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In the United States, numerous states have enabled pharmacists to prescribe hormonal contraception. Little research focuses on the perspectives of potential users of this service in rural communities. This study sought to describe awareness of, interest in, acceptability of, and support for pharmacist-prescribed contraception in a rural California county.
Study DesignWe conducted a community-based survey in 2019–20 in Tulare County, California. Researchers partnered with community members to design, implement, and analyze the survey. We recruited respondents who were ages 15 to 44 and assigned female sex at birth, using passive community-based approaches, social media advertisements, and social networks. Analyses focused on 177 respondents with a potential future need for contraception.
ResultsThirty-one percent of respondents were aware that pharmacists could prescribe hormonal contraception in California, with more accurate knowledge among older respondents (p = 0.015). After receiving brief educational information about pharmacist-prescribed contraception, respondents expressed high levels of support and acceptability: they perceived pharmacist-prescribed contraception to be safe, time saving, and more convenient. Respondents were more comfortable talking about contraception with traditional contraceptive care providers compared to asking pharmacists questions about contraception. Fifty-seven percent were somewhat or very interested in obtaining contraception from a pharmacist, with higher levels of interest among those who preferred to use a different method.
ConclusionAwareness of pharmacist-prescribed contraception in a rural California community was low, though people are supportive of and interested in utilizing this service. This research suggests that increased availability of pharmacist-prescribed contraception could support individuals’ reproductive self-determination and address gaps in access.
1. IntroductionIn rural communities in the United States (US), an approach for addressing healthcare access inequities is expanding care offered through pharmacies [1Rural–urban differences in health care access among women of reproductive age: a 10-year pooled analysis., , 3Radford A Indira Richardson M Mason M Rutledge S ]. As of March 2022, 24 states and the District of Columbia have enabled pharmacists to prescribe contraception (sometimes referred to as “pharmacy access”) []. California passed legislation authorizing pharmacist prescribing of hormonal contraception in 2013, with services beginning in 2016 following implementation of a statewide protocol [[5]California Senate Bill No. 493. Pharmacy practice. 2013.
,[6]California State Board of PharmacyLogan R, Gomez AM, Rafie S, Malcolm N, Stern L, Hart J Priority roadmap for policy-ready contraceptive research environmental scan report: pharmacist-prescribed hormonal contraception. Washington, D.C.: The Coalition to Expand Contraceptive Access; 2021.
]. In 2020, 65% of reproductive-age women in the US were comfortable with pharmacists prescribing contraception []. Notably, a qualitative study of California pharmacists found that while pharmacists saw broad benefits to prescribing contraception, the perception of little community interest was a disincentive to offering it [[18]Gomez AM McCullough C Fadda R Ganguly B Gustafson E Severson N et al.Facilitators and barriers to implementing pharmacist-prescribed hormonal contraception in California independent pharmacies.]. Few studies center the perspectives of potential users of this service, particularly since pharmacist-prescribed contraception has been implemented. In analysis of survey data from 4 states, individuals obtaining pharmacist-prescribed contraception did so primarily for ease and convenience. Compared to respondents receiving clinic-based contraceptive care, those obtaining pharmacist-prescribed contraception were significantly more likely to indicate they would return to their provider and refer them to a friend [[19]Rodriguez MI Edelman AB Skye M Darney BG. Reasons for and experience in obtaining pharmacist prescribed contraception.]. Likewise, another study found that users of pharmacist-prescribed contraception in California reported high satisfaction with the service, comfort with the pharmacist, and visit privacy [[20]Rafie S Wollum A Grindlay K Patient experiences with pharmacist-prescribed hormonal contraception in California independent and chain pharmacies.]. Despite the paucity of contemporary research, several studies suggest that when people are made aware of the service, they are willing to use it [[9]Meredith AH Vahary EB Wilkinson TA Meagher CG Vielott T Ott MA Adolescents’ perceptions of contraception access through pharmacies.,[10]O'Connell MB Samman L Bailey T King L Wellman GS Attitudes of Michigan female college students about pharmacists prescribing birth control in a community pharmacy.,[21]Meredith A Olenik N Farris K Hudmon Suchanek K Women's perceptions of pharmacist-prescribed hormonal contraception.,[22]Walker T Colayco D Yacobi R Lawless GD Factors associated with unintended pregnancy, contraceptive risk-taking, and interest in pharmacist-provided birth control.]. Little research focuses on communities facing the greatest barriers to contraceptive access [[17]Logan R, Gomez AM, Rafie S, Malcolm N, Stern L, Hart J Priority roadmap for policy-ready contraceptive research environmental scan report: pharmacist-prescribed hormonal contraception. Washington, D.C.: The Coalition to Expand Contraceptive Access; 2021.
