January 30,2014 — Summary of "'I'll See What I Can Do': What Adolescents Experience When Requesting Emergency Contraception," Wilkinson et al., Journal of Adolescent Health, January 2014.
Regulations regarding nonprescription access to emergency contraception have changed rapidly in recent years, potentially creating confusion among consumers and pharmacy staff, wrote Tracey Wilkinson of the University of Southern California's Keck School of Medicine and the Children's Hospital of Los Angeles, and colleagues.
Noting that the U.S. had the highest teen pregnancy rate in the industrialized world, the researchers added that it "is important to understand what adolescents experience when they interact with pharmacy staff to try to obtain EC."
They developed a study in which "mystery callers" posed as adolescents to collect data on how pharmacy staff addressed questions and concerns about nonprescription EC access.
Two female research assistants, posing "as 17-year-olds who had recently had unprotected intercourse," called 943 commercial pharmacies in Austin, Texas; Cleveland; Nashville, Tenn.; Philadelphia; and Portland, Ore., between September 2010 and December 2010 to inquire about EC availability.
The age 17 was selected to reflect FDA dispensing rules at the time, under which behind-the-counter access was allowed at age 17 but identification was still required to prove age at the time of purchase. Researchers included states that had no pharmacy access laws that superseded federal regulations.
The research assistants followed successive steps from "semi-structured interview scripts" that were pre-tested using pharmacies in states not included in the study. They called the pharmacies on weekdays between 9 a.m. and 5 p.m., when they likely would be fully staffed.
The first step in the script required callers to ask about same-day availability of EC. If EC was available, callers asked if they could obtain EC as 17-year-olds. If they were told they could obtain EC, callers inquired about the age threshold for purchasing it without a prescription. Finally, callers asked pharmacists about privacy and if they needed parental notification to obtain EC.
To analyze the data, the researchers reviewed each call transcript and developed "codes to characterize the content of each phone call," which they applied to the transcripts and sorted using software. They then identified connections across codes and extracted various themes.
The researchers found that 80% of the 943 pharmacies that were called had EC available on the day they were contacted, of which 57% gave the caller correct information about EC access. Three-quarters of the pharmacies provided qualitative data, while the others responded with "yes" or "no" answers, according to the study.
The researchers identified four major themes. First, pharmacy staff members used "ethics-laden terms" -- both personal and religious -- to convey policies on dispensing EC. In some cases, collective terms such as "we" or "our pharmacy" were used to convey the values of the pharmacy, rather than the individual speaking on the phone, while at other times, an individual cited his or her personal ethical beliefs.
There also were a few instances in which pharmacy staff members gave the callers a lower priority than other customers, advising them to "come in and ask the pharmacist," the researchers wrote.
The second theme involved pharmacy staff members' confusion about whether they could dispense EC to a 17-year-old, given recent changes in government policies. The researchers noted several conversations in which the pharmacy staff member had to put the caller on hold to verify the age requirements. In some instances, even after the staff member checked, the caller was incorrectly told she would not be able to purchase EC without a prescription or photo ID proving she was at least 18.
The third theme that emerged was pharmacy staff members creating false barriers to EC access, the most common of which was age. Other false barriers included gender, parental involvement and prescription requirements. Although most barriers were contrived, pharmacy staff often helped the caller around them, such as telling the caller to bring an 18-year-old friend to purchase EC for her or pharmacists offering to "see what [they] can do" to help the caller overcome the barriers.
Some pharmacy staff members correctly cited the barrier of the identification requirement, but "the stringency with which this was enforced varied," the researchers found.
The fourth theme was related to the degree of confidentiality in providing EC. "There was a wide range of answers to this question," the researchers wrote, explaining that some pharmacies made it clear that confidentiality was guaranteed; some offered "a more conditional confidentiality," saying a parent might be contacted in some scenarios; and some gave responses that "left the impression that there was no guarantee of confidentiality because of the requirements of the medication and the age of the caller."
"The results suggest that equipping adolescents with information regarding how and when to take EC is essential, but by itself may be insufficient to overcome barriers related to access," the researchers wrote, adding, "Our data suggest that the actual process of obtaining EC from pharmacy personnel can be challenging for adolescents and complicated by moral judgment, misinformation, and inconsistent responses from pharmacy staff."
They noted, "[T]o help ensure that all laws are appropriately implemented, further education of pharmacy staff and physicians and the work of various advocacy groups can increase guaranteed access to EC when it is needed."
The findings "help augment understanding of the experience adolescents have when obtaining information regarding EC," they continued, concluding, "For guaranteed timely access to EC for adolescents, a multifactorial approach to improving access is likely to be required."