits for IUD insertion were significant barriers.14,23,24 Same-day IUD insertion protocols are feasible and significantly increase the uptake of the CuIUD for EC.20,21 In nine geographically diverse Planned Parenthood clinics, 1%e16% of women chose the CuIUD, and 77% of insertions for EC were performed the same day.20 Furthermore, one study showed that when a collaborative care pathway from pharmacists who provided Cu-IUD counselling was coupled with a rapid access referral for an IUD fitting, acceptance of the emergency Cu-IUD increased three-fold.17 Our pharmacists were largely aware of Health Canada’s weight advisory. However, it is inconceivable that they rarely encountered the need to counsel women about weight and LNG-EC effectiveness, given that almost half (46.2%) of adult Canadian women are overweight (BMI >25 kg/m2) or obese (BMI >30 kg/m2).25 Nonetheless, our pharmacists acknowledged feeling uncomfortable discussing weight, as previously described among other community pharmacists involved in weight management.26 Pharmacists may feel more comfortable introducing the topic of weight in the context of diabetes, hyperlipidemia, and hypertension,26 because patients expect it. However, women are not expecting to discuss their weight when they are purchasing EC, and the physical layout of some pharmacies is not conducive to private conversations about potentially sensitive topics, such as weight and sex. Pharmacists may require additional training and support to confidently discuss body weight to ensure they provide comprehensive care to all women seeking EC.27 In light of
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the evolving evidence about the effect of weight on efficacy of hormonal contraception, although pharmacists should not discourage overweight women from using LNG-EC, they could recommend the Cu-IUD or UPA to women with a BMI >30 or >35 kg/m2, respectively.1 Our study’s strengths included the semistructured interview format, which allowed participants to describe indepth their dispensing practices and their attitudes towards LNG-EC and Cu-IUD counselling. A peer interviewer provided an understanding, nonjudgmental environment, and facilitated participant recruitment. Conversely, some participants may have withheld information for fear of being judged by “one of their own.” One limitation was that UPA was not discussed because it was not available in Canada during the study period. Another weakness was the lack of discussion about the pharmacist’s role in counselling about “quick start” of regular contraception following EC, in light of some pharmacists’ encounters with repeat LNG-EC users. Finally, this study took place in a large urban centre close to a sexual health clinic and three universities, and our results should be interpreted through this lens. Future work could explore how the availability of UPA has affected pharmacists’ LNG-EC and Cu-IUD counselling and dispensing practices, especially among pharmacists working in rural or remote settings. CONCLUSION
This group of urban Ontario pharmacists embraced their role in EC counselling, yet this rarely included a discussion of the more effective Cu-IUD option, even for women with delayed presentation to the pharmacy. Many pharmacists were also hesitant to discuss body weight, given the continued controversy about the impact of weight on the effectiveness of LNG-EC. Pharmacists wanted more education about alternative EC methods and collaborative care pathways to expedite timely Cu-IUD insertion. ACKNOWLEDGEMENTS
The authors would like to thank all the pharmacists who participated in the study. Dr. Dunn receives salary support from the Department of Family and Community Medicine, University of Toronto, and the Women’s College Research Institute.
