Barriers to Adolescents’ Getting Emergency
Contraception Through Pharmacy Access in California:
Diferences by Language and Region
By Olivia
Sampson, Sandy
K. Navarro, Amna
Khan, Norman
Hearst, Tina R.
Raine, Marji Gold,
Suellen Miller and
Heike Thiel de
Bocanegra
Olivia Sampson
is former research
fellow, and Norman
Hearst is professor,
both in the Department of Family and
Community Medicine;
Sandy K. Navarro is
social scientist, Bixby
Center for Reproductive Health Research
and Policy; and Amna
Khan was a medical
student in the School
of Medicine—all
at the University
of California, San
Francisco (UCSF).
Tina R. Raine and
Suellen Miller are
associate professors, Department of
Obstetrics, Gynecology and Reproductive
Sciences, UCSF. Heike
Thiel de Bocanegra is
academic coordinator
and director, Family
PACT UCSF Program
Support and Evaluation, Bixby Center for
Global Reproductive
Health, UCSF. Marji
Gold is professor,
Department of Family
and Social Medicine,
Albert Einstein College of Medicine and
Montefiore Medical
Center, Bronx, NY.
110
CONTEXT: In California, emergency contraception is available without a prescription to females younger than 18
through pharmacy access. Timely access to the method is critical to reduce the rate of unintended pregnancy among
adolescents, particularly Latinas.
METHODS: In 2005–2006, researchers posing as English- and Spanish-speaking females—who said they either were
15 and had had unprotected intercourse last night or were 18 and had had unprotected sex four days ago—called
115 pharmacy-access pharmacies in California. Each pharmacy received one call using each scenario; a call was
considered successful if the caller was told she could come in to obtain the method. Chi-square tests were used to
assess diferences between subgroups. In-depth interviews with 22 providers and pharmacists were also conducted,
and emergent themes were identiied.
RESULTS: Thirty-six percent of all calls were successful. Spanish speakers were less successful than English speakers
(24% vs. 48%), and callers to rural pharmacies were less successful than callers to urban ones (27% vs. 44%). Although
rural pharmacies were more likely to ofer Spanish-language services, Spanish-speaking callers to these pharmacies
were the least successful of all callers (17%). Spanish speakers were also less successful than English speakers when
calling urban pharmacies (30% vs. 57%). Interviews suggested that little cooperation existed between pharmacists
and clinicians and that dispensing the method at clinics was a favorable option for adolescents.
CONCLUSIONS: Adolescents face signiicant barriers to obtaining emergency contraception, but the expansion
of Spanish-language services at pharmacies and greater collaboration between providers and pharmacists could
improve access.
Perspectives on Sexual and Reproductive Health, 2009, 41(2):110–118, doi: 10.1363/4111009
Despite a general decline in adolescent birthrates in the
United States since 1991, the nation continues to have
one of the highest adolescent birthrates among industrialized countries, and recent data indicate that U.S. rates
have begun to rise since 2006.1,2 In California, the birthrate among adolescents mirrors the national trend, but
the overall decline has been more modest among Latina
adolescents.3–5 Poverty and other socioeconomic factors
are known to be associated with higher rates of adolescent
pregnancy.6,7 Adolescent birthrates in California are highest among Latinas and in the largely rural region known
as the Central Valley.2,8 Two-thirds of the 50,000 annual
adolescent births in the state are to Latinas, even though
the current numbers of Latina and white females in the
15–19 age-group are similar.2,5 Education about, access to
and use of effective contraceptives, including emergency
contraception, are critical tools in reducing unintended
adolescent pregnancy. In addition to helping decrease
abortion rates,9 reducing the rate of adolescent pregnancy
is important because adolescent mothers are less likely
than adolescents without children to go to college, and
their children are more likely to live in poverty than are
children born to older women.10 Furthermore, pregnant
adolescents are less likely than older pregnant women to
receive adequate prenatal care, and lack of such care is associated with poor birth outcomes.11,12
Addressing adolescent pregnancy requires an understanding of the multiple factors involved at the community level, such as social capital, socioeconomic status,
sociopolitical climate and access to health services. Our
study considers the role of pharmacy access to emergency
contraception in reducing unintended pregnancy among
adolescents, and focuses on language barriers to such
access. We are aware of no studies that have explored
Spanish speakers’ experiences with seeking emergency
contraception through pharmacy access in rural California. Because Latinas are projected to make up more than
half of California’s adolescents by 2050,13 it is important to
understand the barriers that some members of this community might face.
