- Email: [email protected]
Pharmacist and student pharmacist perspectives on providing preconception care in the United States
SCIENCE AND PRACTICE Journal of the American Pharmacists Association xxx (2018) 1e6
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
RESEARCH NOTES
Pharmacist and student pharmacist perspectives on providing preconception care in the United States Cydnee Ng, Rana Najjar, Natalie DiPietro Mager, Sally Rafie* a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 August 2017 Accepted 10 April 2018
Objectives: The primary objective was to assess pharmacist and student pharmacist current involvement and interest in providing preconception care services. Secondary objectives were to assess comfort in providing these services to various subpopulations in addition to training and resource needs. Methods: A cross-sectional online survey was conducted in the United States and its territories from August 26 to October 14, 2016. Pharmacists and student pharmacists were recruited via a Facebook advertisement to participate in a self-administered survey assessing experiences, interest, and comfort in providing preconception care services in addition to training and resource needs. Results: Three hundred thirty-two responses were included in the final analysis from the United States and its territories. Most respondents were female (72%) and pharmacists (65%). Respondents reported providing preconception care services, from routine immunizations (54%) to sexually transmitted disease (STD) and HIV screening and management (13%). Respondents also expressed strongest interest in providing new services for STD and HIV screening and management (68%) and minimizing risk of medication teratogenicity (62%). Respondents were most comfortable providing services to female adults (88%) and female adolescents (65%) compared with male adults (61%) and male adolescents (32%). Respondents indicated that tools, such as patient medical records (67%), patient educational materials (66%), and clinical guidelines (60%), would facilitate adoption of preconception care services. Conclusion: This study provides the first insights on the involvement, interest, and comfort of pharmacists and student pharmacists in the United States and its territories related to preconception care. Most respondents indicated that they are currently providing or are interested in providing preconception care services. Tools and resources should be developed to facilitate pharmacist provision of preconception care services. © 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
The United States has high rates of infant mortality, maternal mortality, and other adverse pregnancy outcomes compared with other industrialized countries.1 Before conceiving, certain measures should be taken by men and women of reproductive potential to minimize unfavorable health outcomes.2 Preconception care involves the recognition and management of biomedical or behavioral issues that must occur before
Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article. Funding: This work was supported by Ohio Northern University. Previous presentation: A subset of these data was presented at the American Pharmacists Association Annual Meeting and Exposition, San Francisco, CA, March 25, 2017. * Correspondence: Sally Rafie, 200 West Arbor Dr., #8765, San Diego, CA 92103. E-mail address: srafi[email protected] (S. Rafie).
pregnancy to optimize health.2,3 For women of reproductive potential, recommended preconception care interventions can be broadly organized into 4 categories: counseling, maternal assessment, screening, and vaccinations.4 While preconception health may be more readily associated with women's health, preconception health in men of reproductive potential is equally important. Preconception care for men can help to ensure that pregnancies are intended, to improve pregnancy outcomes, to decrease transmission of sexually transmitted diseases (STDs), and to improve men's health.5 In 2006, the U.S. Centers for Disease Control and Prevention (CDC) Preconception Care Work Group and the Select Panel on Preconception Care established 10 recommendations to improve preconception care for men and women of reproductive potential. These recommendations include 1) encouraging men and women to have a reproductive life plan; 2) increasing public awareness of preconception care; 3) providing risk
https://doi.org/10.1016/j.japh.2018.04.020 1544-3191/© 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE C. Ng et al. / Journal of the American Pharmacists Association xxx (2018) 1e6
assessments and patient counseling; 4) providing services for identified risks; 5) providing care to women with previous adverse pregnancy outcomes (interconception care); 6) providing prepregnancy checkups to persons and couples planning pregnancy; 7) providing health insurance to lowincome women; 8) implementing public health programs and strategies; 9) conducting research; and 10) improving monitoring of preconception health.2 Preconception care services for men and women of reproductive potential include exercise and nutrition counseling, immunizations, disease state and medication management, substance use management, and provision of contraception.4 Although many of the same preconception care services are provided to both men and women, some specific services address differing physiological needs of men and women to optimize pregnancy outcomes, such as monitoring of the effect of health risks on sperm quality in men and folic acid supplementation in women.5 Health professionals can provide preconception care services within their scope of practice. As nearly half of all pregnancies (45%) in the United States are unintended, health professionals should provide preconception care as part of routine health care to all patients of reproductive potential, regardless of pregnancy intention.2,3,6 However, gaps currently exist in the provision of preconception care services. For example, in a March of Dimes and Gallup survey of U.S. women age 18-45 years, only 32% of respondents reported a health care provider discussing folic acid use before pregnancy7; however, almost 90% of the surveyed women would likely take folic acid daily if advised by a health care provider.7 Similarly, 39% of surveyed women age 18-45 years with physicians associated with women’s health practices at Mayo Clinic Arizona recall having discussions about optimizing their health before pregnancy.8 In addition, the Pregnancy Risk Assessment Monitoring System found that in 2009, only 18.4% of surveyed women age 18-44 years in 4 U.S. states who had a live birth reported receiving counseling from a health professional on at least 5 of 11 lifestyle behaviors and contraceptive strategies included in their survey.9 Surveys of men in the United States have also demonstrated a need for family planning and preconception care services.10,11 Because of their training and accessibility to the public, pharmacists are well positioned to meet patients’ needs in preconception care and to close the gaps in the provision of such care in the United States and its territories.4,12 For example, a recent demonstration project showed that community pharmacists can successfully deliver aspects of preconception care via a medication therapy management framework.13 Pharmacists can provide preconception care in areas such as disease state and medication management, immunizations, folic acid supplementation, substance use counseling, smoking cessation, and contraceptive counseling. However, no studies have been performed on a national level to assess pharmacist or student pharmacist experiences, interest, and comfort with preconception care comprehensively.