REFERENCES 1. Black A, Guilbert E. Society of Obstetricians and Gynecologists of Canada clinical practice guidelines no. 329: Canadian contraception
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consensuseemergency contraception. J Obstet Gynaecol Can 2015;37:S1e28. 2. Cleland K, Zhu H, Goldstuck N, et al. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod 2012;27:1994e2000. 3. Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet 2010;375:555e62. 4. Glasier A, Cameron ST, Blithe D, et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonogestrel. Contraception 2011;84:363e7. 5. Plan B® Product Monograph Version 9.0. Health Canada Drug Product Database. Paladin Labs Inc. October 20, 2016. Available at: https://healthproducts.canada.ca/dpd-bdpp/index-eng.jsp. Accessed November 28, 2016. 6. Healthy Canadians. Emergency Contraceptive Pills to Carry Warnings for Reduced Effectiveness in Women Over a Certain Body Weight. March 26, 2014. Available at: http://healthycanadians.gc.ca/recall-alert-rappel-avis/ hc-sc/2014/38701a-eng.php. Accessed August 2, 2016. 7. US Food and Drug Administration. Plan B® and Plan B® One Step Tablets Information. May 24, 2016. Available at: http://www.fda.gov/ Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsand Providers/ucm109775.htm. Accessed July 2, 2016. 8. European Medicines Agency. Levonorgestrel and Ulipristal Remain Suitable Emergency Contraception for All Women, Regardless of Bodyweight. July 24, 2014. Available at: http://www.ema.europa.eu/ema/index.jsp? curl¼pages/news_and_events/news/2014/07/news_detail_002145. jsp&mid¼WC0b01ac058004d5c1. Accessed July 2, 2016. 9. Edelman AB, Cherala G, Blue SW, et al. Impact of obesity on the pharmacokinetics of levonorgestrel-based emergency contraception: single and double dosing. Contraception 2016;94:52e7. 10. Whelan AM, Langille DB, Hurst E. Nova Scotia pharmacists’ knowledge of, experiences with and perception of factors interfering with their ability to provide emergency contraceptive pill consultations. Int J Pharm Pract 2013;23:314e21. 11. Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs 2008;62:107e15. 12. National Association of Pharmacy Regulatory Authorities. National Statistics. 2016. Available at: http://napra.ca/pages/Practice_Resources/ National_Statistics.aspx. Accessed August 14, 2016. 13. Erdman JN, Cook RJ. Protecting fairness in women’s health: the case of emergency contraception. In: Flood C, editor. Just Medicare: what’s in, what’s out, how we decide:. Toronto: University of Toronto Press; 2006. p. 137e67. 14. Harper CC, Speidel JJ, Drey EA, et al. Copper intrauterine device for emergency contraception: clinical practice among contraceptive providers. Obstet Gynecol 2012;119:220e6. 15. Batur P, Cleland K, McNamara M, et al. Emergency contraception: a multispecialty survey of clinician knowledge and practice. Contraception 2016;93:145e52. 16. Tam N, Soon JA, Trouton K, et al. Barriers to providing copper IUDs for emergency contraception: a qualitative study of community pharmacists. Poster presented at: Family Medicine Forum of the College of Family Physicians of Canada. November 13e15 2014; Quebec City, QC. 17. Clement KM, Mansour DJ. Improving uptake of the copper intrauterine device for emergency contraception by educating pharmacists in the community. J Fam Plann Reprod Health Care 2014;40:41e5. 18. Turok DK, Gurtcheff SE, Handley E, et al. A survey of women obtaining emergency contraception: are they interested in using the copper IUD? Contraception 2011;83:441e6. 19. Schwarz EB, Kavanaugh M, Douglas E, et al. Interest in intrauterine contraception among seekers of emergency contraception and pregnancy testing. Obstet Gynecol 2009;113:833e9.
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20. Kohn JE, Nucatola DL. EC4U: results from a pilot project integrating the copper IUC into emergency contraceptive care. Contraception 2016;94:48e51.
24. Bergin A, Tristan S, Terplan M, et al. A missed opportunity for care: twovisit IUD insertion protocols inhibit placement. Contraception 2012;86:694e7.
21. Schwarz EB, Papic M, Parisi SM, et al. Routine counselling about intrauterine contraception for women seeking emergency contraception. Contraception 2014;9:66e71.
25. Statistics Canada. Body Mass Index, Overweight or Obese, Self-Reported, Adult, by Age Group and Sex (Percent). Available at: http://www.statcan. gc.ca/tables-tableaux/sum-som/l01/cst01/health81a-eng.htm. Accessed November 27, 2016.
22. Pharmacy Act: Regulation Respecting the Prescription of a Medication by a Pharmacist. April 1, 2017. Available at: http://legisquebec.gouv.qc.ca/en/ ShowDoc/cr/P-10,%20r.%2018.2. Accessed April 27, 2017.
26. Gray L, Chamberlain R, Morris C. “Basically you wait for an ‘in’”: community pharmacist views on their role in weight management in New Zealand. J Prim Health Care 2016;8:365e71.
23. Michie L, Cameron ST, Glasier A, et al. Pharmacy-based interventions for initiating effective contraception following the use of emergency contraception: a pilot study. Contraception 2014;90:447e53.
27. Mold F, Forbes A. Patients’ and professionals’ experiences and perspectives of obesity in health-care settings: a synthesis of current research. Health Expect 2013;16:119e42.