BACKGROUND
Facilitating easy access to emergency contraception can
help adolescents avert pregnancy when their contraceptive method has failed or they have not used a method.
Plan B—a dedicated progestin-only product available in
the United States since 1999—is more effective than the
Yuzpe regimen of combined oral hormones.14 Package
Perspectives on Sexual and Reproductive Health
labeling indicates that Plan B (two 0.75 mg pills of levonorgestrel) can be used up to 72 hours after unprotected
intercourse, and that it is up to 89% effective in preventing pregnancy.15 Studies have shown that the method is
effective up to 120 hours16,17 after unprotected intercourse,
but how many pharmacists or health care providers offer
the method over this longer period is not known. Pharmacy protocols in California, and in most other states, indicate that the method should be offered over this longer
period,* although such use is at the discretion of the pharmacist.18 In 2003, only 8% of California women reported
having ever used emergency contraception,19 and studies
have shown that awareness of the method is relatively low
among Latina women in the state, particularly those who
are foreign-born, without a high school diploma or living
below the poverty level.20–22
In August 2006, the U.S. Food and Drug Administration
(FDA) permitted pharmacists to dispense Plan B without
a physician’s prescription to women 18 or older (with
proof of age). Nevertheless, barriers to access remain for
younger females, those without proper proof of age and
those who rely on publicly funded health insurance, like
Medi-Cal (the California Medicaid program),† for reproductive health services.23 Plan B costs between $25 and
$50 without insurance coverage, and this cost presents a
financial barrier to some women. Low-income California
residents at risk for getting pregnant or causing a pregnancy, including adolescents, may be eligible for the state’s
publicly funded program Family PACT, which provides
clients with emergency contraception and other reproductive health services at no cost through participating clinics;
enrolled clients also can obtain emergency contraception
at no cost from pharmacies.‡
Since 2002 in California, adolescents younger than 18
have been able to obtain emergency contraception from
designated pharmacy-access pharmacies without a clinician’s prescription.24 Pharmacists can dispense Plan B
under a statewide protocol adopted by the State Board of
Pharmacy and the Medical Board of California (in 2003),
or under a collaborative agreement with a licensed physician (since 2001). At the time of this study, approximately
one-fifth of pharmacies in California had enrolled in the
pharmacy-access system.25 The state protocol indicates
that if no pharmacist certified to provide Plan B is available, staff should refer clients to another pharmacy-access
pharmacy or to a local Family PACT clinic.24
Studies of pharmacy access to emergency contraception
in California25 and Washington26 have shown that young
women like the program because it is convenient and
confidential, and allows timely access; however, studies in
California have indicated that women’s knowledge about
pharmacy access and of which pharmacies participate is
lacking.25,27 In studies that employed a mystery-shopper
approach, emergency contraception was made available
on the same day to 20% of English-speaking shoppers in
Albuquerque, New Mexico;28 39% in Jacksonville, Florida;29 and 75% in New York City.30
Qualitative studies have revealed that adolescents find
it difficult to request emergency contraception from pharmacists or clinicians because of concerns about being
negatively judged or previous negative experiences regarding such requests,31 and that clinicians do not regularly
discuss or provide emergency contraception in advance of
need.32 Quantitative studies have found that clinicians do
not discuss the method at well-adolescent checkups,33 and
that some pharmacists feel inadequately trained to serve
adolescents.34 Neither advance prescription of nor pharmacy access to emergency contraception increases risky
sexual behavior or STDs in adolescents, and easy access
to the method does not cause young women to abandon
regular forms of contraception;35,36 however, clinicians and
pharmacists continue to harbor concerns about the provision of the method, especially to adolescents.30,32,33
Most pharmacy-access pharmacies in California are located in urban areas, and some rural counties may have
