Women’s perspectives of direct pharmacy access to oral contraception

Introduction

Aside from the emergency contraceptive pill (ECP), contraceptive methods in Australia are currently prescription medicines (Australian Government, Therapeutic Goods Administration 2016). International literature suggests consumers experience barriers associated with contraceptive prescription requirements, including medical appointment costs, and temporal and geographical challenges (Landau et al. 2006; Dennis and Grossman 2012; Manski and Kottke 2015), and that eliminating the need to visit a clinician for contraceptive prescriptions would simplify and increase access (Dennis and Grossman 2012). As such, community pharmacists in over 100 countries now dispense many contraceptive methods without a medical prescription (Grossman 2015). Consistent with international evidence (Lindh et al. 2017; Teal and Edelman 2021), enhancing access to oral contraceptive pills (OCPs) is crucial as these are the most commonly used contraceptive methods in Australia (Richters et al. 2016).

There are several pharmacy-oriented models of care that could be implemented in Australia ranging from direct off-the-shelf access (as is prevalent in countries where OCPs are unregulated products) to pharmacist-prescribed OCPs (in which pharmacists perform consultations and dispensing with GP collaboration for a prescription retrospectively) (Grindlay et al. 2013). Most trialled care models involve mandatory pharmacist consultations, with some involving a screening questionnaire prior to a consultation with the pharmacist. This approach has been demonstrated as a safe and acceptable way to screen for contraindications to the OCP (Shotorbani et al. 2006; Xu et al. 2014). Prior research further indicates the vast majority of consumers are satisfied with direct pharmacy access due to increased convenience and decreased costs (Gardner et al. 2008; Parsons et al. 2013).

While international studies have suggested consumers are in favour of OTC access (Dennis and Grossman 2012; Grossman et al. 2013; Corscadden et al. 2017), there is limited research on consumer preferences in Australia. Moreover, it is important to explore women’s views on different models of OTC access (e.g. with pharmacist consultation ± self-screening or off-the-shelf) to provide information on how to best shape future models of care. While deregulation to a direct off-the-shelf model is unlikely to occur any time soon (given the Therapeutic Goods Administration declined an application to downregulate OCPs to pharmacist-only medicines in 2021) (Therapeutic Goods Administration 2021), we wanted to explore women’s thinking irrespective of the current restrictions to determine what features of direct pharmacy provision women value in potential models of care. This study aimed to investigate Australian women’s perspectives on direct pharmacy access to OCPs, their perceptions of various OTC access models, and their preferred model.

Methods

A qualitative study design using in-depth interviews was chosen to gain a detailed understanding of consumers’ perspectives on which aspects of pharmacy access were important to women and why (Kim et al. 2017). Women living in Australia, aged 18–44 years, were recruited via a post to a Facebook group due to social media’s proven effectiveness in recruiting women of reproductive age and from a younger adult demographic (Harris et al. 2015; Whitaker et al. 2017). The community group ‘Girls trade’ was selected as it aims to connect women from across Australia and trade information and items, and has a following of 66 000 members. The advertisement included a brief description of the project and link to an online eligibility survey in Qualtrics (Qualtrics, Provo, UT). To be eligible, potential participants had to have a current want/need to use oral contraception for the purpose of pregnancy prevention, i.e. they needed to have been or anticipate being sexually active with a cis man in the last 6 months or next 6 months, respectively; not currently be pregnant or trying to get pregnant; not have given birth in the last 2 months; not have undergone a hysterectomy/tubal ligation or their partner a vasectomy; and not be currently using long-acting reversible contraception (e.g. intrauterine device/implant).

After confirming their eligibility, interested potential participants provided demographic details (age, postcode, and level of education) and details of current contraceptive use using the same Qualtrics survey.

Postcodes determined the Index of Relative Socio-economic Advantage and Disadvantage (IRSAD) Census data, ranking each postcode from one through 10 (Australian Bureau of Statistics 2016). Participants were purposively sampled using IRSAD, aiming to interview at least one participant from each decile, to allow sample stratification based on age and IRSAD. While the sample size was too small for generalisation, stratification facilitated capturing major variations and comparisons, discussing differences in consumers from different socio-economic backgrounds (Patton 2015). Participants provided informed consent through an online Qualtrics form and received a A$50 gift voucher as compensation.

Rather than our recruitment methods being guided by the concept of data saturation we decided to cease recruitment after 20 interviews, having gained adequate amount and depth of data to explicate shared meanings across participants’ quotes, as aligned with reflexive thematic analysis methods (Braun and Clarke 2021).

Results

Three-hundred and fifty-two women completed the recruitment screening survey, of which 186 met the inclusion criteria. The 20 women purposively sampled and interviewed had a median age of 22 years old (Table 1).

Four themes were identified, as described below.

Discussion

Overall, we found the need to visit a GP for OCPs is perceived as not only an inconvenience, but in some cases a considerable barrier to access. Many participants would prefer to be able to access their OCP directly from a pharmacist. However, they emphasised the importance of pharmacists being appropriately trained to safely deliver contraceptive care, ensuring women are able to receive contraceptive advice in private dedicated counselling rooms.

While US studies suggest women may feel uncomfortable seeking contraception information from pharmacists due to inadequate training (Meredith et al. 2020a, 2020b), and women in Australia have previously reported reluctance to discuss their sexual health with a pharmacist (Hobbs et al. 2011), we found that women were confident in a pharmacist’s ability to provide OCPs and advice that is relevant to their contraceptive needs. Despite not all participants having a regular pharmacist, the majority still felt comfortable receiving consultations from pharmacists. This discordance between prior research and our findings may be due to participants’ perception of Australian pharmacists having undergone appropriate training necessary for consultations and prescriptionless dispensing.