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Beyond Plan B: A Qualitative Study of Canadian Pharmacists’ Emergency Contraception Counselling Practices Karen Wong, MD;1 Susan Hum, MSc;2 Lisa McCarthy, PharmD;2,3,4 Sheila Dunn, MD2,4,5 1
Faculty of Medicine, University of Toronto, Toronto, ON
2
Women’s College Research Institute, Women’s College Hospital, Toronto, ON
3
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
4
Department of Family and Community Medicine, University of Toronto, Toronto, ON
5
Dalla Lana School of Public Health, University of Toronto, Toronto, ON
Abstract Objective: Pharmacists are often the front-line health care providers for women seeking emergency contraception (EC). This study explored Ontario pharmacists’ EC counselling practices and their perceived barriers to recommending the most effective EC method, the copper IUD (Cu-IUD). Methods: This qualitative study used one-on-one, semistructured interviews with 20 pharmacists working in pharmacies located within a 1-km radius of a large sexual health clinic that offered postcoital IUDs in downtown Toronto. Results: All pharmacists provided counselling about levonorgestrel (LNG-EC), and all considered it important. Nevertheless, they rarely discussed the Cu-IUD, even in circumstances where LNG-EC could be less effective, such as delayed presentation or for women with BMI >25 kg/m2. Some pharmacists felt conflicted in their dual roles as health care and customer service provider when counselling about and selling EC, and many felt uncomfortable discussing body weight. Pharmacists were not well informed about the Cu-IUD. They identified many pharmacist-specific barriers to counselling about the Cu-IUD for EC, as well as health systems issues around Cu-IUD provision and insertion. Conclusion: Ontario pharmacists embraced their role in EC counselling, yet their discussions rarely included the most effective Cu-IUD option. Educating and training pharmacists about the Cu-IUD and establishing referral pathways for IUD insertion could expand their counselling about this EC option.
Key Words: Emergency contraception, copper intrauterine device, pharmacists, counselling Corresponding Author: Dr. Sheila Dunn, Women’s College Research Institute, Women’s College Hospital, Toronto, ON. [email protected] Competing interests: See Acknowledgements. Received on February 26, 2017 Accepted on April 29, 2017
Copyright ª 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2017;-(-):1e7 https://doi.org/10.1016/j.jogc.2017.04.042
INTRODUCTION
I
n many countries, pharmacists are available to provide patient education and counselling without an appointment. This accessibility is particularly important for timesensitive issues, such as emergency contraception. Currently, there are three approved EC options available in Canada: the 150-mg levonorgestrel pill; the 30-mg ulipristal acetate prescription pill; and the copper intrauterine device, which is the most effective method, with a pregnancy rate of <0.1%.1,2 LNG-EC has been available from pharmacist-supervised areas (“behind-the-counter”) without a prescription since 2001 in Quebec (and 2005 in other provinces) and for self-selection (“over-the-counter”) in most provinces since 2008. At the time of this study, UPA was not available in Canada. Research has raised questions about LNG-EC’s effectiveness for women with a BMI >25 kg/m2.1,3,4 In Canada, the product monograph was changed,5 consistent with a 2014 Health Canada advisory alerting health care providers that LNG-EC may be less effective in women weighing over 75 kg (and BMI >30 kg/m2).6 However, this advisory is contentious, and according to the US Food and Drug Administration and other organizations, the evidence is inconclusive.7e9 -
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Because pharmacists are often the front-line health care providers for women seeking advice about EC, this study sought to explore their attitudes towards and current practices regarding LNG-EC counselling. We also examined their perceived barriers to counselling about the Cu-IUD for EC.
Table 1. Interview guide Interview topic Store details
What are the store hours? How many scripts do you do per day? Where is emergency contraception stocked?
Pharmacist demographics
When were you licensed to practice pharmacy in Ontario? Where did you get your pharmacy degree?
LNG-EC
How often do you counsel women who purchase these products? What do you discuss? Are you aware of the Health Canada warning? Have you ever discussed the issue of weight and LNG-EC with a patient?
Cu-IUD
Do you carry the Cu-IUD? What is your experience with it for EC? Would you ever recommend it for EC? Under what circumstances? What are the challenges to discussing Cu-IUD as EC? Where would you refer a patient to for insertion?