only one.24,37 We compared access to emergency contraception in seven rural counties, where adolescent birthrates are the highest in the state (51–70 per 1,000 females
aged 15–19), with access in two urban counties, where
adolescent birthrates are much lower overall (23–27 per
1,000).§8 The rural counties have a collective population
of more than three million, and have about 8,000 adolescent births annually;3,11 48–57% of the populations in
these counties self-identify as Latino.12 The urban counties
have a similar total population (2.6 million) and report
about 2,600 adolescent births per year, but 21–22% of
their collective population self-identify as Latino. Because
the timeliness of use is critical, we examined how pharmacy staff handled “late” requests and whether the method
was being offered up to 120 hours after unprotected intercourse. The study was conducted prior to both the 2006
FDA ruling making Plan B available behind the counter for
women 18 or older and the FDA decision in April 2009
to make the method available without prescription to
17-year-old women. Despite these advances in access to
Plan B, the findings are still pertinent, since adolescents
younger than 17 must use pharmacy access to obtain the
method if they do not have a prescription.
*Protocols in other states with pharmacy access (Alaska, Hawaii, Maine,
Massachusetts, New Mexico, Vermont and Washington) indicate that
the method can be offered for up to 120 hours; pharmacists in New
Hampshire may determine when to prescribe the method.
‡In California, all Planned Parenthood clinics and many community clinics are Family PACT providers and may enroll eligible clients directly into
the program.
†Medi-Cal covers low-income persons, but does not pay for over-thecounter medications without a prescription; hence, Plan B is not covered if
a woman 17 or older asks for it at the pharmacy without a prescription.
Volume 41, Number 2, June 2009
§The rural counties are Fresno, Kern, Kings, Madera, Merced and Tulare
in the Central Valley, plus Monterey, which was included because it is demographically similar to the others. The two urban counties are Alameda
and Contra Costa.
111
Barriers to Adolescents’ Getting Emergency Contraception in California
METHODS
The study’s main focus was on quantitative data collected
from phone calls made by simulated adolescent clients
to pharmacies to request emergency contraception. To
broaden the scope of the cross-sectional quantitative data,
we conducted in-depth interviews with pharmacists and
health care providers regarding the provision of the method to adolescents. This mixed methods approach uses a
concurrent nested model,38 whereby both quantitative and
qualitative data are collected simultaneously, and the qualitative data inform the larger quantitative part of the study.
The study was approved by the Committee on Human
Research of the University of California, San Francisco.
Mystery-Shopper Data
Three female research assistants in their early 20s, posing
as English- or Spanish-speaking adolescents, called 115
pharmacies between August 2005 and April 2006. Phone
numbers for the pharmacies were taken from a Web site
(<http://www.ec-help.org>) that lists, by county, the locations and phone numbers of pharmacists participating in
pharmacy access to emergency contraception. All participating pharmacies in the study counties were called; calls
lasted 2–3 minutes. The mystery-caller script was written
in English, piloted in English, translated into Spanish and
then back-translated into English to check for accuracy.
The callers were instructed to follow the script and handwrite recipients’ responses and comments during the calls.
Because small rural pharmacies may have variable weekend hours or may be closed on Sundays, the calls were
made during regular business hours, Monday to Friday
between 11 A.M. and 4:30 P.M.
Two scenarios were used: In the first, the caller stated that
she was 15 and had had unprotected sex the previous night;
in the second, the caller stated that she was 18 and had had
unprotected sex four days earlier. Each pharmacy received
four calls, one in each language describing each scenario, so
a total of 460 calls were made. Callers were instructed to call
a pharmacy only once, even if they were told to call back at
a later time. We chose to vary the supposed timing of the
request by the caller’s age, with the understanding that this
would not allow analysis of the independent impact of age
or timing on access to emergency contraception.
