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Pharmacy access to emergency hormonal contraception in Jacksonville, FL: a secret shopper survey
Contraception 75 (2007) 126 – 130
Original research article
Pharmacy access to emergency hormonal contraception in Jacksonville, FL: a secret shopper surveyB,BB Amy C. French, Andrew M. Kaunitz4 Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL 32209, USA Received 10 August 2006; revised 31 August 2006; accepted 6 September 2006
Abstract Objective: Emergency hormonal contraception (EC) has the potential to reduce the number of unintended pregnancies and induced abortions, but many barriers to more prevalent usage exist. We evaluated one aspect of access — pharmacy availability of levonorgestrel EC (Plan B) or alternatives — in Jacksonville, FL. Method: Female bsecret shoppersQ presented in person and by telephone to pharmacies in Jacksonville, FL, and inquired if Plan B would be available if they were to return with a prescription. Availability of the medication, as well as offers of EC alternatives or alternate methods of obtaining EC, was noted. Furthermore, pharmacist and pharmacy staff knowledge regarding appropriate use of the product was assessed. Results: Of 54 pharmacies visited by secret shoppers, 21 (39%) had Plan B in stock and were willing to dispense it. Sixteen pharmacies (29%) could order it and have it available within 24 h, or knew of nearby pharmacies that stocked the medication. Neither Plan B nor other EC options were offered by 17 pharmacies (31%). One hundred thirty-three pharmacies, including those that were visited in person, were contacted by telephone. Forty-two (32%) of these had Plan B in stock. Another 22 pharmacies (17%) offered to order Plan B for availability within 24 h or less. Furthermore, 11 pharmacies suggested other stores that were more likely to carry it. Of 40 pharmacy staff members asked how long following unprotected intercourse a patient had to take the product, 20 (50%) correctly stated 72 h. Conclusion: Plan B was not in stock in a majority of pharmacies within this large city. Availability was increased by offers to order the medication or by suggestions to seek the prescription at nearby pharmacies. Many pharmacists and their staff were unfamiliar with the medication and its correct usage. D 2007 Elsevier Inc. All rights reserved. Keywords: Pharmacy access; Emergency hormonal contraceptives; Secret shopper survey
1. Introduction Approximately half of all pregnancies in the United States are unintended — resulting from contraceptive failure or nonuse of contraceptives [1,2]. Of these unintended pregnancies, over 40% end in abortion [3]. Emergency hormonal contraception (EC) has the potential to substantially reduce the rate of unintended pregnancy and induced abortion, but many barriers to the timely use of the medication exist [4,5]. EC represents a safe and effective method of preventing pregnancy when used after unprotected intercourse [1,6].
B
No external funding was received to support this project. Disclosure: Dr. Kaunitz is a consultant to Duramed and owns stocks in Walgreen’s. 4 Corresponding author. Tel.: +1 904 244 3109; fax: +1 904 244 3124. E-mail address: [email protected] (A.M. Kaunitz). BB
0010-7824/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2006.09.004
Regimens using various oral contraceptives have been found to be effective since the Yuzpe method was first introduced in the 1970s [7]. Currently, a levonorgestrel-only method is preferred because of fewer side effects and improved efficacy [5]. Plan B (Duramed, Pomona, NY), a two-tablet levonorgestrel formulation, represents the only dedicated EC method in the United States. When used within 72 h of unprotected intercourse, combined estrogen/progestin (Yuzpe method) and progestin-only methods prevent approximately 75% of pregnancies that otherwise would have occurred [1,4]. Recent studies have found that the time limit for the use of either method may be extended to 120 h following unprotected sex, although earlier use is likely to be most effective [8–10]. A copper T 380A IUD may also be placed up to 5 days after unprotected intercourse to prevent pregnancy when longterm birth control is desired [1], but it is not commonly used for emergency contraception in the United States.
A.C. French, A.M. Kaunitz / Contraception 75 (2007) 126–130
Many obstacles to obtaining EC have been identified [11,12]. Lack of awareness, misconceptions by health care providers and consumers (including the belief that EC may cause abortion or may be synonymous with bthe abortion pillQ mifepristone), and challenges faced by women seeking to fill a prescription quickly have all represented barriers [11–14]. In September 2005, the Food and Drug Administration (FDA) again denied over-the-counter access of EC [15] despite recommendations by the American College of Obstetricians and Gynecologists and the advisory committees of the FDA that EC be available over the counter [16–18]. While EC remains available by prescription only, pharmacies play a key role in access. Regional studies have found that same-day availability ranges from 20% in Albuquerque, NM, to 75% in New York City [12–14]. When pharmacists’ attitudes and knowledge were surveyed, many thought that it was synonymous with mifepristone or caused an abortion, or gave incorrect information about when it could be used [13,14,19]. This study assessed pharmacist knowledge regarding the timing of EC usage and whether a sham patient is able to obtain EC at pharmacies in the Jacksonville, FL, area.