METHODS
We conducted semistructured, one-on-one interviews with 20 pharmacists who worked in community pharmacies in downtown Toronto. These pharmacies had extended hours and were located within a 1-km radius of three universities and a large sexual health clinic that offered postcoital IUDs. Our sampling strategy focused on pharmacists practicing in these locations because we believed that their proximity to the sexual health clinic and universities might provide them with more EC counselling opportunities than their peers working in outlying areas. Eligible participants were Ontario-licensed pharmacists who worked within the recruitment area. We used multiple recruitment strategies: contacting pharmacy managers or owners; directly approaching pharmacists in stores; and a snowball sampling technique for additional participants. Sampling continued until thematic saturation was achieved. We developed a 13-question interview guide based on an earlier survey that examined pharmacists’ perceived barriers to providing LNG-EC (Table 1).10 The interview guide was pilot tested with two pharmacists employed outside the recruitment area and was revised to improve comprehension and flow. The study was approved by the Women’s College Hospital Research Ethics Board (#2014-0111-E). K.W., an Ontario-registered pharmacist who attended medical school at the time of this study, conducted all the interviews either in person or by telephone between March and August 2015. Interviews lasted approximately 20 minutes. They were recorded and transcribed verbatim when participants consented to audio recording; otherwise, field notes were taken during and after the interview. Data Analysis
K.W. and S.D. reviewed the data after 10 interviews by using a modified constant comparative approach and modified the
ABBREVIATIONS Cu-IUD
copper IUD
EC
emergency contraception
LNG-EC levonorgestrel pill UPA
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ulipristal acetate
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Examples of questions
interview guide to explore emerging themes. Once all interviews were completed, three researchers (K.W., S.D., S.H.) independently conducted an inductive content analysis of the data through multiple readings of the notes and transcripts.11 Themes were identified and were then compared and discussed in multiple team meetings with all authors. Descriptive statistics were calculated using Microsoft Excel (Microsoft Corporation, Redmond, WA). RESULTS
We conducted 20 interviews, with 11 female (55%) and nine male (45%) pharmacists. Their mean (±SD) age and years of clinical experience were 30.7 ± 8.5 (minimum 23, maximum 59 years) and 7.6 ± 8.9 years (minimum 1, maximum 23 years), respectively. All but four pharmacists were trained at the University of Toronto. They worked in pharmacies with mean weekly store hours of 88.5 ± 27.8 (minimum 40, maximum 168 hours). Table 2 describes the pharmacists’ demographics, the pharmacies’ characteristics, and the EC products they carried. Most pharmacies stocked LNG-EC in the pharmacistsupervised area (85%), and the brand product, Plan B (94%), was stocked twice as often as generics (47%). In 70% of pharmacies, generic LNG-EC was available from “self-selection” shelves. Current LNG-EC Counselling Practices
Our pharmacists all strongly believed that EC counselling was important, and they liked LNG-EC in the pharmacist-
Beyond Plan B: A Qualitative Study of Canadian Pharmacists' Emergency Contraception Counselling Practices
Table 2. Pharmacists’ demographics and pharmacy characteristics Age group (years)
Training location
Years of experience
Weekly store hours
Product stocked in pharmacist-supervised area
Product available for self-selection
M
<25
Toronto
<5
86
Generic, Plan B
Generic
M
25e34
Toronto
<5
40
Plan B
None
M
25e34
Toronto
<5
47.5
None
Plan B
F
25e34
Toronto
<5
60
None
Plan B
M
25e34
Toronto
<5
78
Generic, Plan B
None
F
25e34
Toronto
<5
81
Plan B
Plan B
F
25e34
IPG
<5
81
Plan B
Plan B
F
25e34
Toronto
<5
84.5
Generic, Plan B
Generic
M
25e34
Toronto
<5
98
Generic, Plan B
Generic
F
25e34
Toronto
<5
109
Plan B
None
M
25e34
Toronto
<5
112
Plan B
None
M
25e34
Toronto
<5
112
Plan B
None
M
25e34
IPG
<5
168
Not specified
Not specified
M
25e34
Toronto
5e9
85
Plan B
Plan B
F
25e34
IPG
5e9
98
Generic, Plan B
Generic
F
25e34
Toronto
10e19
112
Generic
Generic
F
35e44
IPG
5e9
83.5
Plan B
Plan B
F
35e44
Toronto
10e19
92
Generic, Plan B
Generic
F
35e44
Toronto
20e29
57.5
Plan B
Generic
F
55e64
Toronto
30
84.5
Generic, Plan B
Generic
Sex
M: male; F: female; IPG: international pharmacy graduate, including India, Iran, Japan, and United Kingdom in this study.