services to various subpopulations and the training and resource needs for adopting these services. Methods This study was a cross-sectional survey conducted from August 26 to October 14, 2016, of pharmacists and student pharmacists in the United States and its territories. Respondents were recruited with a paid targeted social media advertisement created with Facebook's advertisement tool to participate in an online survey between August 26 and September 16, 2016. The advertisement was targeted to Facebook users who were English-speaking pharmacists or student pharmacists age 18 years or older in the United States, Puerto Rico, Guam, Northern Mariana Islands, the U.S. Virgin Islands, and American Samoa. The advertisement was displayed on behalf of the Birth Control Pharmacist Facebook page to individuals who self-identified as affiliated with or interested in a school of pharmacy, pharmacy as their field of study, or pharmacy as their job title in their Facebook profile. In addition to the paid advertisement, the post was shared organically among Facebook users. The survey tool was developed using preconception health recommendations published by the CDC.2 The survey was created with the Qualtrics survey software system (Provo, UT). It was pilot tested with individuals outside the pharmacy profession to identify technical difficulties and areas of confusion. The survey format and questions were modified according to feedback from the pilot testers. The survey was then distributed electronically through the Facebook advertisement, which linked to the survey. The survey tool is in Appendix 1, available on JAPhA.org as supplemental content. The self-administered survey assessed current practices, interest, and comfort in providing preconception care services, training and resource needs, and professional and personal demographics. Respondents completed the survey in approximately 8 minutes. Upon completion, respondents were directed to a website with resources about preconception health. The first 200 respondents were given the opportunity to receive a $5 Starbucks or Amazon gift card for their participation if they voluntarily provided an e-mail address. The survey was otherwise anonymous. Survey responses were excluded from final analysis for the following reasons: respondent not a pharmacist or student pharmacist, respondent outside of the United States or its territories, less than 70% of the survey completed, duplicate device Internet protocol (IP) addresses, or duplicate e-mail addresses. Device IP addresses and e-mail addresses were removed before analysis to deidentify each respondent. Data were analyzed using Microsoft Office Excel 2011 (Redmond, WA) and IBM SPSS version 22 (Armonk, NY). Simple logistic regression was used to identify statistical differences in response to survey questions based on respondent sex or geographic location, with alpha defined a priori as less than 0.05. The study was deemed exempt by the Ohio Northern University Institutional Review Board.
Objectives Results The primary objective of this study was to assess pharmacist and student pharmacist current involvement and interest in providing preconception care services. Secondary objectives were to assess comfort in providing preconception care 2
The recruitment advertisement reached 15,380 people and resulted in 362 link clicks, and 523 responses were received. After applying the exclusion criteria, 332 respondents were
SCIENCE AND PRACTICE Pharmacist perspectives on providing preconception care
included in the data analysis. Table 1 summarizes respondent characteristics. Table 2 summarizes the distribution of respondents currently providing various preconception care services and, if not currently providing such services, their interest level in doing so. Respondents most commonly reported current provision of the following services: routine immunizations (n ¼ 179 of 329; 54%), diabetes management services (n ¼ 174 of 327; 53%), and smoking cessation (n ¼ 171 of 328; 52%). Female respondents reported providing 7 services more often than male respondents did: weight management (P ¼ 0.038), immunizations (P ¼ 0.037), phenylketonuria (PKU) management (P < 0.001), thyroid disease management (P < 0.001), illicit drug counseling (excluding marijuana; P ¼ 0.015), minimizing risk of medication teratogenicity (P ¼ 0.004), and contraceptive counseling (P ¼ 0.014). Respondents were most interested in providing new services for STD and HIV screening and management (n ¼ 212 of 313; 68%) and minimizing the risk of medication teratogenicity (n ¼ 204 of 327; 62%). Respondents from the West or U.S. territories were more interested in 7 specific new preconception care services: weight management (West, P ¼ 0.001; territories, P ¼ 0.023), immunizations (West, P < 0.001; territories, P ¼ 0.014), STD and HIV screening and management (territories, P ¼ 0.009), diabetes management (West, P ¼ 0.041), PKU management (West, P ¼ 0.001; territories, P ¼ 0.028), smoking cessation (West, P ¼ 0.014), and contraceptive counseling (West, P ¼ 0.005). When asked of their interest in providing preconception care to specific patient populations, respondents (n ¼ 330) were interested in providing services to female adults (n ¼ 304 of 330; 92%) and female adolescents (n ¼ 277 of 330; 84%). Approximately half of respondents were interested in providing services to male adults (n ¼ 175 of 330; 53%) and male adolescents (n ¼ 151 of 330; 46%). Female respondents were more interested than male respondents in providing such services to male adults (P < 0.001). When asked about their comfort in providing preconception care services, respondents (n ¼ 330) were comfortable providing these services to female adults (n ¼ 290 of 330; 88%), female adolescents (n ¼ 213 of 330; 65%), and male adults (n ¼ 201 of 330; 61%). However, only about one-third (n ¼ 106 of 330; 32%) were comfortable providing such services to male adolescents. Female respondents were more comfortable than male respondents providing preconception care to male adults (P < 0.001), male adolescents (P ¼ 0.008), and female adolescents (P < 0.001). When asked which preconception care topics they had studied in pharmacy school, pharmacists (n ¼ 217) most often indicated folic acid supplementation (n ¼ 160 of 217; 74%), weight management (n ¼ 152 of 217; 70%), diabetes management (n ¼ 129 of 217; 59%), immunizations (n ¼ 125 of 217; 58%), and smoking cessation (n ¼ 109 of 217; 50%). Education regarding substance use counseling was reported the least often (alcohol, n ¼ 55 of 217, 25%; other illicit drugs, n ¼ 24 of 217, 11%; marijuana, n ¼ 15 of 217, 7%). To facilitate the delivery of preconception care, respondents (n ¼ 318) requested access to patient medical records (n ¼ 213 of 318; 67%), patient education materials (n ¼ 209 of 318; 66%), and clinical guidelines (n ¼ 191 of 318; 60%). Respondents most often reported live continuing education programs as the preferred format for education or training, followed by pharmacy school curricula and pharmacy journals or magazines.
Table 1 Summary of respondent characteristics (N ¼ 332) Characteristic Sex Male Female No response Age (years) <30 30e39 40e49 50e59 60 No response Title and years of practice or anticipated year of graduation Pharmacist 5 years or less 6 to 10 years 11 to 20 years More than 20 years Student pharmacist 2016 2017 2018 2019 2020 Unknown Primary practice setting Independent community pharmacy Chain community pharmacy Ambulatory care clinic Hospital Compounding or mail-order pharmacy Managed care or pharmaceutical industry Not currently practicing, retired Not currently working Other Direct patient care in primary practice setting Direct patient care No direct patient care Not currently practicing No response Geographic location Northeast Midwest South West U.S. territory No response a
Responses, n (%)a 76 (23) 245 (74) 11 (3) 120 62 108 28 4 10
(36) (19) (33) (8) (1) (3)
217 71 83 20 43 115 3 35 37 22 16 2
(65) (21) (25) (6) (13) (35) (3) (30) (32) (19) (14) (2)
61 149 23 29 17 20 0 27 6
(18) (45) (7) (9) (5) (6) (0) (8) (2)
278 27 26 1
(84) (8) (8) (0.3)
45 61 96 32 52 46
(13) (18) (29) (10) (16) (14)
Total of percentages might not equal 100% because of rounding.
