key: cord-0837757-n5pi1x8u
authors: Siddiqui, Nawal; Rafie, Sally; Bull, Shasta Tall; Mody, Sheila K.
title: Access to Contraception in Pharmacies During the COVID-19 Pandemic
date: 2021-08-08
journal: J Am Pharm Assoc (2003)
DOI: 10.1016/j.japh.2021.08.002
sha: 2108fcc857d93f84cc24911f306c287e9b250960
doc_id: 837757
cord_uid: n5pi1x8u

Background As a result of the COVID-19 pandemic, shifts in traditional contraception access points have presented new challenges, leading people to seek alternate sources of contraception care, including pharmacies. Pharmacists in one-quarter of US states are able to prescribe hormonal contraception, a model known as pharmacy access. Pharmacy access became available in California in 2016 and Colorado in 2017. Objective To characterize how access to contraception products and services in pharmacies changed during the COVID-19 pandemic, including pharmacist prescribing practices and innovations in service delivery. Methods We conducted a cross-sectional survey among California and Colorado pharmacists from September to October 2020. Survey questions included pharmacist and pharmacy practice site characteristics, prescribing practices, pharmacist perspectives, and pharmacy services in the context of the COVID-19 pandemic. Results A total of 128 pharmacists participated in the study with 38% (n=49) from California and 62% (n= 79) from Colorado. Among participants, 41% (n=53) prescribed contraception, of which 94% (n=50) continued, 4% (n=2) started, and 2% (n=1) suspended during the pandemic. Most participants reported interest (79%) and effort (75%) in prescribing contraception to be about the same during the pandemic. Community need for contraceptive services was perceived to be slightly or much higher (45%) or about the same (47%). Patient interest in pharmacy access was perceived to be slightly or much higher by 26% and about the same by 57%. When distributing contraception prescriptions, pharmacies increased curbside (from 12% to 52%), home delivery (from 40% to 60%), and mailing options (from 41% to 71%) during the pandemic. Conclusions Pharmacists prescribing hormonal contraception who participated in this study remained committed to providing this service during the pandemic. Some perceived increased community need for contraception and patient interest in direct pharmacy access. There was an increase in options for patients to receive contraception prescriptions with minimal contact.

Colorado, statewide protocols dictate this practice, require patient self-screening, blood 45 pressure measurement, and other procedures. 5,6 In addition, the Colorado protocol requires a 46 private space to ensure confidentiality. 6

There are over 3500 pharmacies offering pharmacy access to contraception, though less 48 widespread than desired. 7-10 While statewide policies facilitate implementation of this service, 49 numerous barriers mitigate realizing its potential reach and effectiveness. 11-14 Barriers that have 50 been previously reported include time constraints, staff shortages, lack of 51 payment/reimbursement for service, liability concerns, and training needs. [13] [14] Pharmacists are 52 motivated to provide this service in order to increase patient access and provide patient care services. [15] [16] It is unknown how delivery of pharmacist contraception care has been impacted 54 and changed during the COVID-19 public health emergency. 

There were no differences in the contraceptive methods offered to prescribe before and 144 during the pandemic as reported in Table 2 . Respondents 94% (n=50) did not observe a change 145 in the contraceptive methods being requested by patients.

The majority of pharmacists most frequently prescribed a 12-month duration prescription 147 both before (60%, n=31) and during (60%, n=30) the pandemic. Pharmacies most commonly 148 dispensed 3 months of contraception before (64%, n=34) and during (69%, n=36) the pandemic.

Respondents who selected that they either most frequently prescribed or dispensed less than a 150 12-month supply of contraception (n=48) were directed to a multiple-choice question asking why 151 they prescribed or dispensed less than a 12-month supply of birth control. Among those, the 152 vast majority (83%, n=40) selected "Insurance/Cost" as the reason. contraception in the pandemic. Almost all respondents prescribing contraception indicated that 158 they would definitely (70%, n=37) or probably (24%, n=13) continue beyond the pandemic. 

Pharmacists were asked to indicate if any of the following were barriers to providing 169 contraception services during the COVID-19 pandemic: 38% (n=20) indicated staffing or 170 workflow challenges, 32% (n=17) reported the in-person blood pressure measurement, 23% (n=12) reported changes to patient insurance status, lack of personal protective equipment was 172 indicated by 7% (n=4). Twenty-one percent (n=11) of respondents indicated that they had 173 experienced no barriers to providing contraception services since the start of the pandemic.

Thirteen percent (n=7) of pharmacists who prescribed recognized a change in the payor mix 175 of their patient population during the pandemic; with a shift of formerly insured patients to cash 176 pay or no insurance. While Colorado Medicaid cannot presently be billed for pharmacist services.

The goal of this study was to understand how contraception access and services in 

The barriers to pharmacists prescribing contraception that have been previously 207 characterized before the pandemic and found to persist during the pandemic are workflow and 208 staffing concerns. 14 The second most recognized barrier was the requirement for in-person 

The strengths of this study include the geographic diversity with representation amongst 234 urban, suburban, and rural respondents, as well as practice settings. This survey was also 235 distributed to pharmacists six months into the COVID-19 pandemic, minimizing potential recall 236 bias. However, we acknowledge the limitations of this study, primarily that there was a low 237 response rate and small sample size. The low response rate may be attributed to the lack of a 238 guaranteed incentive and the time for survey completion in a particularly busy and stressful 239 pandemic environment for pharmacists. 25, 26 Because state association lists were used for 240 recruitment, emails may have been ignored or auto-filtered; similar studies also have reported 241 similar response rates. 14, 27 Additionally, the time frame of this study may be insufficient to 242 capture a significant number of interventions given that patients may only seek care from a 243 pharmacist once per year for a renewal of their prescription.

Although this was a multistate study of Colorado and California, these are two states 245 with established policies for pharmacist prescribing and extended supply of contraception. We 246 do not know the generalizability of our findings to states without the support of these policies.

Expanding the scope of this study to states with less established policy or pharmacist 248 prescribing infrastructure presents an area of future research. 

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