supervised areas. “I think Schedule 2 [behind-the-counter] makes sense. I think there is some importance to us being able to educate and counsel. I mean a lot of peopledif it’s Schedule 3 [self-selection]dpeople may take it and it may not be effective because they’re not taking it correctly at the appropriate time” [Participant 5]. Many pharmacists described having quick conversations with patients: “[A] brief counsel, I mean I tend to just do it with everyone. Even if they say, oh I’ve taken it” [Participant 17]. They commonly asked whether LNG-EC had been used previously, and the time frame since unprotected intercourse; then they described how to take it properly and the possible side effects. The extent of counselling was driven by patients’ queries. “The degree of information I provide is usually dependent on how much they want to know and whether or not they have any questions for me” [Participant 20]. One pharmacist reported that “Sometimes I’ve counselled someone a little too often, and then I want to talk to them about another form of birth control” [Participant 2]. Oral contraceptives were often recommended, or repeat EC users were referred to a sexual health clinic.
Many pharmacists did not believe that patient counselling created a barrier to EC access. However, some pharmacists felt conflicted in their dual roles as a health care professional and a customer service provider. They felt pressured by patients to provide faster service, rather than detailed counselling. “So a lot of times, it’s get in and get out for them. It’s less like, I want to talk to you about it” [Participant 8]. Most pharmacists were comfortable and believed that patients also felt comfortable in discussing EC. However, a few pharmacists acknowledged that some women might feel uncomfortable under two situations. “They’re usually receptive to talking about it, but I don’t know if they’d be receptive to a male pharmacist” [Participant 2]. Another pharmacist noted, “It’s tough because of the privacy issues in community pharmacies . people will start to get uncomfortable if other patients are waiting for their prescriptions to be filled” [Participant 12]. Our pharmacists rarely discussed the Cu-IUD, except “I’ve encountered several cases where people who have passed the 72-hour window for Plan B, and I mentioned one option would be using the Cu-IUD” [Participant 4].
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However, this occurrence was rare because pharmacists reported that most patients asked for and purchased LNGEC within 24 hours after unprotected intercourse. Whether women exceeded the 72-hour window or the weight threshold for LNG-EC effectiveness, most pharmacists still recommended it because “It’s better than nothing” [Participant 6]. These patients were then advised to follow up with a physician for a possible pregnancy. Discussing LNG-EC and Body Weight
Most of our pharmacists were aware of Health Canada’s weight advisory, but many had yet to counsel overweight women requesting LNG-EC. “I’ve never encountered that situation where that judgment call was required. Although, young women who’ve asked have been very noticeably under the weight category” [Participant 1]. Two pharmacists had each counselled one overweight woman about the Cu-IUD, but neither woman was interested. Pharmacists described weight as “a difficult subject to talk about” [Participant 4]. They struggled with, “Do you ask them? Because some customers might take weight as a touchy topic they don’t want to discuss” [Participant 16]. Pharmacists did not want to ask directly about weight, and judging a person’s weight by appearance was difficult. To overcome this dilemma, two pharmacists described distributing a copy of Health Canada’s weight advisory to patients who appeared overweight, and another incorporated a scripted phrase into his counselling. Barriers to Counselling About the Cu-IUD for EC
Barriers to pharmacists’ counselling on the Cu-IUD for EC included limited knowledge and misperceptions about IUDs, as well as health systems issues around IUD provision and insertion. A major factor influencing both pharmacists’ and patients’ consideration of the Cu-IUD was the widespread brand recognition of Plan B. “People come a lot asking for Plan B. They’re not asking for ‘emergency contraception’. They’ve had years of marketing and people trust it.” [Participant 6]. So much so, that pharmacists reported that many women refused a generic LNG-EC when it was offered to them. Contrary to Plan B, patients were largely unaware of the Cu-IUD for either EC or regular contraception. “No one comes in to ask for the copper IUD. The women that I talk to, they don’t even know copper IUDs exist” [Participant 4]. Because patients did not ask about Cu-IUDs, one pharmacist admitted, “I’m not the most [informed] . you