Discussion This study provides the first insights on the involvement, interest, and comfort of pharmacists and student pharmacists across the United States in providing preconception care and identifies training and resource needs for providing such care. Surveyed pharmacists and student pharmacists were either providing or interested in providing various preconception care services to optimize patient health. Respondents were most involved with providing routine immunizations, diabetes management, and smoking cessation, serving as confirmation that pharmacists are consistently providing these general preconception care services. Respondents were also eager to implement services to meet patients' needs in preconception
3
SCIENCE AND PRACTICE
4
16 3 2 11 4 23 6 14 8 18 15 4 2 38 71 50 38 81 47 52 56 57 52 57 73 76 50 55 13 46 60 9 49 25 38 29 40 25 12 20 48 7 13 15 8 25 5 26 13 17 6 21 21 6 4 53 49 38 41 60 40 50 57 57 36 49 47 55 51 43 38 47 51 15 55 24 30 26 59 30 32 39 45 5 Abbreviation used: STD, sexually transmitted disease. a Total of percentages might not equal 100% because of rounding.
14 11 6 20 4 25 11 16 6 20 19 5 3 46 57 42 40 68 43 51 57 57 42 52 56 62 51 48 29 47 54 13 53 24 33 27 52 28 25 33 46 6 Weight management Folic acid supplementation Routine immunizations STD and HIV screening and management Diabetes management Phenylketonuria management Thyroid disease management Alcohol counseling Smoking cessation Marijuana counseling Other illicit drug counseling Minimizing risk of medication teratogenicity Contraception counseling Other
Interested in providing (%)a Currently providing (%)a Interested in providing (%)a Currently providing (%)a Not interested in providing (%)a Interested in providing (%)a Currently providing (%)a
All respondents Preconception health service
Table 2 Respondents' current practices and interest in providing preconception health services
Licensed pharmacists
Not interested in providing (%)a
Student pharmacists
Not interested in providing (%)a
C. Ng et al. / Journal of the American Pharmacists Association xxx (2018) 1e6
care, particularly STD and HIV screening and management and minimizing risk of medication teratogenicity. The CDC estimates that approximately 150,000 HIV cases are undiagnosed in the United States.14 Moreover, 40% of infants with congenital HIV are born to mothers with undiagnosed HIV.15 Therefore, developing services for STD and HIV screening and management would help to reduce vertical transmission. Potential opportunities for such services include community pharmacy clinics and patient counseling when over-the-counter screening tests are purchased.16 In addition, pharmacists are well positioned to provide counseling to reduce the risk of medication teratogenicity. More than 80% of pregnant women take over-the-counter or prescription medications.17 However, according to the March of Dimes and Gallup survey, only 3% of women surveyed were aware that certain medications should be avoided during pregnancy to reduce health risks.7 Although respondents were most interested in and comfortable providing preconception care to female patients, training and encouragement are needed to increase such attitudes toward providing services to male patients, especially male adolescents. Pharmacists also reported receiving education on preconception care topics, such as folic acid supplementation, weight management, diabetes management, immunizations, and smoking cessation. However, substance use management should be better incorporated into education. Respondents also indicated interest in receiving more training about preconception care topics, particularly STD and HIV screening and management, minimizing risk of medication teratogenicity, and PKU management. In addition to novel and improved education and training programs, respondents specified that access to patient medical records, patient education materials, and clinical guidelines would help to facilitate the delivery of preconception care. The surveyed pharmacists and student pharmacists shared similar attitudes toward providing preconception care to those of health professionals worldwide. In this study, respondents generally reported current involvement or interest in providing various preconception care services. A study conducted in the United Kingdom of health professionals ranging from general practitioners (GPs), practice nurses, and midwives found that these professionals perceived preconception care as important, rating many of the topics listed in the present study of high importance.18 In addition, family physicians (FPs) and GPs surveyed in Japan have been providing similar services: smoking cessation (58%), alcohol counseling (34%), weight management (11%), and folic acid supplementation (5%).19 Although Japan also has one of the highest rates of unintended pregnancies (40%) among the developed countries, differences in provision of preconception care services might be explained by differing topics of higher priority in Japan, such as screening for rubella infections and anemia, and differing responsibilities among FPs, GPs, and pharmacists in preconception care, such as addressing fertility issues.19,20 Despite the fact that the U.K. study assessed importance, rather than interest and comfort, in providing preconception care specifically to people planning a pregnancy, and despite differences in relevant preconception care services among pharmacists in the United States and FPs and GPs in Japan, health professionals worldwide are aware of the importance of incorporating preconception care services into their practice to meet patients' needs.
SCIENCE AND PRACTICE Pharmacist perspectives on providing preconception care
Speculation regarding the reduced interest and comfort that survey respondents expressed in providing preconception care to male patients, especially adolescents, can be made. First, survey respondents may have misperceptions regarding the role that preconception health in men plays in optimizing pregnancy outcomes. A study with 7 GPs in London concluded that, though willing to provide general preconception care services such as healthy lifestyle behaviors, smoking cessation, subfertility, genetic counseling, and screening for blood disorders, these GPs generally did not provide preconception care to male patients and perceived preconception care to be more focused on female patients.21 This misperception of the importance of preconception care in men may reflect a lack of knowledge and understanding, which may serve as the underlying cause of the reduced interest and comfort in providing such care to male patients. Second, survey respondents' decreased interest in providing preconception care to male patients might also reflect the lack of interest in male patients in receiving preconception health education. In a study of 132 primarily white, well-educated men age 18-45 years associated with primary care practices at Mayo Clinic Arizona, 46.2% of men reported no interest in receiving preconception health education.22 A general disinterest in preconception care could lead to a lack of demand for preconception care services among these patients, which could drive the