Can private pharmacy providers offer comprehensive reproductive health services to users of emergency contraceptives? Evidence from Nairobi, Kenya

Abstract

Objective

To evaluate the provision of reproductive health information and services to users of emergency contraceptives (ECs) by private pharmacists.

Methods

The study involved intervention (9) and control (8) pharmacies, with baseline and endline assessments of EC provision through the use of mystery clients. Intervention pharmacies received weekly updates on EC, fliers with three key messages on EC, and information, education, and communication materials. Logistic regression models are estimated to predict the provision of reproductive health services to EC clients.

Results

The differences between the control and intervention pharmacies with respect to the provision of additional information on EC and regular family planning services are in the expected direction but statistically insignificant. In contrast, the likelihood of providing information or referral for counseling or testing for sexually transmitted infections or HIV was lower in the intervention than in the control pharmacies but the difference was also not statistically significant.

Conclusion

Pharmacy providers in the country face institutional challenges in providing reproductive health services to EC clients.

Practice implications

The challenges could be addressed through pre-service training, targeted in-service training, sensitization of clients, and point-of-sale materials such as brochures, posters and package inserts.

Introduction

In many countries, clients who are in need of emergency contraceptive (EC) pills mostly obtain them over-the-counter from private pharmacies largely because of the conveniences such outlets offer, namely, affordability, quick service delivery, and confidentiality [1], [2], [3], [4], [5], [6], [7]. This has contributed to improved access to the method that is used for preventing pregnancy after sex by those who are in need of the services, including those who engage in unprotected sex, experience method failure or are survivors of sexual assault [8]. Nonetheless, the increased availability of the pills has created concerns from providers, policy makers and the media regarding its potential impact on client contraceptive decision making and sexual behavior [7], [9], [10], [11]. One of the major concerns is that clients tend to rely on the pills, perhaps due to their perceived convenience, as a regular family planning method at the expense of more effective ongoing contraceptive methods. They might therefore be placing themselves at greater risk of pregnancy given that the pills are less effective than regular family planning methods and the evidence that increased access does not affect the rate of unintended pregnancies [12], [13], [14]. In addition, there are fears that the pills might encourage promiscuity, especially among adolescents, since clients have easy access to a method of preventing pregnancy that does not require consulting a health care provider.

Available evidence mostly from randomized trials does, however, indicate that increased over-the-counter access to EC pills does not affect contraceptive decision-making and sexual behavior of clients, including promoting promiscuity among adolescents [13], [15], [16], [17], [18], [19], [20]. Rather, increased over-the-counter access to EC provides a potential avenue for reaching clients with other reproductive health information and services, including regular contraception, prevention or treatment of sexually transmitted infections (STIs), and HIV prevention. For instance, in cases where the need for EC is occasioned by regular unprotected sex or method failure, the client might be in need of a new or more reliable method of family planning. Moreover, in high STI/HIV prevalence settings where the need for EC arises from regular unprotected sex with many partners, the client might be in need of counseling and testing services given that the pills do not protect against these infections.

The potential for involving pharmacists in the provision of other reproductive health information and services to EC clients raises some important research and programmatic questions. First, how feasible is working with private pharmacies to provide EC users with these additional services? Second, assuming that it is feasible, can this improve the uptake of these services among EC users? This paper presents findings from a pilot study conducted in 2008 in Nairobi, Kenya that sought to respond to the first question by evaluating the provision of family planning and STI/HIV information, services and referrals to clients seeking EC at private pharmacies. Although existing evidence suggests that pharmacists are willing to take up the enhanced role as reproductive health care providers [2], [21], [22], in some settings this might be hampered by the nature of training of pharmacists and the challenge of balancing the business motive vis-à-vis performing the role of reproductive health service provider [23], [24]. In Kenya, for instance, the curriculum for training pharmacists mostly focuses on the chemical composition and mixing of drugs, drug doses, side-effects, mode of action and administration. Pharmacists therefore lack training on counseling clients on preventive health care. In addition, private pharmacists are business people who have to balance this motive with providing additional reproductive health information and services. The latter may require asking about the client's medical history and might scare away those clients who are not comfortable with the process. This is in contrast to public health facilities where EC pills are available at no fee but clients may first be asked a few questions by the provider before being given the pills.