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don’t see it, you don’t really know much about it. It’s not something I talk about on a regular basis” [Participant 6]. Although most pharmacists were aware of the Cu-IUD for EC from their pharmacy education, most did not know the following: it is a nonprescription device; it comes in varying lengths and widths, copper content, and price; and specialized training is required to insert it. Many pharmacists had assumed incorrectly that all family doctors or general practitioners in walk-in clinics are trained to insert IUDs. Many pharmacists also had negative views about Cu-IUDs. Some considered them too risky to recommend. “Just comparing the copper IUD with the oral EC, it seems like there are a lot more side effects to it, and it just has to do with how it’s inserted and infections can happen, perforations can happen” [Participant 19]. Another pharmacist had additional concerns: “In the past I’ve seen women who have got scarring, and then weren’t able to have kids afterwards. I’ve seen a couple of accidental pregnancies with it” [Participant 2]. Another barrier to recommending the Cu-IUD was cost. Some pharmacists cited the expense of one brand of CuIUD ($216) compared with LNG-EC ($40); and many were unaware of lower-cost Cu-IUDs ($75). Because of the perceived higher cost and lack of patient demand, many pharmacies did not keep Cu-IUDs in-stock. When needed, it would be ordered for next day delivery. “It’s a bit of a Catch 22dif they don’t want it, and they don’t feel comfortable with it, you’re not going to stock it. And if you don’t stock it, you’re never going to recommend it” [Participant 6]. Logistically, another reason why “it’s a little harder to do emergency IUD is because you still have to find someone to do the insertion” [Participant 16]. Only a few of our pharmacists knew of trained IUD providers nearby, and although some were aware of local sexual health clinics, gynecologists, or family doctors who had previously prescribed IUDs, most pharmacists did not know where women could get an IUD inserted. Overall, pharmacists felt that the Cu-IUD for EC was inconvenient, “You know, taking two tablets is infinitely more convenient than going to the doctor and having someone insert it” [Participant 3]. It was also logistically challenging for such a time-sensitive issue. To overcome potential time delays, one pharmacist suggested that a collaborative care approach from the pharmacy to an IUD provider would be helpful. “I think providing the
Beyond Plan B: A Qualitative Study of Canadian Pharmacists' Emergency Contraception Counselling Practices
information around the patient to make the decision is good. And then maybe if there was an easier way or a quicker way for them to get the attention from a physician in order to get this, then that would be a great way” [Participant 17]. DISCUSSION
Our pharmacists felt strongly about the importance of EC counselling, and they supported having LNG-EC stocked behind-the-counter, although it is regulated for over-thecounter purchase.12 They did not believe that counselling imposed an unnecessary barrier to EC access, as suggested in one study.13 However, our pharmacists’ EC counselling did not typically include the more effective Cu-IUD, a pattern that is consistent among other health care professionals. The Cu-IUD had never been recommended for EC by 85% of physicians and advanced practice clinicians working in a California family planning clinic,14 and only 36% of reproductive health specialists working in academic centres in the United States provided emergency Cu-IUD in their practices.15 One barrier to comprehensive EC counselling by our pharmacists was their limited knowledge or experience with the Cu-IUD, and they wanted more information about different brands and costs of this device, practice algorithms, and names of area-trained IUD providers. A Canadian study showed that when pharmacists were more educated about Cu-IUDs, they were more likely to recommend them.16 A UK study also demonstrated that educating community pharmacists increased referral and uptake of the Cu-IUD for EC.17 Similarly, women may consider the Cu-IUD if they are better informed. Survey studies have shown that roughly 10% of women who sought EC were interested in the CuIUD when it was proposed.18,19 Furthermore, two studies demonstrated that when women seeking EC received structured counselling about the Cu-IUD as part of their EC care or were offered intrauterine contraceptive implants (with EC pills), roughly 10% chose a device, especially when same-day insertion was offered.20,21 Although the percentage of women who chose the Cu-IUD or another IUD in these two studies was small, all EC seekers should be offered this option.20 It could improve the uptake of the Cu-IUD for EC and provide women with reliable, ongoing contraception, especially repeat LNG-EC users. Current guidelines recommend that health care providers discuss a plan for ongoing contraception with women who