reduced interest of pharmacists in providing such services. Third, survey respondents' lack of comfort in providing preconception care to male adolescents may reflect general discomfort in discussing such matters with young men. Studies in the Netherlands and Japan found that discomfort with discussing preconception care topics that are more personal hinders the effective provision of preconception care.19,23 Education and training programs regarding communication and interviewing skills have been suggested to help reduce timidity and reluctance in providing preconception care to patients.23 Therefore, U.S. pharmacists and other health professionals worldwide can develop programs to improve knowledge and comfort in discussing preconception health to increase and improve care of all patients. Additional research regarding the attitudes and experiences of health professionals in providing preconception care to male patients is warranted. The surveyed pharmacists and student pharmacists also shared similar perceptions to those of health professionals worldwide regarding a need for tools and resources to provide preconception care more effectively. Studies in the Netherlands and United Kingdom concluded that more knowledge of preconception care, tools, clear guidelines, and a clear distribution of responsibilities among collaborative health care providers are needed to provide better preconception care.18,23 Education, tools, and resources must be made readily available to pharmacists to optimize preconception care to meet patients' needs. Because this was an exploratory study, further study with specific populations of pharmacists or student pharmacists would glean more in-depth insights regarding experiences and attitudes about preconception care. For example, surveys could be performed using e-mail distribution lists from statespecific Boards of Pharmacy or certain pharmacy associations. In addition, studies examining the coverage of preconception care topics in pharmacy programs across the United States and
its territories might identify potential changes to curricula needed to better prepare pharmacists to provide such care. Research is also needed to determine patient acceptability of preconception care services delivered by pharmacists. As more pharmacists begin to develop novel services that include preconception care, studies should evaluate both the health and economic outcomes of these programs. Dissemination of preconception services and the value of such services will facilitate widespread replication of similar services at pharmacy practice sites. Limitations to the study include possible response bias and the nature of self-reported data. The survey was also shared among some respondents' social network, particularly in Puerto Rico. Because of the administration of an online survey tool, results might not be generalizable to all pharmacists and student pharmacists in the United States or its territories. However, this study included respondents from all regions of the United States, including its territories, indicating a broad geographic distribution of the survey. In addition, this study included respondents who practice in a wide range of health care settings and many in community pharmacies (63%) where pharmacists are most accessible to patients. Conclusion Pharmacists have great potential to improve preconception health. Most surveyed pharmacists and student pharmacists are currently providing or are interested in providing various preconception care services. Because of the strong interest in providing new STD and HIV management and medication management services, these services should be considered first for implementation. Current gaps include a need for more information regarding PKU and substance use management and to increase interest and comfort in providing preconception care to men, especially adolescents. Tools and resources should be developed to facilitate further pharmacist provision of preconception care. Supplementary Data Supplementary data related to this article can be found at https://doi.org/10.1016/j.japh.2018.04.020. References 1. MacDorman MF, Matthews TJ, Mohangoo AD, Zeitlin J. International comparisons of infant mortality and related factors: United States and Europe, 2010. Natl Vital Stat Rep. 2014;63(5):1e6. 2. Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care e United States: a report of the CDC/ATSDR preconception care work group and the select panel on preconception care. MMWR Recomm Rep. 2006;55(RR-6):1e23. 3. Kent H, Johnson K, Curtis M, et al. Proceedings of the preconception health and health care clinical, public health, and consumer workgroup meetings. Centers for Disease Control and Prevention; June 27-28, 2006; Atlanta, GA. Available at: http://www.cdc.gov/preconception/ documents/WorkgroupProceedingsJune06.pdf. Accessed April 24, 2017. 4. DiPietro Mager NA. Fulfilling an unmet need: roles for clinical pharmacists in preconception care. Pharmacotherapy. 2016;36(2):141e151. 5. Frey KA, Navarro SM, Kotelchuck M, Lu MC. The clinical content of preconception care: preconception care for men. Am J Obstet Gynecol. 2008;199(6):S389eS395. 6. Guttmacher Institute. Unintended pregnancy in the United States, September 2016. Available at: https://www.guttmacher.org/fact-sheet/ unintended-pregnancy-united-states. Accessed April 24, 2017.
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7. Gallup Organization, March of Dimes Foundation. Improving preconception health: women's knowledge and use of folic acid. White Plains, NY: March of Dimes; 2008. Available at: https://www.marchofdimes.org/peristats/ pdfdocs/2008FolicAcidSurveyReport.pdf. Accessed April 24, 2017. 8. Frey KA, Files JA. Preconception healthcare: what women know and believe. Matern Child Health J. 2006;10:S73eS77. 9. Robbins CL, Zapata LB, Farr SL, et al. Core state preconception health indicators e pregnancy risk assessment monitoring system and behavioral risk factor surveillance system, 2009. MMWR Surveill Summ. 2014;63(SS-03): 1e62. 10. Casey FE, Sonenstein FL, Astone NM, et al. Family planning and preconception health among men in their mid-30s: developing indicators and describing need. Am J Mens Health. 2016;10(1):59e67. 11. Choiriyyah I, Sonenstein FL, Astone NM, et al. Men aged 15-44 in need of preconception care. Matern Child Health J. 2015;19(11):2358e2365. 12. El-Ibiary SY, Raney EC, Moos MK. The pharmacist's role in promoting preconception health. J Am Pharm Assoc (2003). 2014;54(5): e288ee303. 13. DiPietro Mager NA, Bright DR, Markus D, et al. Use of targeted medication reviews to deliver preconception care: a demonstration project. J Am Pharm Assoc (2003). 2017;57(1):90e94. 14. Centers for Disease Control and Prevention. Today's HIV/AIDS epidemic. Available at: https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/ todaysepidemic-508.pdf. Accessed July 19, 2017. 15. Lassi ZS, Imam AM, Dean SV, Bhutta ZA. Preconception care: preventing and treating infections. Reprod Health. 2014;11(suppl 3):S4. 16. Dugdale C, Zaller N, Bratberg J, et al. Missed opportunities for HIV screening in pharmacies and retail clinics. J Manag Care Spec Pharm. 2014;20(4):339e345.