,[23]Landau S Besinque K Chung F Dries-Daffner I Maderes NM McGhee BT et al.Pharmacist interest in and attitudes toward direct pharmacy access to hormonal contraception in the United States.]. One study examined the perspectives and needs of people in a resource limited setting, with 43% of participants (n = 97) in a rural California farming community expressing interest in pharmacist-prescribed contraception [[22]Walker T Colayco D Yacobi R Lawless GD Factors associated with unintended pregnancy, contraceptive risk-taking, and interest in pharmacist-provided birth control.].Availability of pharmacist-prescribed contraception in California remains limited. One year after implementation, only 5% to 11% of community pharmacies (pharmacies with medications and services available to the general public) offered pharmacist-prescribed contraception statewide, with no difference by urban-rural location [[24]Batra P Rafie S Zhang Z Singh AV Bird CE Sridhar A et al.An evaluation of the implementation of pharmacist-prescribed hormonal contraceptives in California.,[25]Availability of pharmacist-prescribed contraception in California, 2017.]. Two studies have addressed availability in rural settings. While data from Oregon and New Mexico showed no difference in availability by rural-urban location [[26]Rodriguez MI Garg B Williams SM Souphanavong J Schrote K Darney BG Availability of pharmacist prescription of contraception in rural areas of Oregon and New Mexico.], a qualitative study with pharmacists in rural New Mexico suggested that pharmacist-prescribed contraception could help address access barriers faced by rural residents, particularly those who were uninsured or had difficulty reaching clinics for contraceptive care [[27]Herman A McCauley G Thaxton L Borrego M Sussman AL Espey E Perspectives on prescribing hormonal contraception among rural New Mexican pharmacists.].Rural settings pose unique circumstances for implementation of pharmacist-prescribed contraception that warrant further exploration. Previous research in rural environments has revealed significant barriers in healthcare access associated with sociocultural and geographic factors [28Yarger J Decker MJ Campa MI Brindis CD Rural–urban differences in awareness and use of family planning services among adolescent women in California., 29Douthit N Kiv S Dwolatzky T Biswas S Exposing some important barriers to health care access in the rural USA., 30Ranji U Long M Salganicoff A Rosenzweig C Silow-Carroll S Beyond the numbers: access to reproductive health care for low-income women in five communities.]. Using a participatory research design, this study sought to describe community members’ awareness of, attitudes toward, interest in, and comfort with pharmacist-prescribed contraception in a rural California community.2. Materials and methodsBetween November 2019 and May 2020, we conducted a community-based survey of people assigned female sex at birth in Tulare County, California. Tulare County is located in the Central Valley, a largely agricultural region that faces some of the state’s greatest reproductive health inequities [30Ranji U Long M Salganicoff A Rosenzweig C Silow-Carroll S Beyond the numbers: access to reproductive health care for low-income women in five communities., 31Greene J Badley E Nguyen T Adams M Cutler K , 32Mccain C Krakowiak P Sun D Reynen D Ramos D Ahmad S et al.California pregnancy-associated mortality review: California pregnancy-related deaths, 2008-2016.]. Sixty-six percent of Tulare County residents are Latinx, while 28% are white, 4% Asian, 3% Native American, and 2% Black []. Half of households speak a language other than English at home, with 22% of residents born outside of the US [].Through an academic-community partnership informed by reproductive justice, we sought to foreground community perspectives on pharmacist-prescribed contraception. Conceptualized by Black women in the US in the 1990s, reproductive justice is a social movement, framework, and means of praxis anchored in 4 central tenets: the rights to parent, to have a child, to not have a child, and to bodily self-determination [[34]Reproductive justice: an introduction.]. The ways that researchers engage reproductive justice is evolving: in the present study, we implemented community-based participatory research processes to center the expertise of community members throughout the life of the project []. As such, we developed a community research program in which community members trained as co-researchers. Community researchers ranged in age from 14 to 51, represented multiple communities in Tulare County, and participated in sessions in English or Spanish. In 2019, we collaborated closely with ten community researchers to develop and pilot the survey. In 2020, 6 of these community researchers returned to the project to collaborate on analysis and dissemination activities, including the present paper.Community researchers contributed to recruitment, disseminating printed materials to their social networks. We also recruited participants via passive approaches, including leaving study materials at community-based organizations, events, and public spaces, as well as via geographically targeted social media advertisements. Eligibility criteria included: age between 15 and 44 years, residence in Tulare County, and assignment of female sex at birth. Respondents provided informed consent or assent electronically and completed the survey online in English or Spanish. Upon completion, respondents received a $5 gift card. The Committee for the Protection of Human Subjects at the University of California, Berkeley approved the study protocol.