127
formulation and whether a prescription could be filled that day. If the medication was not available, she asked whether it can be ordered quickly and whether the pharmacist can recommend any other options. When appropriate, the shopper asked pharmacy staff if they knew why it was not available at that pharmacy. Immediately upon leaving the pharmacy, the shopper recorded responses to her questions. Of the 142 pharmacies, nine could not be reached with multiple phone attempts, possibly because they have gone out of business. A total of 133 were reached by phone, and 48 of these were visited in person. An additional two pharmacies were visited in person but could not be reached by phone. A shopper called pharmacies during the day to ask if they had Plan B in stock, stating that she would have a written prescription to fill later in the day. Availability, as well as alternate suggestions made by the pharmacy staff, was recorded. Secret shoppers recorded whether the pharmacy staff offered to order Plan B or offered an alternative, such as trying a particular pharmacy that is more likely to carry it. Plan B was considered bavailableQ if it could be provided on that day or within 24 h of the request. If the product was not available within 24 h or could not be obtained at all, the responses provided by the pharmacists were noted.
2. Methods A bsecret shopperQ method, both in person and on the phone, was used. Research assistants presented anonymously as women in need of EC. They asked the pharmacist or pharmacy technician if a Plan B prescription could be filled that day and, if not, whether the pharmacy staff could suggest alternative methods. The pharmacists or pharmacy staff were not informed that the visit or call was part of a research project. Institutional Review Board approval was obtained prior to the beginning of the study. A list of all pharmacies in Jacksonville, FL, was generated using the Jacksonville phone book and was cross-referenced with an online search engine, YellowPages.com. Of 157 identified pharmacies, 11 were eliminated because they were no longer in business and 4 were eliminated because they provided compounded or chemotherapeutic agents only, leaving a total of 142 pharmacies to be surveyed. Nine drugstore or supermarket chains were represented, comprising 122 of the pharmacies overall. In April 2006, four female obstetric and gynecology residents between the ages of 28 and 39 years served as secret shoppers and presented to 54 pharmacies. Visits were at the convenience of the secret shoppers at various days of the week and times of the day. Pharmacy staff members were then asked if they carried Plan B. If the staff member was not familiar with the product, the shopper explained that it was bemergency birth control.Q If the staff person was not a pharmacist, the research assistant requested that she be allowed to ask the pharmacist. Next, the research assistant asked the pharmacy staff how long following unprotected sex she had to begin the EC
3. Results Plan B was available at the time of presentation at 21 of 54 pharmacies (39%) visited. Sixteen pharmacies (29%) provided options facilitating the availability of the medication within 24 h, either by ordering Plan B for the next day, calling other pharmacies or suggesting nearby pharmacies that were more likely to carry it. Seventeen pharmacies (31%) did not have Plan B in stock and did not offer any options for obtaining the prescription. One pharmacy (2%) had it in stock but the pharmacist would not dispense it (Table 1). By phone, 42 pharmacies (32%) stated that they would be able to fill a prescription for Plan B if it was presented on that day. Twenty-three pharmacies (17%) offered to order the medication, but one of these stated that it would take more than 24 h. Eleven stores (8%) suggested trying other pharmacies or clinics that are more likely to carry Plan B. A total of 25% of pharmacies provided a reasonable option by obtaining a prescription from another store or by ordering it within 24 h (Table 1). Of the 48 pharmacies that were both phoned and visited in person, 34 in-person and telephone responses Table 1 Plan B availability in Jacksonville, FL, pharmacies: April 2006
Available immediately Available in b 24 h Not available in b 24 h
In person (n = 54) [n (%)]
By phone (n = 131) [n (%)]
21 (39) 16 (29) 17 (31)
42 (32) 33 (25) 58 (44)
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Table 2 Plan B availability in Jacksonville, FL, by type of pharmacy: April 2006
4. Discussion
Pharmacy
Number of stores
In stock [n (%)]
Available in b 24 h [n (%)]
Not available [n (%)]
CVS Kmart Pavilion Publix SavRite Target Walgreen’s Wal-Mart Winn-Dixie
21 5 5 18 3 7 34 8 22
2 0 0 4 0 7 17 3 5
7 (33) 2 (40) 1 (20) 6 (33) 0 N/A 2 (6) 1 (13) 4 (18)
12 (57) 3 (60) 4 (80) 8 (44) 3 (100) N/A 15 (44) 4 (50) 13 (59)