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17. Lassi ZS, Imam AM, Dean SV, Bhutta ZA. Preconception care: screening and management of chronic disease and promoting psychological health. Reprod Health. 2014;11(suppl 3):S5. 18. Heyes T, Long S, Mathers N. Preconception care: practice and beliefs of primary care workers. Fam Pract. 2004;21(1):22e27. 19. Kitamura K, Fetters MD, Ban N. Preconception care by family physicians and general practitioners in Japan. BMC Fam Pract. 2005;6:31. 20. Kitamura K, Fetters MD, Ban N. Contraceptive care by family physicians and general practitioners in Japan: attitudes and practices. Fam Med. 2004;36(4):279e283. 21. Ojukwu O, Patel D, Stephenson J, et al. General practitioners' knowledge, attitudes and views of providing preconception care: a qualitative investigation. Ups J Med Sci. 2016;121(4):256e263. 22. Frey KA, Engle R, Noble B. Preconception healthcare: what do men know and believe? J Mens Health. 2012;9(1):25e35. 23. Poels M, Koster MPH, Franx A, van Stel HF. Healthcare providers' views on the delivery of preconception care in a local community setting in the Netherlands. BMC Health Serv Res. 2017;17(1):92. Cydnee Ng, PharmD candidate, Pharmacy Student at University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA Rana Najjar, PharmD candidate, Pharmacy Student, Ohio Northern University, Raabe College of Pharmacy, Ada, OH Natalie DiPietro Mager, PharmD, MPH, Associate Professor of Pharmacy Practice, Ohio Northern University, Raabe College of Pharmacy, Ada, OH Sally Rafie, PharmD, Pharmacist Specialist, University of California San Diego Health, San Diego, CA; and Founder, Birth Control Pharmacist, San Diego, CA
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
RESEARCH NOTES
Pharmacist and student pharmacist perspectives on providing preconception care in the United States Cydnee Ng, Rana Najjar, Natalie DiPietro Mager, Sally Rafie* a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 August 2017 Accepted 10 April 2018
Objectives: The primary objective was to assess pharmacist and student pharmacist current involvement and interest in providing preconception care services. Secondary objectives were to assess comfort in providing these services to various subpopulations in addition to training and resource needs. Methods: A cross-sectional online survey was conducted in the United States and its territories from August 26 to October 14, 2016. Pharmacists and student pharmacists were recruited via a Facebook advertisement to participate in a self-administered survey assessing experiences, interest, and comfort in providing preconception care services in addition to training and resource needs. Results: Three hundred thirty-two responses were included in the final analysis from the United States and its territories. Most respondents were female (72%) and pharmacists (65%). Respondents reported providing preconception care services, from routine immunizations (54%) to sexually transmitted disease (STD) and HIV screening and management (13%). Respondents also expressed strongest interest in providing new services for STD and HIV screening and management (68%) and minimizing risk of medication teratogenicity (62%). Respondents were most comfortable providing services to female adults (88%) and female adolescents (65%) compared with male adults (61%) and male adolescents (32%). Respondents indicated that tools, such as patient medical records (67%), patient educational materials (66%), and clinical guidelines (60%), would facilitate adoption of preconception care services. Conclusion: This study provides the first insights on the involvement, interest, and comfort of pharmacists and student pharmacists in the United States and its territories related to preconception care. Most respondents indicated that they are currently providing or are interested in providing preconception care services. Tools and resources should be developed to facilitate pharmacist provision of preconception care services. © 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
The United States has high rates of infant mortality, maternal mortality, and other adverse pregnancy outcomes compared with other industrialized countries.1 Before conceiving, certain measures should be taken by men and women of reproductive potential to minimize unfavorable health outcomes.2 Preconception care involves the recognition and management of biomedical or behavioral issues that must occur before
Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article. Funding: This work was supported by Ohio Northern University. Previous presentation: A subset of these data was presented at the American Pharmacists Association Annual Meeting and Exposition, San Francisco, CA, March 25, 2017. * Correspondence: Sally Rafie, 200 West Arbor Dr., #8765, San Diego, CA 92103. E-mail address: srafi[email protected] (S. Rafie).
pregnancy to optimize health.2,3 For women of reproductive potential, recommended preconception care interventions can be broadly organized into 4 categories: counseling, maternal assessment, screening, and vaccinations.4 While preconception health may be more readily associated with women's health, preconception health in men of reproductive potential is equally important. Preconception care for men can help to ensure that pregnancies are intended, to improve pregnancy outcomes, to decrease transmission of sexually transmitted diseases (STDs), and to improve men's health.5 In 2006, the U.S. Centers for Disease Control and Prevention (CDC) Preconception Care Work Group and the Select Panel on Preconception Care established 10 recommendations to improve preconception care for men and women of reproductive potential. These recommendations include 1) encouraging men and women to have a reproductive life plan; 2) increasing public awareness of preconception care; 3) providing risk
https://doi.org/10.1016/j.japh.2018.04.020 1544-3191/© 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE C. Ng et al. / Journal of the American Pharmacists Association xxx (2018) 1e6
assessments and patient counseling; 4) providing services for identified risks; 5) providing care to women with previous adverse pregnancy outcomes (interconception care); 6) providing prepregnancy checkups to persons and couples planning pregnancy; 7) providing health insurance to lowincome women; 8) implementing public health programs and strategies; 9) conducting research; and 10) improving monitoring of preconception health.2 Preconception care services for men and women of reproductive potential include exercise and nutrition counseling, immunizations, disease state and medication management, substance use management, and provision of contraception.4 Although many of the same preconception care services are provided to both men and women, some specific services address differing physiological needs of men and women to optimize pregnancy outcomes, such as monitoring of the effect of health risks on sperm quality in men and folic acid supplementation in women.5 Health professionals can provide preconception care services within their scope of practice. As nearly half of all pregnancies (45%) in the United States are unintended, health professionals should provide preconception care as part of routine health care to all patients of reproductive potential, regardless of pregnancy intention.2,3,6 However, gaps currently exist in the provision of preconception care services. For example, in a March of Dimes and Gallup survey of U.S. women age 18-45 years, only 32% of respondents reported a health care provider discussing folic acid use before pregnancy7; however, almost 90% of the surveyed women would likely take folic acid daily if advised by a health care provider.7 Similarly, 39% of surveyed women age 18-45 years with physicians associated with women’s health practices at Mayo Clinic Arizona recall having discussions about optimizing their health before pregnancy.8 In addition, the Pregnancy Risk Assessment Monitoring System found that in 2009, only 18.4% of surveyed women age 18-44 years in 4 U.S. states who had a live birth reported receiving counseling from a health professional on at least 5 of 11 lifestyle behaviors and contraceptive strategies included in their survey.9 Surveys of men in the United States have also demonstrated a need for family planning and preconception care services.10,11 Because of their training and accessibility to the public, pharmacists are well positioned to meet patients’ needs in preconception care and to close the gaps in the provision of such care in the United States and its territories.4,12 For example, a recent demonstration project showed that community pharmacists can successfully deliver aspects of preconception care via a medication therapy management framework.13 Pharmacists can provide preconception care in areas such as disease state and medication management, immunizations, folic acid supplementation, substance use counseling, smoking cessation, and contraceptive counseling. However, no studies have been performed on a national level to assess pharmacist or student pharmacist experiences, interest, and comfort with preconception care comprehensively.