2.1 MeasuresSurvey topics included awareness of and attitudes towards pharmacist-prescribed contraception, interest in use, contraceptive use and access, and sociodemographic characteristics. We developed key measures in collaboration with community researchers. All English survey questions used the term “birth control” rather than contraception, following the convention of national surveys [], US public health goals [], and validated quality measures [] and using the language that community researchers deemed most accessible. First, we asked respondents to the best of their knowledge, “Can women go directly to a pharmacy in California to get some kinds of birth control, without seeing a doctor or nurse first?” (response options: yes, no, not sure). Later in the survey, we provided educational information about pharmacist-prescribed contraception, stating that California pharmacists had been able to prescribe 4 types of methods since 2016, that some pharmacies only served individuals ages 18 and older, and that health insurance covers the cost of the medication, but individuals may have to pay a consultation fee. Following this educational information, we assessed acceptability of pharmacist-prescribed contraception. We asked, “In general, how comfortable do you feel asking pharmacists questions about birth control?” (response options: very, somewhat, a little, or not at all comfortable). To assess interest in using this service, we asked, “How interested would you be in getting birth control directly from a pharmacist, without seeing a doctor or nurse first?” (response options: very, somewhat, a little, or not at all interested; not sure). We additionally asked respondents about other aspects of acceptability and their support for pharmacist-prescribed contraception (items in Tables 4 and 5).We assessed several aspects of contraceptive access and use, including contraceptive use in the last month, preference for using another method, and comfort discussing contraception with a physician or nurse. We assessed sociodemographic characteristics, including participants’ age, gender, and current insurance coverage for contraception.
2.2 AnalysisTwo hundred fifteen eligible respondents completed the survey. To focus on potential users of pharmacist-prescribed contraception, we excluded 38 respondents indicating that they did not want or need to use contraception, for a final sample size of 177 respondents. We produced descriptive statistics and used chi-squared tests to examine the association between awareness of pharmacist-prescribed contraception and other key measures (age, insurance, and desire to use a different contraceptive method). We repeated this bivariate analysis for interest in using pharmacist-prescribed contraception. We used Stata statistical analysis software (version 15.1) for all analyses.
4. DiscussionOur study—the first, to our knowledge, to use a participatory research approach and focus on rural community members’ awareness, attitudes, and interest in pharmacist-prescribed contraception—indicates that while there is strong interest and support for pharmacist-prescribed contraception, awareness is low. In addition to the contemporary nature of our data, we contribute numerous insights around respondents’ comfort with the service, community benefits, and greater interest among those not using their preferred contraceptive method. Respondents were more comfortable talking about contraception with physicians and nurses than asking pharmacists questions about contraception. Most respondents noted that pharmacist-prescribed contraception would be very beneficial to people, especially teens, in their community, and about half thought it would be very or somewhat beneficial to them personally. About half of respondents were very or somewhat interested in obtaining pharmacist-prescribed contraception in the future; among these participants, two-thirds would prefer to use a different contraceptive method.
Our findings broadly resonate with the scant existing research on community perspectives on pharmacist-prescribed contraception, which generally uses data collected when this service was hypothetical. Other contemporary research has found high levels of interest in pharmacist-prescribed contraception [[9]Meredith AH Vahary EB Wilkinson TA Meagher CG Vielott T Ott MA Adolescents’ perceptions of contraception access through pharmacies.,[10]O'Connell MB Samman L Bailey T King L Wellman GS Attitudes of Michigan female college students about pharmacists prescribing birth control in a community pharmacy.,[22]Walker T Colayco D Yacobi R Lawless GD Factors associated with unintended pregnancy, contraceptive risk-taking, and interest in pharmacist-provided birth control.]. Several qualitative studies find that participants appreciated receiving contraceptive care in traditional settings and their relationships with those providers; participants also had concerns about privacy in the pharmacy and judgment from pharmacists [[9]Meredith AH Vahary EB Wilkinson TA Meagher CG Vielott T Ott MA Adolescents’ perceptions of contraception access through pharmacies.,[21]Meredith A Olenik N Farris K Hudmon Suchanek K Women's perceptions of pharmacist-prescribed hormonal contraception.,[39]Zuniga C Wollum A Katcher T Grindlay K Youth perspectives on pharmacists’ provision of birth control: findings from a focus group study.]. With regards to attitudes towards pharmacist-prescribed contraception, several studies find that participants perceived pharmacies as more accessible and convenient than clinic- or office-based contraceptive care providers [[9]Meredith AH Vahary EB Wilkinson TA Meagher CG Vielott T Ott MA Adolescents’ perceptions of contraception access through pharmacies.,[21]Meredith A Olenik N Farris K Hudmon Suchanek K Women's perceptions of pharmacist-prescribed hormonal contraception.,[39]Zuniga C Wollum A Katcher T Grindlay K Youth perspectives on pharmacists’ provision of birth control: findings from a focus group study.,[40]Wilkinson TA Miller C Rafie S Landau SC Rafie S Older teen attitudes toward birth control access in pharmacies: a qualitative study.], while another study found that users of pharmacist-prescribed contraception chose pharmacies for reasons of convenience and ease and reported higher satisfaction with their care compared to users of clinic-based care [[19]Rodriguez MI Edelman AB Skye M Darney BG. Reasons for and experience in obtaining pharmacist prescribed contraception.].This study has several important implications for clinical practice and policy. First, pharmacists should be aware of people's comfort level discussing contraception with pharmacists and enhance comfort with private space in the pharmacy, approachability, and patient-centered care. Additionally, our analysis finds that, after receiving brief educational information, respondents of all ages had interest in pharmacist-prescribed contraception. Policymakers should consider not including age restrictions to realize the promise of increased contraceptive access via pharmacies. Affordability was a primary consideration for respondents. Thus, policymakers should enact policies requiring coverage parity for contraceptive services across healthcare providers, including pharmacists. Finally, given low levels of awareness, public education efforts (including those addressing cost) are much-needed, particularly for adolescents and young adults.