These two scenarios were selected to explore as many
potential barriers as possible with the fewest phone calls.
We assumed that pharmacists would be most comfortable providing emergency contraception according to
FDA guidelines (i.e., within 72 hours), and more comfortable telling an 18-year-old than telling a 15-year-old
that she could have the method. Thus, we assumed that
females who called the morning after unprotected sex and
requested emergency contraception would not be refused
because of the timing of the request, but that they may be
told they were too young to obtain the method without a
prescription. And we assumed that older adolescents were
less likely to be refused because of their age, but might be
told that it was too late to take emergency contraception.
112
Each call began with “Hello…the condom broke (last
night/four nights ago), and I’m afraid to get pregnant. Is
there anything I can take?” Following the script, the caller
stated her age, then asked whether her parents must be
informed and how much the method costs. Callers speaking Spanish were instructed to continue the script as far as
possible in Spanish, and not to switch into English, except
to say in broken English “Speak Spanish?” If no pharmacy
staff or translation service was available to provide services
in Spanish, the caller simply ended the call.
A call was considered successful if pharmacy staff told
the caller she could come in immediately to obtain emergency contraception from a certified pharmacist. A call
was considered unsuccessful if the caller was unable to
communicate with pharmacy staff or was told she could
not obtain the method; callers wrote down any reasons
volunteered for why they could not obtain emergency
contraception. If they were told to try another pharmacy
or clinic, these responses were categorized as “unsuccessful calls given a referral.” Referrals were later categorized
as “specific” or “vague,” depending on whether the caller
was given a phone number, name or address of a clinic
or pharmacy. This study did not follow up the referrals
because of budget constraints, and because our focus was
to determine availability at listed pharmacies at the time
of the call.
Data were analyzed using SAS version 9.1; Pearson’s chisquare tests were used to determine the significance of differences between subgroups.
Qualitative Data
Callers’ handwritten comments on the calls (e.g., noting
that they had been put on hold for a long time, or that staff
were pleasant or rude) were included as anecdotal impressions to complement the data.
To further expand our understanding of the provision
of emergency contraception to adolescents by rural pharmacies, we conducted in-depth interviews with 22 health
professionals (clinicians and pharmacists). Initially, health
professionals working in the Central Valley were recruited
via mailings to pharmacies and clinics; however, because
we failed to recruit enough participants in this manner,
we turned to a snowball sampling method, in which one
researcher telephoned and e-mailed professionals to secure their participation. All but three participants worked
in the rural counties; one participant worked outside the
study area. The researcher is a female, English-speaking
family physician, and this likely affected recruitment, as
recruiting family physicians appeared easier than recruiting pharmacists or other providers. Hence, the researcher’s
language and profession may also have affected the interviews and the themes that emerged.
The researcher developed a semistructured interview
guide, and as themes emerged from the interviews and
from anecdotal mystery-shopper data, the interview tool
was modified to explore pharmacists’ and providers’
perspectives on their comfort in providing emergency
Perspectives on Sexual and Reproductive Health
contraception to adolescents, on the safety of the method
for adolescents, on Spanish-language services regarding
method provision, on the convenience of prescribing the
method to adolescents and on where they thought rural
adolescents are most comfortable obtaining the method.
After participants gave their consent, interviews were audiotaped, and detailed notes were taken; transcriptions
were made immediately afterward. We used QSR NVIVO2 to analyze the interviews in an interpretive framework and code them for emergent themes. In keeping with
the method of grounded theory,39 data collection stopped
when saturation of themes had occurred.