use EC pills, including “quick start” of hormonal contraception after LNG EC.1 Notably, Quebec Bill 41 authorizes pharmacists to dispense hormonal contraception after EC.22 However, only a few of our pharmacists reported discussing regular contraceptive options or referred frequent LNG-EC users to a sexual health clinic. A Scottish pilot study demonstrated that the uptake of effective contraception was significantly increased when pharmacists supplied women with 1 month of progestogen-only pills or offered rapid access to a sexual health clinic to discuss contraceptive options after purchasing EC.23 There were many systemic barriers to recommending the Cu-IUD for EC. Pharmacies seldom had Cu-IUDs in stock, and the brand most often prescribed or ordered was expensive ($216). With no established networks or referral pathways for emergency IUD insertion, most pharmacists would have difficulty referring a woman for this service. In other settings, lack of trained IUD providers and the need for two clinic visits for IUD insertion were significant barriers.14,23,24 Same-day IUD insertion protocols are feasible and significantly increase the uptake of the CuIUD for EC.20,21 In nine geographically diverse Planned Parenthood clinics, 1%e16% of women chose the CuIUD, and 77% of insertions for EC were performed the same day.20 Furthermore, one study showed that when a collaborative care pathway from pharmacists who provided Cu-IUD counselling was coupled with a rapid access referral for an IUD fitting, acceptance of the emergency Cu-IUD increased three-fold.17 Our pharmacists were largely aware of Health Canada’s weight advisory. However, it is inconceivable that they rarely encountered the need to counsel women about weight and LNG-EC effectiveness, given that almost half (46.2%) of adult Canadian women are overweight (BMI >25 kg/m2) or obese (BMI >30 kg/m2).25 Nonetheless, our pharmacists acknowledged feeling uncomfortable discussing weight, as previously described among other community pharmacists involved in weight management.26 Pharmacists may feel more comfortable introducing the topic of weight in the context of diabetes, hyperlipidemia, and hypertension,26 because patients expect it. However, women are not expecting to discuss their weight when they are purchasing EC, and the physical layout of some pharmacies is not conducive to private conversations about potentially sensitive topics, such as weight and sex. Pharmacists may require additional training and support to confidently discuss body weight to ensure they provide comprehensive care to all women seeking EC.27 In light of
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the evolving evidence about the effect of weight on efficacy of hormonal contraception, although pharmacists should not discourage overweight women from using LNG-EC, they could recommend the Cu-IUD or UPA to women with a BMI >30 or >35 kg/m2, respectively.1 Our study’s strengths included the semistructured interview format, which allowed participants to describe indepth their dispensing practices and their attitudes towards LNG-EC and Cu-IUD counselling. A peer interviewer provided an understanding, nonjudgmental environment, and facilitated participant recruitment. Conversely, some participants may have withheld information for fear of being judged by “one of their own.” One limitation was that UPA was not discussed because it was not available in Canada during the study period. Another weakness was the lack of discussion about the pharmacist’s role in counselling about “quick start” of regular contraception following EC, in light of some pharmacists’ encounters with repeat LNG-EC users. Finally, this study took place in a large urban centre close to a sexual health clinic and three universities, and our results should be interpreted through this lens. Future work could explore how the availability of UPA has affected pharmacists’ LNG-EC and Cu-IUD counselling and dispensing practices, especially among pharmacists working in rural or remote settings. CONCLUSION
This group of urban Ontario pharmacists embraced their role in EC counselling, yet this rarely included a discussion of the more effective Cu-IUD option, even for women with delayed presentation to the pharmacy. Many pharmacists were also hesitant to discuss body weight, given the continued controversy about the impact of weight on the effectiveness of LNG-EC. Pharmacists wanted more education about alternative EC methods and collaborative care pathways to expedite timely Cu-IUD insertion. ACKNOWLEDGEMENTS
The authors would like to thank all the pharmacists who participated in the study. Dr. Dunn receives salary support from the Department of Family and Community Medicine, University of Toronto, and the Women’s College Research Institute.