Several key features set this study apart from extant research: it is community-focused; it provides data on knowledge of, attitudes towards, and interest in pharmacist-prescribed contraception; and it does so in a state where pharmacist-prescribed contraception is currently available. Its strengths include a rural focus, a high proportion of respondents younger than 25 and identifying with a racialized group, and the use of a gender inclusive approach. Respondents were able to complete the survey in English or Spanish. Additionally, this study was conducted through a reproductive justice-centered partnership between academic researchers (including a pharmacist) and community members. The primary limitation of this study is sample non-representativeness; while a population-based survey would provide representative estimates of metrics of interest, such data collection was cost prohibitive. While the distribution of racial/ethnic identities in our sample is similar to the overall county population, other groups are underrepresented, such as individuals born outside of the US []. Additionally, this study had a narrow geographical focus. We found that respondents were more comfortable engaging in discussions about contraception with traditional providers in traditional contraceptive care settings than pharmacists; notably, our data do not address whether discomfort was rooted in the idea of pharmacists as contraceptive care providers, the pharmacy setting, or both.With declining access to reproductive healthcare in rural settings [[1]Rural–urban differences in health care access among women of reproductive age: a 10-year pooled analysis.,], future research should highlight the needs and experiences of rural communities. This study suggests several important directions for user-centered, community-based research on pharmacist-prescribed contraception. First, it highlights the importance of community-centered research approaches, including participatory research, to foreground the important perspectives of potential and actual users of pharmacist-prescribed contraception. Second, implementation research should investigate the ways that pharmacies are addressing anticipated barriers to patients engaging in contraceptive care. Strategies for ensuring patient privacy, building trust and comfort, and reducing stigma associated with contraceptive care are key topics of interest. Third, our finding that respondents who wanted to use a different contraceptive method were more likely to be interested in pharmacist-prescribed contraception suggests the need for future research on what gaps this service is filling and the ways that availability of this contraceptive care option may improve reproductive self-determination. Finally, given the limited availability of the service [[24]Batra P Rafie S Zhang Z Singh AV Bird CE Sridhar A et al.An evaluation of the implementation of pharmacist-prescribed hormonal contraceptives in California.,[25]Availability of pharmacist-prescribed contraception in California, 2017.], few respondents had obtained or attempted to obtain pharmacist-prescribed contraception. As implementation increases in California and other states, it is important to understand the experiences of people using or attempting to use this service, including quality of care, and whether anticipated privacy or comfort concerns play out. In particular, understanding why patients seek pharmacist-prescribed contraception may have implications for other settings and reveal whether implementation of this service is creating access and/or improving quality for people facing barriers versus people for whom care is already accessible, or both [[17]Logan R, Gomez AM, Rafie S, Malcolm N, Stern L, Hart J Priority roadmap for policy-ready contraceptive research environmental scan report: pharmacist-prescribed hormonal contraception. Washington, D.C.: The Coalition to Expand Contraceptive Access; 2021.
].In conclusion, this study suggests that increased availability of pharmacist-prescribed contraception could support individuals’ reproductive self-determination and increase access, as respondents who wanted to use a different contraceptive method expressed greater interest. As pharmacists have noted that uncertainty about demand for pharmacist-prescribed contraception has factored into their hesitance to implement this service [[18]Gomez AM McCullough C Fadda R Ganguly B Gustafson E Severson N et al.Facilitators and barriers to implementing pharmacist-prescribed hormonal contraception in California independent pharmacies.], these data provide important evidence of community interest in and need for pharmacist-prescribed contraception.
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