RESULTS
Mystery-Shopper Calls
Language barriers and regional differences. Fifty-two
percent of the 115 pharmacy-access pharmacies offered
Spanish-language services to callers; a higher proportion
of rural than of urban pharmacies offered such services
(61% vs. 44%; p<.01). Overall, 36% of calls to pharmacies were successful (Table 1). Spanish speakers were less
successful than English speakers (24% vs. 48%), and callers to rural pharmacies were less successful than callers
to urban pharmacies (27% vs. 44%). Even though rural
pharmacies were more likely to offer Spanish-language
services, Spanish-speaking callers to rural pharmacies
were the least successful of all callers (17%). Furthermore,
Spanish speakers were less successful than English speakers when calling urban pharmacies (30% vs. 57%), and
English speakers who called rural pharmacies had less
success than those who called urban pharmacies (37% vs.
57%). In addition, 18-year-old English speakers requesting emergency contraception more than 72 hours after
having had unprotected sex were less likely to be successful when calling rural pharmacies than when calling urban
pharmacies (32% vs. 58%).
Although the caller’s age and the timeliness of the call
were not independent factors, there were no significant
differences between the scenarios for either language
group. Spanish speakers who called the only pharmacyaccess pharmacy in the rural county of Tulare had no access to emergency contraception, as this pharmacy offered
no Spanish-language services.
Most English-speaking callers were connected directly to
the pharmacist, whereas many Spanish speakers were put
on hold to wait for a translator. One Spanish speaker had
to speak to a male janitor, who then translated the caller’s
sensitive information about her unprotected intercourse
and menstrual history to an English-speaking pharmacist.
All callers reported that staff did not initiate interpreter
services unless they asked in broken English whether anyone at the pharmacy could speak Spanish. One Spanishspeaking caller heard laughter when she asked to speak
to someone in Spanish, and noted feeling she was “being
laughed at for daring to ask to be spoken to in Spanish.”
The same caller noted being spoken to loudly in English,
“as if this would help me understand English better.”
䊉
Volume 41, Number 2, June 2009
TABLE 1. Percentage of mystery-shopper phone calls that
were considered successful for obtaining emergency contraception from pharmacies, by scenario, according to
region of pharmacy, California, 2005–2006
Scenario
All
Rural
Urban
N
%
N
%
N
%
All
460
36
212
27**
248
44
Spanish-speaking
Age 15, <24 hours
Age 18, >72 hours
230
115
115
24††
28
20
106
53
53
17†
19
15
124
62
62
30††
35
24
English-speaking
Age 15, <24 hours
Age 18, >72 hours
230
115
115
48
50
46
106
53
53
37*
42
32**
124
62
62
57
56
58
*Significantly different from percentage for urban at p<.01. **Significantly
different from percentage for urban at p<.001. †Significantly different from
percentage for English-speaking at p<.01. ††Significantly different from percentage for English-speaking at p<.001. Notes: A call was considered successful if the caller was told she could come in to obtain the method. Callers simulated two scenarios: They were 15 and had had unprotected sex the previous
night, or they were 18 and had had unprotected sex four days earlier.
Spanish-speaking callers considered it helpful when a
dial-up translation service was offered or when staff spoke
directly to them in broken Spanish.
䊉 Reasons
for method unavailability. Ninety-seven
Spanish speakers could not communicate with pharmacy staff in Spanish and so could not have obtained
emergency contraception. The other 198 unsuccessful
callers were given a variety of reasons for why the method
was unavailable, which we collapsed into six categories
(Table 2). Thirty-nine percent of unsuccessful callers
were told that no pharmacist certified to dispense the
method was on-site. Some of these callers were told that
the certified pharmacist was on vacation or not working
that day; others were told that a prescription was needed.