REFERENCES 1. Black A, Guilbert E. Society of Obstetricians and Gynecologists of Canada clinical practice guidelines no. 329: Canadian contraception
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consensuseemergency contraception. J Obstet Gynaecol Can 2015;37:S1e28. 2. Cleland K, Zhu H, Goldstuck N, et al. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod 2012;27:1994e2000. 3. Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet 2010;375:555e62. 4. Glasier A, Cameron ST, Blithe D, et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonogestrel. Contraception 2011;84:363e7. 5. Plan B® Product Monograph Version 9.0. Health Canada Drug Product Database. Paladin Labs Inc. October 20, 2016. Available at: https://healthproducts.canada.ca/dpd-bdpp/index-eng.jsp. Accessed November 28, 2016. 6. Healthy Canadians. Emergency Contraceptive Pills to Carry Warnings for Reduced Effectiveness in Women Over a Certain Body Weight. March 26, 2014. Available at: http://healthycanadians.gc.ca/recall-alert-rappel-avis/ hc-sc/2014/38701a-eng.php. Accessed August 2, 2016. 7. US Food and Drug Administration. Plan B® and Plan B® One Step Tablets Information. May 24, 2016. Available at: http://www.fda.gov/ Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsand Providers/ucm109775.htm. Accessed July 2, 2016. 8. European Medicines Agency. Levonorgestrel and Ulipristal Remain Suitable Emergency Contraception for All Women, Regardless of Bodyweight. July 24, 2014. Available at: http://www.ema.europa.eu/ema/index.jsp? curl¼pages/news_and_events/news/2014/07/news_detail_002145. jsp&mid¼WC0b01ac058004d5c1. Accessed July 2, 2016. 9. Edelman AB, Cherala G, Blue SW, et al. Impact of obesity on the pharmacokinetics of levonorgestrel-based emergency contraception: single and double dosing. Contraception 2016;94:52e7. 10. Whelan AM, Langille DB, Hurst E. Nova Scotia pharmacists’ knowledge of, experiences with and perception of factors interfering with their ability to provide emergency contraceptive pill consultations. Int J Pharm Pract 2013;23:314e21. 11. Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs 2008;62:107e15. 12. National Association of Pharmacy Regulatory Authorities. National Statistics. 2016. Available at: http://napra.ca/pages/Practice_Resources/ National_Statistics.aspx. Accessed August 14, 2016. 13. Erdman JN, Cook RJ. Protecting fairness in women’s health: the case of emergency contraception. In: Flood C, editor. Just Medicare: what’s in, what’s out, how we decide:. Toronto: University of Toronto Press; 2006. p. 137e67. 14. Harper CC, Speidel JJ, Drey EA, et al. Copper intrauterine device for emergency contraception: clinical practice among contraceptive providers. Obstet Gynecol 2012;119:220e6. 15. Batur P, Cleland K, McNamara M, et al. Emergency contraception: a multispecialty survey of clinician knowledge and practice. Contraception 2016;93:145e52. 16. Tam N, Soon JA, Trouton K, et al. Barriers to providing copper IUDs for emergency contraception: a qualitative study of community pharmacists. Poster presented at: Family Medicine Forum of the College of Family Physicians of Canada. November 13e15 2014; Quebec City, QC. 17. Clement KM, Mansour DJ. Improving uptake of the copper intrauterine device for emergency contraception by educating pharmacists in the community. J Fam Plann Reprod Health Care 2014;40:41e5. 18. Turok DK, Gurtcheff SE, Handley E, et al. A survey of women obtaining emergency contraception: are they interested in using the copper IUD? Contraception 2011;83:441e6. 19. Schwarz EB, Kavanaugh M, Douglas E, et al. Interest in intrauterine contraception among seekers of emergency contraception and pregnancy testing. Obstet Gynecol 2009;113:833e9.
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20. Kohn JE, Nucatola DL. EC4U: results from a pilot project integrating the copper IUC into emergency contraceptive care. Contraception 2016;94:48e51.
24. Bergin A, Tristan S, Terplan M, et al. A missed opportunity for care: twovisit IUD insertion protocols inhibit placement. Contraception 2012;86:694e7.
21. Schwarz EB, Papic M, Parisi SM, et al. Routine counselling about intrauterine contraception for women seeking emergency contraception. Contraception 2014;9:66e71.
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22. Pharmacy Act: Regulation Respecting the Prescription of a Medication by a Pharmacist. April 1, 2017. Available at: http://legisquebec.gouv.qc.ca/en/ ShowDoc/cr/P-10,%20r.%2018.2. Accessed April 27, 2017.
26. Gray L, Chamberlain R, Morris C. “Basically you wait for an ‘in’”: community pharmacist views on their role in weight management in New Zealand. J Prim Health Care 2016;8:365e71.
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27. Mold F, Forbes A. Patients’ and professionals’ experiences and perspectives of obesity in health-care settings: a synthesis of current research. Health Expect 2013;16:119e42.
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