This study found that, in many cases, EC is not immediately available at Jacksonville pharmacies. The reasons most commonly cited by pharmacists for not carrying Plan B were lack of demand and short expiration time. Three pharmacists cited personal beliefs as the reason for not carrying or dispensing Plan B. None of the pharmacists cited store policy as the reason for not carrying the medication. The lack of availability stems from infrequency of prescribing due to lack of information on the part of patients, providers and pharmacists. We do not know how many prescriptions for Plan B are written or filled in Jacksonville, FL. However, many pharmacists stated that they no longer kept it in stock because they had never received a request for it and it expired quickly. We speculate that infrequent receipt of prescriptions by local pharmacists may explain, at least in part, their lack of familiarity with EC. Many pharmacy staff had to be prompted with a description of the medication, and only half of those pharmacists asked knew how long a patient had to take the medication after unprotected intercourse. Many women are not aware of EC and, therefore, may not request the medication. A recent study in California showed that only 34% of adults knew that there was something called the morning-after pill and that there was a medication they could take to prevent pregnancy following unprotected sex [20]. In large part, health care providers may be responsible for the infrequency of prescriptions. One study found that fewer than half of providers who cared for reproductive-age women knew of the proper dosing of EC or had prescribed EC [21]. A survey of university health clinics showed that one third of these facilities do not prescribe EC [22]. Availability within 24 h was defined as a pharmacist offering to order Plan B and have it available within 24 h or suggesting a credible alternative pharmacy nearby. Inconsistencies between in-person and phone questioning likely had many causes. In-person visits were conducted approximately 1 month prior to phone calls and may explain differences in stocking or recent prescriptions filled. Availability within 24 h was greater when pharmacies were visited in person than when pharmacies were contacted by telephone. This is presumably because staff may assume that, if a patient is calling, the staff members do not need to offer to order it; rather, they can decline, knowing that the patient can call any number of pharmacies until she finds the prescription available. However, if a patient does not have ready access to transportation, she might call only the pharmacy that logistically is easiest for her to visit. Several regional studies have investigated access to EC. In general, our study found less immediate availability but similar access within 24 h. In Albuquerque, NM, a secret shopper study found that only 20% of pharmacies stocked either Plan B or Preven but that 53% could fill the prescription within 24 h [12].
(10)
(22) (100) (50) (38) (23)
were consistent. Six pharmacies offered options to provide Plan B within 24 h when asked in person but did not provide any options when asked on the phone. Three pharmacies stated that Plan B was in stock when asked in person but stated that it was not available when asked on the phoned. Conversely, one pharmacy stated that Plan B was available when asked on the phone but stated that it was not in stock or was not available in b24 h when asked in person. Three pharmacies stated that Plan B was in stock when asked on the phone but stated that they did not have it available but could order it within 24 h when asked in person. Among the nine chain pharmacies represented in the survey, availability varied greatly. Target pharmacy was the only chain to have Plan B in stock in all seven stores in Jacksonville, FL. Of 34 Walgreen’s pharmacies, 17 had Plan B in stock and 2 more offered to order it within 24 h. Of eight Wal-Mart pharmacies, three had the product in stock and one store offered to order it. Of 18 Publix pharmacies, only four had the product in stock but six offered to order Plan B or suggested another convenient store that was likely to carry it (Table 2). Winn-Dixie has 22 pharmacies in Jacksonville; five had Plan B in stock, three offered to order it and one staff member suggested a nearby store likely to carry it. Of 21 CVS pharmacies, two had Plan B in stock, six offered to order it and one suggested a nearby pharmacy. Among five Kmart pharmacies, none had the product in stock and two staff members offered to order it. Of three SavRite pharmacies, none stocked Plan B or offered options for obtaining it. Pavilion pharmacies did not stock Plan B at any of its five stores, but one store suggested trying a nearby store for availability within 24 h. Upon questioning by the research assistants, many pharmacy staff members did not know why the prescription was not carried. Two pharmacists cited a fast expiration time with low demand as the reason for not carrying the prescription. Two pharmacists stated that they had just used the last one within the last week and had not yet restocked. Only three pharmacists reported that it was not carried because of the personal beliefs of the pharmacists at that store. No pharmacy staff members cited company policy as the reason for not carrying the prescription.