Pharmacy undergraduate training in Australia includes contraception and blood pressure assessments, and pharmacists have also demonstrated their ability to safely dispense ECPs (Hobbs et al. 2011). However, Australian community pharmacists still face challenges in providing comprehensive contraceptive information and creating safe environments to have these discussions (Buckingham et al. 2023). There is evidently a need for relevant professional development or an accreditation component of potential community pharmacy OCP dispensing. Professional guidelines are also required to ensure standardised practices across the profession (Buckingham et al. 2023). For example, 11 states in the US have granted pharmacy provision of OCPs and have all mandated additional contraception-focused education for dispensing pharmacists. In Australia, a 12-month pilot program is being funded to expand pharmacist scope of practice including extending existing OCP prescriptions, after interested pharmacists undergo additional training (New South Wales Health 2022).

As the likelihood of women accessing OCPs directly from community pharmacists is strongly contingent on women’s comfort and confidence in pharmacists (Meredith et al. 2020a), any OTC model implemented must ensure women are aware that pharmacists are trained to provide these services (including counselling about pregnancy prevention). This echoes similar views of most participants in a large US qualitative study (Baum et al. 2016). Training in safe dispensing and effective communication would be necessary to overcome accessibility challenges and foster consumer confidence in pharmacists.

Some participants expressed concerns about pharmacists’ inability to access medical histories, which could limit effective screening for contraindications. To ameliorate this issue, patient-completed screening forms have been suggested as a strategy, as they have been shown to be safe and effective in community pharmacy settings (Shotorbani et al. 2006; Xu et al. 2014). The appropriateness of such screening was confirmed by our participants. Authors have also called for the better integration of community pharmacy within the primary care system, to promote interdisciplinary collaboration across physician and pharmacist professions. (Piquer-Martinez et al. 2022). This could open new possibilities for contraceptive care in Australia

Prior research consistently shows that appropriately trained pharmacists are capable of safely dispensing OCPs without direct physician involvement. The frequency of prescribing error by pharmacists in separate studies has been found to be very similar to that of physicians (between 5% and 8%) (Grossman et al. 2011; Anderson et al. 2019). In the UK, a successful initiative involved pharmacists consulting with women and determining their eligibility for OCPs based on predefined criteria (National Institute for Health and Care Excellence 2013). Out of 741 consultations, 693 people were correctly provided the OCP, and the remaining 48 individuals were referred to a primary care provider to discuss long active reversible contraception or general concerns (Parsons et al. 2013).

In our study, women recognised the need for different OTC models based on a person’s level of prior experience with OCPs (e.g., participating in a consultation with the pharmacist for inexperienced users versus off-the-shelf availability for experienced users), but emphasised the importance of maintaining preventative screening. In an international study, concerns were expressed by some GPs regarding the potential to reduce preventative screening rates (Rafie et al. 2016). This issue was also a focus of the Pharmaceutical Benefits Advisory Committee in their decision to reject the 2021 proposal to downschedule OCPs (Therapeutic Goods Administration 2021). However, all participants in our study acknowledged the importance of regular preventive screening and stated they would continue to visit their GP for these purposes even if OTC contraception were available. This is consistent with international data where a large US study found 84.8% of women stated identical intentions (Grindlay and Grossman 2018).

Strengths, limitations and future research

The study recruited participants from a single Facebook group, primarily comprising a younger adult demographic in Victoria. This may have resulted in potential socio-demographic bias. However, this may have been minimised by using stratified purposeful sampling to include women from diverse ages and IRSAD ranking. Although this study aimed to recruit women aged 18–44, our women ranged from 18 to 29 years old. Minors were not included in the study, so their opinions and experiences were not reflected. Since the study explored hypothetical models of OTC OCP access, participants’ perspectives on each model may have differed if they had experienced pharmacist contraceptive-prescribing in a real-world setting.

Reflexive thematic analysis was appropriately used to convey a story and establish patterns amongst our participants’ narratives. It was beneficial to our work as it helped facilitate discussions amongst our team, acknowledging researcher subjectivity whilst exploring themes. This was evident in the final theme of different OTC models for different users as we explored how consumer circumstance would affect their method of accessing services.

The findings of this study will be particularly useful for researchers and policy-makers when determining the core components of OTC access models (as is described in Fig. 1). This study indicates the preferred attributes identified include one-on-one consultations with pharmacists, contraindication screening, contraceptive counselling, information about preventative screening, and in-pharmacy privacy considerations Study findings also suggest women would benefit from self-screening questionnaires in combination with pharmacist consultations to enhance privacy and comfort.

Fig. 1.

Models of OTC access to OCPs and women’s perceived benefits and concerns associated with each model. Pharmacist consultation, self-screening questionnaire, and off-the-shelf were explained to the participants while commencement with a GP was independently suggested by some participants.

Further research is necessary to explore the perspectives of Australian GPs and pharmacists on OTC OCP access and its viability. Quantitative studies are needed to assess the safety and feasibility of pharmacy provision of OCPs with the desired attributes identified by consumers. Simulated pharmacist contraception-consultation encounters followed by qualitative interviews with women can provide insights into the effectiveness of this model.

Data availability

The data that support this study will be shared upon reasonable request to the corresponding author.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Declaration of funding

This research did not receive any specific funding.