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Open Access

Dispensing and practice use patterns, facilitators and barriers for uptake of ulipristal acetate emergency contraception in British Columbia: a mixed-methods study

Michelle C. Chan, Sarah Munro, Laura Schummers, Arianne Albert, Frannie Mackenzie, Judith A. Soon, Parkash Ragsdale, Brian Fitzsimmons and Regina Renner
November 30, 2021 9 (4) E1097-E1104; DOI: https://doi.org/10.9778/cmajo.20200193
Michelle C. Chan
Department of Obstetrics and Gynaecology (Chan, Munro, Fitzsimmons, Renner), Centre for Health Evaluation and Outcome Sciences (Munro), Department of Family Practice (Schummers, Soon) and Faculty of Pharmaceutical Sciences (Soon, Ragsdale), University of British Columbia; Women’s Health Research Institute (Albert, Mackenzie), British Columbia Women’s Hospital, Vancouver, BC
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Sarah Munro
Department of Obstetrics and Gynaecology (Chan, Munro, Fitzsimmons, Renner), Centre for Health Evaluation and Outcome Sciences (Munro), Department of Family Practice (Schummers, Soon) and Faculty of Pharmaceutical Sciences (Soon, Ragsdale), University of British Columbia; Women’s Health Research Institute (Albert, Mackenzie), British Columbia Women’s Hospital, Vancouver, BC
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Laura Schummers
Department of Obstetrics and Gynaecology (Chan, Munro, Fitzsimmons, Renner), Centre for Health Evaluation and Outcome Sciences (Munro), Department of Family Practice (Schummers, Soon) and Faculty of Pharmaceutical Sciences (Soon, Ragsdale), University of British Columbia; Women’s Health Research Institute (Albert, Mackenzie), British Columbia Women’s Hospital, Vancouver, BC
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Arianne Albert
Department of Obstetrics and Gynaecology (Chan, Munro, Fitzsimmons, Renner), Centre for Health Evaluation and Outcome Sciences (Munro), Department of Family Practice (Schummers, Soon) and Faculty of Pharmaceutical Sciences (Soon, Ragsdale), University of British Columbia; Women’s Health Research Institute (Albert, Mackenzie), British Columbia Women’s Hospital, Vancouver, BC
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Frannie Mackenzie
Department of Obstetrics and Gynaecology (Chan, Munro, Fitzsimmons, Renner), Centre for Health Evaluation and Outcome Sciences (Munro), Department of Family Practice (Schummers, Soon) and Faculty of Pharmaceutical Sciences (Soon, Ragsdale), University of British Columbia; Women’s Health Research Institute (Albert, Mackenzie), British Columbia Women’s Hospital, Vancouver, BC
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Judith A. Soon
Department of Obstetrics and Gynaecology (Chan, Munro, Fitzsimmons, Renner), Centre for Health Evaluation and Outcome Sciences (Munro), Department of Family Practice (Schummers, Soon) and Faculty of Pharmaceutical Sciences (Soon, Ragsdale), University of British Columbia; Women’s Health Research Institute (Albert, Mackenzie), British Columbia Women’s Hospital, Vancouver, BC
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Parkash Ragsdale
Department of Obstetrics and Gynaecology (Chan, Munro, Fitzsimmons, Renner), Centre for Health Evaluation and Outcome Sciences (Munro), Department of Family Practice (Schummers, Soon) and Faculty of Pharmaceutical Sciences (Soon, Ragsdale), University of British Columbia; Women’s Health Research Institute (Albert, Mackenzie), British Columbia Women’s Hospital, Vancouver, BC
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Brian Fitzsimmons
Department of Obstetrics and Gynaecology (Chan, Munro, Fitzsimmons, Renner), Centre for Health Evaluation and Outcome Sciences (Munro), Department of Family Practice (Schummers, Soon) and Faculty of Pharmaceutical Sciences (Soon, Ragsdale), University of British Columbia; Women’s Health Research Institute (Albert, Mackenzie), British Columbia Women’s Hospital, Vancouver, BC
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Regina Renner
Department of Obstetrics and Gynaecology (Chan, Munro, Fitzsimmons, Renner), Centre for Health Evaluation and Outcome Sciences (Munro), Department of Family Practice (Schummers, Soon) and Faculty of Pharmaceutical Sciences (Soon, Ragsdale), University of British Columbia; Women’s Health Research Institute (Albert, Mackenzie), British Columbia Women’s Hospital, Vancouver, BC
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Article Figures & Tables

Tables

    • View popup
    Table 1:

    Oral contraceptive dispensation and sales data for British Columbia, 2015–2018

    YearNo. of UPA prescriptions dispensed*Drug; total no. of units sold†
    LevonorgestrelUPA
    2015‡< 556 02144
    201648129 478128
    2017149118 897195
    2018167124 910389
    • Note: UPA = ulipristal acetate.

    • ↵* Data from provincial prescription database (PharmNet).

    • ↵† Data from commercial sales database (IQVIA).

    • ↵‡ Data for 2015 represent September to December, not the full calendar year.