A.C. French, A.M. Kaunitz / Contraception 75 (2007) 126–130
A mail survey of pharmacists throughout South Dakota showed that 54% of pharmacists that responded carried EC. Similar to our study, 56% of pharmacists reported low customer demand as the reason for not carrying EC. Unlike the findings in our study, when polled directly, 37% of South Dakota pharmacists reported conscientious objections and 26% reported management decisions as reasons for not carrying EC [14]. Similar to our findings, a phone survey of pharmacists in Pennsylvania found that only 35% could provide EC on the same day [13]. In contrast, a study funded by New York City found that 75% of commercial pharmacies had EC in stock [14]. Despite the media attention on pharmacists’ choice to not dispense Plan B for reasons of conscience [23,24], this did not seem to be a large factor in explaining the unavailability of Plan B in Jacksonville. Only 3 of 54 pharmacies visited by research assistants reported that the prescription was not carried because of the beliefs of the pharmacists. We cannot exclude the possibility, however, that pharmacists’ choice might account for EC not being stocked by other pharmacies. Refusal by pharmacists to carry Plan B for reasons of conscience may have a ripple effect, impacting EC use outside of the specific pharmacy. While only one pharmacist in our study told a patient that she believed Plan B to cause early abortion, that misinformation [1,25] can undermine the decision a patient has reached with her physician and may lead her to rethink finding another pharmacy that does carry the prescription. As pharmacists do not know a patient’s full medical history and do not have a relationship with the patient, some argue that they are not in a position to influence whether a patient receives a lawfully and correctly written prescription [24]. Although availability among chain pharmacies varied greatly, most nationally owned pharmacies do not appear to prohibit access to Plan B. Wal-Mart had previously refused to stock Plan B. As of March, Wal-Mart has stocked the product nationwide, although individual pharmacists can still invoke the conscience clause to refuse to dispense it [23,24,26]. In our study, half of Wal-Mart pharmacies in Jacksonville did not have Plan B in stock, nor did the staff offer to order it or suggest other stores. Only Target pharmacies had 100% stock availability. This study demonstrates barriers to access to the dedicated emergency hormonal product Plan B in commercial pharmacies. Low demand from patients was the most frequently cited reason for not carrying the product. This likely stems from lack of knowledge of the product by patients and clinicians. Pharmacists invoking a conscientious objection to dispensing Plan B not only limit access in that pharmacy but may misinform the patient, causing her to forego the medication. Further education of health care providers, pharmacists and the general public regarding the safety and mechanisms of action is necessary. With greater usage of Plan B, many unintended pregnancies and induced abortions could be prevented. The decision of the FDA in
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August 2006 to implement over-the-counter availability of Plan B in all pharmacies without the need for a prescription for persons z 18 years of age should expand the awareness and, hopefully, the use of EC among women at risk for unintended pregnancy.
References [1] Westhoff C. Emergency contraception. N Engl J Med 2003;349: 1830 – 5. [2] Ellertson C, Webb A, Blanchard K, et al. Modifying the Yuzpe regimen of emergency contraception: a multicenter randomized controlled trial. Obstet Gynecol 2003;101:1160 – 7. [3] Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006;38:90 – 6. [4] Trussell J, Stewart F, Guest F, Hatcher RA. Emergency contraceptive pills: a simple proposal to reduce unintended pregnancies. Fam Plann Perspect 1992;24:269 – 73. [5] ACOG. Emergency contraception. ACOG Practice Bulletin No. 69. American College of Obstetrics and Gynecologists. Obstet Gynecol 2005;106:1443 – 52. [6] Vasilakis C, Jick SS, Jick H. The risk of venous thromboembolism in users of postcoital contraceptive pills. Contraception 1999;59:79 – 83. [7] Yuzpe AA, Thurlow HJ, Ramzy I, Leyshon JI. Post coital contraception — a pilot study. J Reprod Med 1974;13:53 – 8. [8] Ellertson C, Evans M, Ferden S, et al. Extending the time limit for starting the Yuzpe regimen of emergency contraception to 120 hours. Obstet Gynecol 2003;101:1168 – 71. [9] Rodrigues I, Grou F, Joly J. Effectiveness of emergency contraceptive pills between 72 and 120 hours after unprotected intercourse. Am J Obstet Gynecol 2001;184:531 – 7. [10] Von Hertzen H, Piaggio G, Ding J, et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomized trial. Lancet 2002;360:1803 – 10. [11] Trussell J, Duran V, Shochet T, Moore K. Access to emergency contraception. Obstet Gynecol 2000;95:267 – 70. [12] Espey E, Ogburn T, Howard D, Qualls C, Ogburn J. Emergency contraception: pharmacy access in Albuquerque, New Mexico. Obstet Gynecol 2003;102:918 – 21. [13] Bennett W, Petraitis C, D’Anella A, Marcella S. Pharmacists’ knowledge and the difficulty of obtaining emergency contraception. Contraception 2003;68:61 – 7. [14] Van Riper K, Hellerstedt W. Emergency contraceptive pills: dispensing practices, knowledge and attitudes of South Dakota pharmacists. Persp Sex Health Reprod Health 2005;37:19 – 24. [15] FDA takes action on Plan B — statement by FDA Commissioner M. Lester, Crawford, August 26, 2005. Available at: http://www.fda.gov/ bbs/topics/news/2005/NEW01223.html. [16] Krisberg K. Panel favors providing emergency contraception without a prescription. Nation’s Health, 2004. http://www.apha.org/journal/ nation/ectoccover0204.htm [accessed December 10, 2005]. [17] American College of Obstetricians and Gynecologists. Statement of the American College of Obstetricians and Gynecologists supporting the availability of over-the-counter emergency contraception. Washington (DC)7 American College of Obstetricians and Gynecologists; 2001. [18] The Council of the City of New York K. Emergency contraception: is it at your pharmacy yet? Available at: www.nyccouncil.info/pdf_files/ reports/emergpills.pdf, 2004 [accessed December 10, 2005]. [19] Conard LA, Fortenberry D, Blythe M, Orr D. Pharmacists’ attitudes toward and practices with adolescents. Arch Pediatr Adolesc Med 2003;157:361 – 5. [20] Henry J. Kaiser Family Foundation. Emergency contraception in California. Findings from a 2003 Kaiser Family Foundation survey.