services to various subpopulations and the training and resource needs for adopting these services. Methods This study was a cross-sectional survey conducted from August 26 to October 14, 2016, of pharmacists and student pharmacists in the United States and its territories. Respondents were recruited with a paid targeted social media advertisement created with Facebook's advertisement tool to participate in an online survey between August 26 and September 16, 2016. The advertisement was targeted to Facebook users who were English-speaking pharmacists or student pharmacists age 18 years or older in the United States, Puerto Rico, Guam, Northern Mariana Islands, the U.S. Virgin Islands, and American Samoa. The advertisement was displayed on behalf of the Birth Control Pharmacist Facebook page to individuals who self-identified as affiliated with or interested in a school of pharmacy, pharmacy as their field of study, or pharmacy as their job title in their Facebook profile. In addition to the paid advertisement, the post was shared organically among Facebook users. The survey tool was developed using preconception health recommendations published by the CDC.2 The survey was created with the Qualtrics survey software system (Provo, UT). It was pilot tested with individuals outside the pharmacy profession to identify technical difficulties and areas of confusion. The survey format and questions were modified according to feedback from the pilot testers. The survey was then distributed electronically through the Facebook advertisement, which linked to the survey. The survey tool is in Appendix 1, available on JAPhA.org as supplemental content. The self-administered survey assessed current practices, interest, and comfort in providing preconception care services, training and resource needs, and professional and personal demographics. Respondents completed the survey in approximately 8 minutes. Upon completion, respondents were directed to a website with resources about preconception health. The first 200 respondents were given the opportunity to receive a $5 Starbucks or Amazon gift card for their participation if they voluntarily provided an e-mail address. The survey was otherwise anonymous. Survey responses were excluded from final analysis for the following reasons: respondent not a pharmacist or student pharmacist, respondent outside of the United States or its territories, less than 70% of the survey completed, duplicate device Internet protocol (IP) addresses, or duplicate e-mail addresses. Device IP addresses and e-mail addresses were removed before analysis to deidentify each respondent. Data were analyzed using Microsoft Office Excel 2011 (Redmond, WA) and IBM SPSS version 22 (Armonk, NY). Simple logistic regression was used to identify statistical differences in response to survey questions based on respondent sex or geographic location, with alpha defined a priori as less than 0.05. The study was deemed exempt by the Ohio Northern University Institutional Review Board.
Objectives Results The primary objective of this study was to assess pharmacist and student pharmacist current involvement and interest in providing preconception care services. Secondary objectives were to assess comfort in providing preconception care 2
The recruitment advertisement reached 15,380 people and resulted in 362 link clicks, and 523 responses were received. After applying the exclusion criteria, 332 respondents were
SCIENCE AND PRACTICE Pharmacist perspectives on providing preconception care
included in the data analysis. Table 1 summarizes respondent characteristics. Table 2 summarizes the distribution of respondents currently providing various preconception care services and, if not currently providing such services, their interest level in doing so. Respondents most commonly reported current provision of the following services: routine immunizations (n ¼ 179 of 329; 54%), diabetes management services (n ¼ 174 of 327; 53%), and smoking cessation (n ¼ 171 of 328; 52%). Female respondents reported providing 7 services more often than male respondents did: weight management (P ¼ 0.038), immunizations (P ¼ 0.037), phenylketonuria (PKU) management (P < 0.001), thyroid disease management (P < 0.001), illicit drug counseling (excluding marijuana; P ¼ 0.015), minimizing risk of medication teratogenicity (P ¼ 0.004), and contraceptive counseling (P ¼ 0.014). Respondents were most interested in providing new services for STD and HIV screening and management (n ¼ 212 of 313; 68%) and minimizing the risk of medication teratogenicity (n ¼ 204 of 327; 62%). Respondents from the West or U.S. territories were more interested in 7 specific new preconception care services: weight management (West, P ¼ 0.001; territories, P ¼ 0.023), immunizations (West, P < 0.001; territories, P ¼ 0.014), STD and HIV screening and management (territories, P ¼ 0.009), diabetes management (West, P ¼ 0.041), PKU management (West, P ¼ 0.001; territories, P ¼ 0.028), smoking cessation (West, P ¼ 0.014), and contraceptive counseling (West, P ¼ 0.005). When asked of their interest in providing preconception care to specific patient populations, respondents (n ¼ 330) were interested in providing services to female adults (n ¼ 304 of 330; 92%) and female adolescents (n ¼ 277 of 330; 84%). Approximately half of respondents were interested in providing services to male adults (n ¼ 175 of 330; 53%) and male adolescents (n ¼ 151 of 330; 46%). Female respondents were more interested than male respondents in providing such services to male adults (P < 0.001). When asked about their comfort in providing preconception care services, respondents (n ¼ 330) were comfortable providing these services to female adults (n ¼ 290 of 330; 88%), female adolescents (n ¼ 213 of 330; 65%), and male adults (n ¼ 201 of 330; 61%). However, only about one-third (n ¼ 106 of 330; 32%) were comfortable providing such services to male adolescents. Female respondents were more comfortable than male respondents providing preconception care to male adults (P < 0.001), male adolescents (P ¼ 0.008), and female adolescents (P < 0.001). When asked which preconception care topics they had studied in pharmacy school, pharmacists (n ¼ 217) most often indicated folic acid supplementation (n ¼ 160 of 217; 74%), weight management (n ¼ 152 of 217; 70%), diabetes management (n ¼ 129 of 217; 59%), immunizations (n ¼ 125 of 217; 58%), and smoking cessation (n ¼ 109 of 217; 50%). Education regarding substance use counseling was reported the least often (alcohol, n ¼ 55 of 217, 25%; other illicit drugs, n ¼ 24 of 217, 11%; marijuana, n ¼ 15 of 217, 7%). To facilitate the delivery of preconception care, respondents (n ¼ 318) requested access to patient medical records (n ¼ 213 of 318; 67%), patient education materials (n ¼ 209 of 318; 66%), and clinical guidelines (n ¼ 191 of 318; 60%). Respondents most often reported live continuing education programs as the preferred format for education or training, followed by pharmacy school curricula and pharmacy journals or magazines.
Table 1 Summary of respondent characteristics (N ¼ 332) Characteristic Sex Male Female No response Age (years) <30 30e39 40e49 50e59 60 No response Title and years of practice or anticipated year of graduation Pharmacist 5 years or less 6 to 10 years 11 to 20 years More than 20 years Student pharmacist 2016 2017 2018 2019 2020 Unknown Primary practice setting Independent community pharmacy Chain community pharmacy Ambulatory care clinic Hospital Compounding or mail-order pharmacy Managed care or pharmaceutical industry Not currently practicing, retired Not currently working Other Direct patient care in primary practice setting Direct patient care No direct patient care Not currently practicing No response Geographic location Northeast Midwest South West U.S. territory No response a
Responses, n (%)a 76 (23) 245 (74) 11 (3) 120 62 108 28 4 10
(36) (19) (33) (8) (1) (3)
217 71 83 20 43 115 3 35 37 22 16 2
(65) (21) (25) (6) (13) (35) (3) (30) (32) (19) (14) (2)
61 149 23 29 17 20 0 27 6
(18) (45) (7) (9) (5) (6) (0) (8) (2)
278 27 26 1
(84) (8) (8) (0.3)
45 61 96 32 52 46
(13) (18) (29) (10) (16) (14)
Total of percentages might not equal 100% because of rounding.