    • View popup
    Table 2:

    Characteristics of interview participants

    CharacteristicNo. of participants*
    Patients (n = 12)
    Age, yr, median (range)27 (21–39)
    BMI, median (IQR)24.60 (21.66–30.76)
    Location
     Rural6
     Urban6
    Emergency contraception experience
     Reported previous attempts to access9
     Reported previous use10
    Pharmacists (n = 12)
    Location
     Rural6
     Urban6
    Dispensing experience
     Levonorgestrel12
     Ulipristal acetate5
    Prescribers (n = 15)
    Type
     Nurse†3
     Physician12
    Location
     Rural8
     Urban7
    Prescribing experience
     Levonorgestrel15
     Ulipristal acetate4
    • Note: BMI = body mass index, IQR = interquartile range.

    • ↵* Unless otherwise specified.

    • ↵† Nurse practitioner or nurse with certification in contraception.

    • View popup
    Table 3:

    Qualitative results: selected quotes

    ThemeSelected quotes
    Low awareness concerning UPA (knowledge)Patients
    My understanding is if you were to have unprotected sex or … reason why you would think that you might get pregnant, the next day you would take the pill. I understand that it hurts your body a little bit. You get quite sick … And, yeah, that nobody really wants to take it because it kind of makes you a little bit sick. (R63, patient)
    I think everybody should have sex education and I know not everybody in BC has access to … sexual education … But I think that any time somebody’s talking about contraceptives or sex or sexual health or sexuality to youth in schools, I think there needs to be a conversation that’s age appropriate, when they start talking about contraception to be talking about emergency contraception as well. (R17, patient)
    Prescribers and pharmacists
    Just the need to know about what’s up to date and particularly like I said, because I don’t recall recently having anybody come in and actually asking me for it. (R40, prescriber)
    I mean, a lot of societies are like that … previously we could read the whole guideline and then we were limited to just reading the highlights and then recently we were just not allowed. (R56, prescriber)
    Beliefs about or experience of shame and stigma (beliefs about consequences)Patients
    Because I really feel that there’s a sense of you only take this if you really screwed up this time. (R30, patient)
    I think when it comes to having something that somebody would need an emergency contraceptive for it can be even more shaming. Like why didn’t you use this. Why didn’t you use that. How come you’re not using the pill. How come you’re not using a condom. (R17, patient)
    I think it’s a problem people encounter while getting it. So the outcome of having the medication is still the same. But people feel bad about it after because of attitudes that they met from … filling the prescription. (R23, patient)
    Prescribers and pharmacists
    First of all if you’re sexually active it [EC] shouldn’t be your main source of contraception. But obviously accidents do happen, and when those happen, then that should be an option for you and I will be willing to provide you that care. (R51, pharmacist)
    I think that it should be sort of a last-ditch thing … it shouldn’t be used all the time … I mean, normally I’m totally happy to dispense it. I don’t want there to be unwanted pregnancies, unwanted abortions, unwanted children. But I sometimes feel like there should be a little bit more preparation done. (R52, pharmacist)
    Health care system barriers (reinforcement)Prescription status as a barrier
    If I had 2 options, one was a prescribed pill and one was an over-the-counter pill, I would go for the over-the-counter pill. Because I don’t want to book an appointment with my doctor to go get the prescription, to then go to the pharmacy to pick up the medication. I just want to go directly to the pharmacy and get the pill. (R19, patient)
    Counter status
    “[We place it] behind the counter, so we want to make sure we don’t miss anything. So even if someone come[s] to the counter request[ing] emergency contraception, the pharmacist will automatically provide counselling to the patient … We dispense medication. And we have to provide counselling of everything that leaves the drugstore. Every kind of medication we provide counselling. And the counselling is done by the pharmacist. (R111, pharmacist)
    Tension between pharmacist’s duty to care and patient’s desire for privacy and minimal contact
    Someone might be really embarrassed to be in the pharmacy … I know it’s my experience of feeling embarrassed to be inside the pharmacy and want to get out as quickly as possible. Don’t want to look at the pharmacist. You just want to get your pill and leave. (R16, patient)
    Medication stock and demand
    But for sure if the government allows ulipristal to be also prescribed by pharmacists then I think in general pharmacy is — it’s a business. So they would do whatever that would make them money. So if they think that increasing the awareness of this new birth control pill that’s effective for 5 days after rather than 3 days after, and more girls are aware of it and they kept — more girls are asking for it, then they would see it as a business opportunity. Then that would be what would make them, like, advertise or — to advocate for the change. (R31, pharmacist)
    Cost
    I think cost being the big one. (R17, patient).
    • Note: EC = emergency contraception, UPA = ulipristal acetate.

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CMAJ Open: 9 (4)
Vol. 9, Issue 4
1 Oct 2021
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Dispensing and practice use patterns, facilitators and barriers for uptake of ulipristal acetate emergency contraception in British Columbia: a mixed-methods study
Michelle C. Chan, Sarah Munro, Laura Schummers, Arianne Albert, Frannie Mackenzie, Judith A. Soon, Parkash Ragsdale, Brian Fitzsimmons, Regina Renner
Oct 2021, 9 (4) E1097-E1104; DOI: 10.9778/cmajo.20200193

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Dispensing and practice use patterns, facilitators and barriers for uptake of ulipristal acetate emergency contraception in British Columbia: a mixed-methods study
Michelle C. Chan, Sarah Munro, Laura Schummers, Arianne Albert, Frannie Mackenzie, Judith A. Soon, Parkash Ragsdale, Brian Fitzsimmons, Regina Renner
Oct 2021, 9 (4) E1097-E1104; DOI: 10.9778/cmajo.20200193
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