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Menlo Park (CA)7 KFF; 2004. Available at: http://www.kff.org/ womenshealth/upload/Emergency-Contraception-in-California.pdf [accessed March 15, 2006]. [21] Sherman CA, Harvey SM, Beckman LJ, Pettiti DB. Emergency contraception: knowledge and attitudes of health care providers in a health maintenance organization. Women’s Health Issues 2001; 11:448 – 57. [22] Brening RK, Dalve-Endres AM, Patrick K. Emergency contraception (ECPs): current trends in United States college health centers. Contraception 2003;67:449 – 56.
[23] Cantor J, Baum K. The limits of conscientious objection — may pharmacists refuse to fill prescriptions for emergency contraception? N Engl J Med 2004;351:2008 – 12. [24] Wall LL, Brown D. Current commentary: refusals by pharmacists to dispense emergency contraception. Obstet Gynecol 2006;107: 1148 – 50. [25] Glasier A. Emergency postcoital contraception. N Engl J Med 1997; 337:1058. [26] Schienberg J. Wal-Mart dealt morning after setback. Available at: www.cnn.com [accessed May 1, 2006].
Original research article
Pharmacy access to emergency hormonal contraception in Jacksonville, FL: a secret shopper surveyB,BB Amy C. French, Andrew M. Kaunitz4 Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL 32209, USA Received 10 August 2006; revised 31 August 2006; accepted 6 September 2006
Abstract Objective: Emergency hormonal contraception (EC) has the potential to reduce the number of unintended pregnancies and induced abortions, but many barriers to more prevalent usage exist. We evaluated one aspect of access — pharmacy availability of levonorgestrel EC (Plan B) or alternatives — in Jacksonville, FL. Method: Female bsecret shoppersQ presented in person and by telephone to pharmacies in Jacksonville, FL, and inquired if Plan B would be available if they were to return with a prescription. Availability of the medication, as well as offers of EC alternatives or alternate methods of obtaining EC, was noted. Furthermore, pharmacist and pharmacy staff knowledge regarding appropriate use of the product was assessed. Results: Of 54 pharmacies visited by secret shoppers, 21 (39%) had Plan B in stock and were willing to dispense it. Sixteen pharmacies (29%) could order it and have it available within 24 h, or knew of nearby pharmacies that stocked the medication. Neither Plan B nor other EC options were offered by 17 pharmacies (31%). One hundred thirty-three pharmacies, including those that were visited in person, were contacted by telephone. Forty-two (32%) of these had Plan B in stock. Another 22 pharmacies (17%) offered to order Plan B for availability within 24 h or less. Furthermore, 11 pharmacies suggested other stores that were more likely to carry it. Of 40 pharmacy staff members asked how long following unprotected intercourse a patient had to take the product, 20 (50%) correctly stated 72 h. Conclusion: Plan B was not in stock in a majority of pharmacies within this large city. Availability was increased by offers to order the medication or by suggestions to seek the prescription at nearby pharmacies. Many pharmacists and their staff were unfamiliar with the medication and its correct usage. D 2007 Elsevier Inc. All rights reserved. Keywords: Pharmacy access; Emergency hormonal contraceptives; Secret shopper survey
1. Introduction Approximately half of all pregnancies in the United States are unintended — resulting from contraceptive failure or nonuse of contraceptives [1,2]. Of these unintended pregnancies, over 40% end in abortion [3]. Emergency hormonal contraception (EC) has the potential to substantially reduce the rate of unintended pregnancy and induced abortion, but many barriers to the timely use of the medication exist [4,5]. EC represents a safe and effective method of preventing pregnancy when used after unprotected intercourse [1,6].