Discussion This study provides the first insights on the involvement, interest, and comfort of pharmacists and student pharmacists across the United States in providing preconception care and identifies training and resource needs for providing such care. Surveyed pharmacists and student pharmacists were either providing or interested in providing various preconception care services to optimize patient health. Respondents were most involved with providing routine immunizations, diabetes management, and smoking cessation, serving as confirmation that pharmacists are consistently providing these general preconception care services. Respondents were also eager to implement services to meet patients' needs in preconception
3
SCIENCE AND PRACTICE
4
16 3 2 11 4 23 6 14 8 18 15 4 2 38 71 50 38 81 47 52 56 57 52 57 73 76 50 55 13 46 60 9 49 25 38 29 40 25 12 20 48 7 13 15 8 25 5 26 13 17 6 21 21 6 4 53 49 38 41 60 40 50 57 57 36 49 47 55 51 43 38 47 51 15 55 24 30 26 59 30 32 39 45 5 Abbreviation used: STD, sexually transmitted disease. a Total of percentages might not equal 100% because of rounding.
14 11 6 20 4 25 11 16 6 20 19 5 3 46 57 42 40 68 43 51 57 57 42 52 56 62 51 48 29 47 54 13 53 24 33 27 52 28 25 33 46 6 Weight management Folic acid supplementation Routine immunizations STD and HIV screening and management Diabetes management Phenylketonuria management Thyroid disease management Alcohol counseling Smoking cessation Marijuana counseling Other illicit drug counseling Minimizing risk of medication teratogenicity Contraception counseling Other
Interested in providing (%)a Currently providing (%)a Interested in providing (%)a Currently providing (%)a Not interested in providing (%)a Interested in providing (%)a Currently providing (%)a
All respondents Preconception health service
Table 2 Respondents' current practices and interest in providing preconception health services
Licensed pharmacists
Not interested in providing (%)a
Student pharmacists
Not interested in providing (%)a
C. Ng et al. / Journal of the American Pharmacists Association xxx (2018) 1e6
care, particularly STD and HIV screening and management and minimizing risk of medication teratogenicity. The CDC estimates that approximately 150,000 HIV cases are undiagnosed in the United States.14 Moreover, 40% of infants with congenital HIV are born to mothers with undiagnosed HIV.15 Therefore, developing services for STD and HIV screening and management would help to reduce vertical transmission. Potential opportunities for such services include community pharmacy clinics and patient counseling when over-the-counter screening tests are purchased.16 In addition, pharmacists are well positioned to provide counseling to reduce the risk of medication teratogenicity. More than 80% of pregnant women take over-the-counter or prescription medications.17 However, according to the March of Dimes and Gallup survey, only 3% of women surveyed were aware that certain medications should be avoided during pregnancy to reduce health risks.7 Although respondents were most interested in and comfortable providing preconception care to female patients, training and encouragement are needed to increase such attitudes toward providing services to male patients, especially male adolescents. Pharmacists also reported receiving education on preconception care topics, such as folic acid supplementation, weight management, diabetes management, immunizations, and smoking cessation. However, substance use management should be better incorporated into education. Respondents also indicated interest in receiving more training about preconception care topics, particularly STD and HIV screening and management, minimizing risk of medication teratogenicity, and PKU management. In addition to novel and improved education and training programs, respondents specified that access to patient medical records, patient education materials, and clinical guidelines would help to facilitate the delivery of preconception care. The surveyed pharmacists and student pharmacists shared similar attitudes toward providing preconception care to those of health professionals worldwide. In this study, respondents generally reported current involvement or interest in providing various preconception care services. A study conducted in the United Kingdom of health professionals ranging from general practitioners (GPs), practice nurses, and midwives found that these professionals perceived preconception care as important, rating many of the topics listed in the present study of high importance.18 In addition, family physicians (FPs) and GPs surveyed in Japan have been providing similar services: smoking cessation (58%), alcohol counseling (34%), weight management (11%), and folic acid supplementation (5%).19 Although Japan also has one of the highest rates of unintended pregnancies (40%) among the developed countries, differences in provision of preconception care services might be explained by differing topics of higher priority in Japan, such as screening for rubella infections and anemia, and differing responsibilities among FPs, GPs, and pharmacists in preconception care, such as addressing fertility issues.19,20 Despite the fact that the U.K. study assessed importance, rather than interest and comfort, in providing preconception care specifically to people planning a pregnancy, and despite differences in relevant preconception care services among pharmacists in the United States and FPs and GPs in Japan, health professionals worldwide are aware of the importance of incorporating preconception care services into their practice to meet patients' needs.
SCIENCE AND PRACTICE Pharmacist perspectives on providing preconception care
Speculation regarding the reduced interest and comfort that survey respondents expressed in providing preconception care to male patients, especially adolescents, can be made. First, survey respondents may have misperceptions regarding the role that preconception health in men plays in optimizing pregnancy outcomes. A study with 7 GPs in London concluded that, though willing to provide general preconception care services such as healthy lifestyle behaviors, smoking cessation, subfertility, genetic counseling, and screening for blood disorders, these GPs generally did not provide preconception care to male patients and perceived preconception care to be more focused on female patients.21 This misperception of the importance of preconception care in men may reflect a lack of knowledge and understanding, which may serve as the underlying cause of the reduced interest and comfort in providing such care to male patients. Second, survey respondents' decreased interest in providing preconception care to male patients might also reflect the lack of interest in male patients in receiving preconception health education. In a study of 132 primarily white, well-educated men age 18-45 years associated with primary care practices at Mayo Clinic Arizona, 46.2% of men reported no interest in receiving preconception health education.22 A general disinterest in preconception care could lead to a lack of demand for preconception care services among these patients, which could drive the reduced interest of pharmacists in providing such services. Third, survey respondents' lack of comfort in providing preconception care to male adolescents may reflect general discomfort in discussing such matters with young men. Studies in the Netherlands and Japan found that discomfort with discussing preconception care topics that are more personal hinders the effective provision of preconception care.19,23 Education and training programs regarding communication and interviewing skills have been suggested to help reduce timidity and reluctance in providing preconception care to patients.23 Therefore, U.S. pharmacists and other health professionals worldwide can develop programs to improve knowledge and comfort in discussing preconception health to increase and improve care of all patients. Additional research regarding the attitudes and experiences of health professionals in providing preconception care to male patients is warranted. The surveyed pharmacists and student pharmacists also shared similar perceptions to those of health professionals worldwide regarding a need for tools and resources to provide preconception care more effectively. Studies in the Netherlands and United Kingdom concluded that more knowledge of preconception care, tools, clear guidelines, and a clear distribution of responsibilities among collaborative health care providers are needed to provide better preconception care.18,23 Education, tools, and resources must be made readily available to pharmacists to optimize preconception care to meet patients' needs. Because this was an exploratory study, further study with specific populations of pharmacists or student pharmacists would glean more in-depth insights regarding experiences and attitudes about preconception care. For example, surveys could be performed using e-mail distribution lists from statespecific Boards of Pharmacy or certain pharmacy associations. In addition, studies examining the coverage of preconception care topics in pharmacy programs across the United States and