B
No external funding was received to support this project. Disclosure: Dr. Kaunitz is a consultant to Duramed and owns stocks in Walgreen’s. 4 Corresponding author. Tel.: +1 904 244 3109; fax: +1 904 244 3124. E-mail address: [email protected] (A.M. Kaunitz). BB
0010-7824/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2006.09.004
Regimens using various oral contraceptives have been found to be effective since the Yuzpe method was first introduced in the 1970s [7]. Currently, a levonorgestrel-only method is preferred because of fewer side effects and improved efficacy [5]. Plan B (Duramed, Pomona, NY), a two-tablet levonorgestrel formulation, represents the only dedicated EC method in the United States. When used within 72 h of unprotected intercourse, combined estrogen/progestin (Yuzpe method) and progestin-only methods prevent approximately 75% of pregnancies that otherwise would have occurred [1,4]. Recent studies have found that the time limit for the use of either method may be extended to 120 h following unprotected sex, although earlier use is likely to be most effective [8–10]. A copper T 380A IUD may also be placed up to 5 days after unprotected intercourse to prevent pregnancy when longterm birth control is desired [1], but it is not commonly used for emergency contraception in the United States.
A.C. French, A.M. Kaunitz / Contraception 75 (2007) 126–130
Many obstacles to obtaining EC have been identified [11,12]. Lack of awareness, misconceptions by health care providers and consumers (including the belief that EC may cause abortion or may be synonymous with bthe abortion pillQ mifepristone), and challenges faced by women seeking to fill a prescription quickly have all represented barriers [11–14]. In September 2005, the Food and Drug Administration (FDA) again denied over-the-counter access of EC [15] despite recommendations by the American College of Obstetricians and Gynecologists and the advisory committees of the FDA that EC be available over the counter [16–18]. While EC remains available by prescription only, pharmacies play a key role in access. Regional studies have found that same-day availability ranges from 20% in Albuquerque, NM, to 75% in New York City [12–14]. When pharmacists’ attitudes and knowledge were surveyed, many thought that it was synonymous with mifepristone or caused an abortion, or gave incorrect information about when it could be used [13,14,19]. This study assessed pharmacist knowledge regarding the timing of EC usage and whether a sham patient is able to obtain EC at pharmacies in the Jacksonville, FL, area.
127
formulation and whether a prescription could be filled that day. If the medication was not available, she asked whether it can be ordered quickly and whether the pharmacist can recommend any other options. When appropriate, the shopper asked pharmacy staff if they knew why it was not available at that pharmacy. Immediately upon leaving the pharmacy, the shopper recorded responses to her questions. Of the 142 pharmacies, nine could not be reached with multiple phone attempts, possibly because they have gone out of business. A total of 133 were reached by phone, and 48 of these were visited in person. An additional two pharmacies were visited in person but could not be reached by phone. A shopper called pharmacies during the day to ask if they had Plan B in stock, stating that she would have a written prescription to fill later in the day. Availability, as well as alternate suggestions made by the pharmacy staff, was recorded. Secret shoppers recorded whether the pharmacy staff offered to order Plan B or offered an alternative, such as trying a particular pharmacy that is more likely to carry it. Plan B was considered bavailableQ if it could be provided on that day or within 24 h of the request. If the product was not available within 24 h or could not be obtained at all, the responses provided by the pharmacists were noted.
2. Methods A bsecret shopperQ method, both in person and on the phone, was used. Research assistants presented anonymously as women in need of EC. They asked the pharmacist or pharmacy technician if a Plan B prescription could be filled that day and, if not, whether the pharmacy staff could suggest alternative methods. The pharmacists or pharmacy staff were not informed that the visit or call was part of a research project. Institutional Review Board approval was obtained prior to the beginning of the study. A list of all pharmacies in Jacksonville, FL, was generated using the Jacksonville phone book and was cross-referenced with an online search engine, YellowPages.com. Of 157 identified pharmacies, 11 were eliminated because they were no longer in business and 4 were eliminated because they provided compounded or chemotherapeutic agents only, leaving a total of 142 pharmacies to be surveyed. Nine drugstore or supermarket chains were represented, comprising 122 of the pharmacies overall. In April 2006, four female obstetric and gynecology residents between the ages of 28 and 39 years served as secret shoppers and presented to 54 pharmacies. Visits were at the convenience of the secret shoppers at various days of the week and times of the day. Pharmacy staff members were then asked if they carried Plan B. If the staff member was not familiar with the product, the shopper explained that it was bemergency birth control.Q If the staff person was not a pharmacist, the research assistant requested that she be allowed to ask the pharmacist. Next, the research assistant asked the pharmacy staff how long following unprotected sex she had to begin the EC
3. Results Plan B was available at the time of presentation at 21 of 54 pharmacies (39%) visited. Sixteen pharmacies (29%) provided options facilitating the availability of the medication within 24 h, either by ordering Plan B for the next day, calling other pharmacies or suggesting nearby pharmacies that were more likely to carry it. Seventeen pharmacies (31%) did not have Plan B in stock and did not offer any options for obtaining the prescription. One pharmacy (2%) had it in stock but the pharmacist would not dispense it (Table 1). By phone, 42 pharmacies (32%) stated that they would be able to fill a prescription for Plan B if it was presented on that day. Twenty-three pharmacies (17%) offered to order the medication, but one of these stated that it would take more than 24 h. Eleven stores (8%) suggested trying other pharmacies or clinics that are more likely to carry Plan B. A total of 25% of pharmacies provided a reasonable option by obtaining a prescription from another store or by ordering it within 24 h (Table 1). Of the 48 pharmacies that were both phoned and visited in person, 34 in-person and telephone responses Table 1 Plan B availability in Jacksonville, FL, pharmacies: April 2006
Available immediately Available in b 24 h Not available in b 24 h
In person (n = 54) [n (%)]
By phone (n = 131) [n (%)]
21 (39) 16 (29) 17 (31)
42 (32) 33 (25) 58 (44)
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A.C. French, A.M. Kaunitz / Contraception 75 (2007) 126–130
Table 2 Plan B availability in Jacksonville, FL, by type of pharmacy: April 2006
4. Discussion
Pharmacy
Number of stores
In stock [n (%)]
Available in b 24 h [n (%)]
Not available [n (%)]
CVS Kmart Pavilion Publix SavRite Target Walgreen’s Wal-Mart Winn-Dixie
21 5 5 18 3 7 34 8 22
2 0 0 4 0 7 17 3 5
7 (33) 2 (40) 1 (20) 6 (33) 0 N/A 2 (6) 1 (13) 4 (18)
12 (57) 3 (60) 4 (80) 8 (44) 3 (100) N/A 15 (44) 4 (50) 13 (59)
This study found that, in many cases, EC is not immediately available at Jacksonville pharmacies. The reasons most commonly cited by pharmacists for not carrying Plan B were lack of demand and short expiration time. Three pharmacists cited personal beliefs as the reason for not carrying or dispensing Plan B. None of the pharmacists cited store policy as the reason for not carrying the medication. The lack of availability stems from infrequency of prescribing due to lack of information on the part of patients, providers and pharmacists. We do not know how many prescriptions for Plan B are written or filled in Jacksonville, FL. However, many pharmacists stated that they no longer kept it in stock because they had never received a request for it and it expired quickly. We speculate that infrequent receipt of prescriptions by local pharmacists may explain, at least in part, their lack of familiarity with EC. Many pharmacy staff had to be prompted with a description of the medication, and only half of those pharmacists asked knew how long a patient had to take the medication after unprotected intercourse. Many women are not aware of EC and, therefore, may not request the medication. A recent study in California showed that only 34% of adults knew that there was something called the morning-after pill and that there was a medication they could take to prevent pregnancy following unprotected sex [20]. In large part, health care providers may be responsible for the infrequency of prescriptions. One study found that fewer than half of providers who cared for reproductive-age women knew of the proper dosing of EC or had prescribed EC [21]. A survey of university health clinics showed that one third of these facilities do not prescribe EC [22]. Availability within 24 h was defined as a pharmacist offering to order Plan B and have it available within 24 h or suggesting a credible alternative pharmacy nearby. Inconsistencies between in-person and phone questioning likely had many causes. In-person visits were conducted approximately 1 month prior to phone calls and may explain differences in stocking or recent prescriptions filled. Availability within 24 h was greater when pharmacies were visited in person than when pharmacies were contacted by telephone. This is presumably because staff may assume that, if a patient is calling, the staff members do not need to offer to order it; rather, they can decline, knowing that the patient can call any number of pharmacies until she finds the prescription available. However, if a patient does not have ready access to transportation, she might call only the pharmacy that logistically is easiest for her to visit. Several regional studies have investigated access to EC. In general, our study found less immediate availability but similar access within 24 h. In Albuquerque, NM, a secret shopper study found that only 20% of pharmacies stocked either Plan B or Preven but that 53% could fill the prescription within 24 h [12].