its territories might identify potential changes to curricula needed to better prepare pharmacists to provide such care. Research is also needed to determine patient acceptability of preconception care services delivered by pharmacists. As more pharmacists begin to develop novel services that include preconception care, studies should evaluate both the health and economic outcomes of these programs. Dissemination of preconception services and the value of such services will facilitate widespread replication of similar services at pharmacy practice sites. Limitations to the study include possible response bias and the nature of self-reported data. The survey was also shared among some respondents' social network, particularly in Puerto Rico. Because of the administration of an online survey tool, results might not be generalizable to all pharmacists and student pharmacists in the United States or its territories. However, this study included respondents from all regions of the United States, including its territories, indicating a broad geographic distribution of the survey. In addition, this study included respondents who practice in a wide range of health care settings and many in community pharmacies (63%) where pharmacists are most accessible to patients. Conclusion Pharmacists have great potential to improve preconception health. Most surveyed pharmacists and student pharmacists are currently providing or are interested in providing various preconception care services. Because of the strong interest in providing new STD and HIV management and medication management services, these services should be considered first for implementation. Current gaps include a need for more information regarding PKU and substance use management and to increase interest and comfort in providing preconception care to men, especially adolescents. Tools and resources should be developed to facilitate further pharmacist provision of preconception care. Supplementary Data Supplementary data related to this article can be found at https://doi.org/10.1016/j.japh.2018.04.020. References 1. MacDorman MF, Matthews TJ, Mohangoo AD, Zeitlin J. International comparisons of infant mortality and related factors: United States and Europe, 2010. Natl Vital Stat Rep. 2014;63(5):1e6. 2. Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care e United States: a report of the CDC/ATSDR preconception care work group and the select panel on preconception care. MMWR Recomm Rep. 2006;55(RR-6):1e23. 3. Kent H, Johnson K, Curtis M, et al. Proceedings of the preconception health and health care clinical, public health, and consumer workgroup meetings. Centers for Disease Control and Prevention; June 27-28, 2006; Atlanta, GA. Available at: http://www.cdc.gov/preconception/ documents/WorkgroupProceedingsJune06.pdf. Accessed April 24, 2017. 4. DiPietro Mager NA. Fulfilling an unmet need: roles for clinical pharmacists in preconception care. Pharmacotherapy. 2016;36(2):141e151. 5. Frey KA, Navarro SM, Kotelchuck M, Lu MC. The clinical content of preconception care: preconception care for men. Am J Obstet Gynecol. 2008;199(6):S389eS395. 6. Guttmacher Institute. Unintended pregnancy in the United States, September 2016. Available at: https://www.guttmacher.org/fact-sheet/ unintended-pregnancy-united-states. Accessed April 24, 2017.
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7. Gallup Organization, March of Dimes Foundation. Improving preconception health: women's knowledge and use of folic acid. White Plains, NY: March of Dimes; 2008. Available at: https://www.marchofdimes.org/peristats/ pdfdocs/2008FolicAcidSurveyReport.pdf. Accessed April 24, 2017. 8. Frey KA, Files JA. Preconception healthcare: what women know and believe. Matern Child Health J. 2006;10:S73eS77. 9. Robbins CL, Zapata LB, Farr SL, et al. Core state preconception health indicators e pregnancy risk assessment monitoring system and behavioral risk factor surveillance system, 2009. MMWR Surveill Summ. 2014;63(SS-03): 1e62. 10. Casey FE, Sonenstein FL, Astone NM, et al. Family planning and preconception health among men in their mid-30s: developing indicators and describing need. Am J Mens Health. 2016;10(1):59e67. 11. Choiriyyah I, Sonenstein FL, Astone NM, et al. Men aged 15-44 in need of preconception care. Matern Child Health J. 2015;19(11):2358e2365. 12. El-Ibiary SY, Raney EC, Moos MK. The pharmacist's role in promoting preconception health. J Am Pharm Assoc (2003). 2014;54(5): e288ee303. 13. DiPietro Mager NA, Bright DR, Markus D, et al. Use of targeted medication reviews to deliver preconception care: a demonstration project. J Am Pharm Assoc (2003). 2017;57(1):90e94. 14. Centers for Disease Control and Prevention. Today's HIV/AIDS epidemic. Available at: https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/ todaysepidemic-508.pdf. Accessed July 19, 2017. 15. Lassi ZS, Imam AM, Dean SV, Bhutta ZA. Preconception care: preventing and treating infections. Reprod Health. 2014;11(suppl 3):S4. 16. Dugdale C, Zaller N, Bratberg J, et al. Missed opportunities for HIV screening in pharmacies and retail clinics. J Manag Care Spec Pharm. 2014;20(4):339e345.
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17. Lassi ZS, Imam AM, Dean SV, Bhutta ZA. Preconception care: screening and management of chronic disease and promoting psychological health. Reprod Health. 2014;11(suppl 3):S5. 18. Heyes T, Long S, Mathers N. Preconception care: practice and beliefs of primary care workers. Fam Pract. 2004;21(1):22e27. 19. Kitamura K, Fetters MD, Ban N. Preconception care by family physicians and general practitioners in Japan. BMC Fam Pract. 2005;6:31. 20. Kitamura K, Fetters MD, Ban N. Contraceptive care by family physicians and general practitioners in Japan: attitudes and practices. Fam Med. 2004;36(4):279e283. 21. Ojukwu O, Patel D, Stephenson J, et al. General practitioners' knowledge, attitudes and views of providing preconception care: a qualitative investigation. Ups J Med Sci. 2016;121(4):256e263. 22. Frey KA, Engle R, Noble B. Preconception healthcare: what do men know and believe? J Mens Health. 2012;9(1):25e35. 23. Poels M, Koster MPH, Franx A, van Stel HF. Healthcare providers' views on the delivery of preconception care in a local community setting in the Netherlands. BMC Health Serv Res. 2017;17(1):92. Cydnee Ng, PharmD candidate, Pharmacy Student at University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA Rana Najjar, PharmD candidate, Pharmacy Student, Ohio Northern University, Raabe College of Pharmacy, Ada, OH Natalie DiPietro Mager, PharmD, MPH, Associate Professor of Pharmacy Practice, Ohio Northern University, Raabe College of Pharmacy, Ada, OH Sally Rafie, PharmD, Pharmacist Specialist, University of California San Diego Health, San Diego, CA; and Founder, Birth Control Pharmacist, San Diego, CA