(10)
(22) (100) (50) (38) (23)
were consistent. Six pharmacies offered options to provide Plan B within 24 h when asked in person but did not provide any options when asked on the phone. Three pharmacies stated that Plan B was in stock when asked in person but stated that it was not available when asked on the phoned. Conversely, one pharmacy stated that Plan B was available when asked on the phone but stated that it was not in stock or was not available in b24 h when asked in person. Three pharmacies stated that Plan B was in stock when asked on the phone but stated that they did not have it available but could order it within 24 h when asked in person. Among the nine chain pharmacies represented in the survey, availability varied greatly. Target pharmacy was the only chain to have Plan B in stock in all seven stores in Jacksonville, FL. Of 34 Walgreen’s pharmacies, 17 had Plan B in stock and 2 more offered to order it within 24 h. Of eight Wal-Mart pharmacies, three had the product in stock and one store offered to order it. Of 18 Publix pharmacies, only four had the product in stock but six offered to order Plan B or suggested another convenient store that was likely to carry it (Table 2). Winn-Dixie has 22 pharmacies in Jacksonville; five had Plan B in stock, three offered to order it and one staff member suggested a nearby store likely to carry it. Of 21 CVS pharmacies, two had Plan B in stock, six offered to order it and one suggested a nearby pharmacy. Among five Kmart pharmacies, none had the product in stock and two staff members offered to order it. Of three SavRite pharmacies, none stocked Plan B or offered options for obtaining it. Pavilion pharmacies did not stock Plan B at any of its five stores, but one store suggested trying a nearby store for availability within 24 h. Upon questioning by the research assistants, many pharmacy staff members did not know why the prescription was not carried. Two pharmacists cited a fast expiration time with low demand as the reason for not carrying the prescription. Two pharmacists stated that they had just used the last one within the last week and had not yet restocked. Only three pharmacists reported that it was not carried because of the personal beliefs of the pharmacists at that store. No pharmacy staff members cited company policy as the reason for not carrying the prescription.
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A mail survey of pharmacists throughout South Dakota showed that 54% of pharmacists that responded carried EC. Similar to our study, 56% of pharmacists reported low customer demand as the reason for not carrying EC. Unlike the findings in our study, when polled directly, 37% of South Dakota pharmacists reported conscientious objections and 26% reported management decisions as reasons for not carrying EC [14]. Similar to our findings, a phone survey of pharmacists in Pennsylvania found that only 35% could provide EC on the same day [13]. In contrast, a study funded by New York City found that 75% of commercial pharmacies had EC in stock [14]. Despite the media attention on pharmacists’ choice to not dispense Plan B for reasons of conscience [23,24], this did not seem to be a large factor in explaining the unavailability of Plan B in Jacksonville. Only 3 of 54 pharmacies visited by research assistants reported that the prescription was not carried because of the beliefs of the pharmacists. We cannot exclude the possibility, however, that pharmacists’ choice might account for EC not being stocked by other pharmacies. Refusal by pharmacists to carry Plan B for reasons of conscience may have a ripple effect, impacting EC use outside of the specific pharmacy. While only one pharmacist in our study told a patient that she believed Plan B to cause early abortion, that misinformation [1,25] can undermine the decision a patient has reached with her physician and may lead her to rethink finding another pharmacy that does carry the prescription. As pharmacists do not know a patient’s full medical history and do not have a relationship with the patient, some argue that they are not in a position to influence whether a patient receives a lawfully and correctly written prescription [24]. Although availability among chain pharmacies varied greatly, most nationally owned pharmacies do not appear to prohibit access to Plan B. Wal-Mart had previously refused to stock Plan B. As of March, Wal-Mart has stocked the product nationwide, although individual pharmacists can still invoke the conscience clause to refuse to dispense it [23,24,26]. In our study, half of Wal-Mart pharmacies in Jacksonville did not have Plan B in stock, nor did the staff offer to order it or suggest other stores. Only Target pharmacies had 100% stock availability. This study demonstrates barriers to access to the dedicated emergency hormonal product Plan B in commercial pharmacies. Low demand from patients was the most frequently cited reason for not carrying the product. This likely stems from lack of knowledge of the product by patients and clinicians. Pharmacists invoking a conscientious objection to dispensing Plan B not only limit access in that pharmacy but may misinform the patient, causing her to forego the medication. Further education of health care providers, pharmacists and the general public regarding the safety and mechanisms of action is necessary. With greater usage of Plan B, many unintended pregnancies and induced abortions could be prevented. The decision of the FDA in
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August 2006 to implement over-the-counter availability of Plan B in all pharmacies without the need for a prescription for persons z 18 years of age should expand the awareness and, hopefully, the use of EC among women at risk for unintended pregnancy.
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