In cases where staff said that callers needed a prescription, it can be assumed that the pharmacist was out or
no longer worked there, or that staff were unaware of the
pharmacy-access program. A higher proportion of callers
to urban pharmacies than of callers to rural pharmacies
TABLE 2. Percentage distribution of unsuccessful calls, by reason pharmacy staff
gave for unavailability of emergency contraception, according to language of caller
and region of pharmacy
Reason
No certified pharmacist available
Implied ethical reason‡
Too late to use method
Out of stock
No reason given
No contact made§
Total
Total
(N=198)
39
13
11
2
21
14
100
Language
Region
Spanish
(N=78)
English
(N=120)
Rural
(N=119)
Urban
(N=79)
41
21†
10
1
9††
18
100
38
8
11
3
29
12
100
31*
20**
12
2
27
8*
100
52
1
9
3
13
23
100
*Significantly different from percentage for urban at p<.01. **Significantly different from percentage for
urban at p<.001. †Significantly different from percentage for English-speaking at p<.01. ††Significantly
different from percentage for English-speaking at p<.001. ‡For example, staff thought the caller was too
young or the method was unacceptable. §Caller never contacted pharmacy because phone number was
disconnected or changed. Note: Results exclude the 97 calls made by Spanish-speaking callers (36 rural and
61 urban) to pharmacies without Spanish-language services.
113
Barriers to Adolescents’ Getting Emergency Contraception in California
were told that no certified pharmacist was available (52%
vs. 31%).
Thirteen percent of unsuccessful callers said they were
denied access because of implied ethical reasons, such as
they were too young, they needed to have their parents
come in with them or pharmacy staff did not believe the
method was acceptable. This reason was reported more
often by Spanish speakers than by English speakers (21%
vs. 8%), and more often by callers to rural pharmacies
than by callers to urban pharmacies (20% vs. 1%). Eleven
percent of unsuccessful callers were told that it was too
late for them to take the method (all of these callers had
said they had had unprotected sex more than 72 hours
ago); the proportion did not vary by language or region.
Most of these callers were told to see a doctor because 72
hours had passed; however, four were told that nothing
could be done and that they “would have to wait to see
what happens.”
Only 2% of unsuccessful callers were told that the pharmacy was out of stock, and 21% were given no reason for
why the method was not available (9% of Spanish speakers and 29% of English speakers). Among all unsuccessful
callers, 14% could not get through to the listed pharmacy
because the number had changed or been disconnected
(8% of rural callers and 23% of urban callers).
䊉 Referrals. Seventy-eight percent of unsuccessful callers
(excluding Spanish speakers who could not obtain services in Spanish) received at least one type of referral: Pharmacy staff told them to call either another pharmacy or a
clinic to obtain emergency contraception. Referrals were
classified as vague (e.g., “Check in the Yellow Pages for
another pharmacy,” “Call your doctor,” “Go to a clinic”) or
specific (i.e., callers were given the phone number, name
or address of a local clinic or pharmacy). Overall, 68% of
referrals were specific, and 32% were vague. Fifty-five percent of referrals were to pharmacies, and 45% were to clinics; however, 77% of clinic referrals were vague, whereas
71% of pharmacy referrals included relevant telephone
numbers.
䊉 Costs. Only 7% of callers were informed that emergency
contraception could be obtained for free at Planned Parenthood or local community clinics, and only one caller
was specifically told that the method could be obtained
without cost through the Family PACT program. Callers
reported that pharmacy staff quoted costs of $25–50 for
emergency contraception.
In-Depth Interviews
Interviews were conducted with nine pharmacists and 13
clinical providers (five family doctors, five nurses or nurse
practitioners, and three educators or outreach workers at
rural clinics). Of the nine pharmacists, four were female,
and eight worked in rural communities. Because we used
snowball sampling, we ended up with only three pharmacists who were certified to dispense emergency contraception, and one of them was not working in a pharmacy at
the time of the study. Eleven of the clinicians were female,
114
and 11 worked in rural communities; one had never prescribed emergency contraception. The salient themes from
the interviews revealed that language, pharmacist availability, pharmacists’ knowledge of and clinical comfort
regarding the method, and lack of pharmacist-clinician
communication and collaboration were barriers to obtaining access to emergency contraception.
䊉 Language barriers. Pharmacists who did not speak
Spanish said they preferred to refer Spanish-speaking clients to other pharmacies or clinics—even if these were
in another county—where they assumed clients would
receive Spanish-language services. Community clinicians
felt that Spanish-speaking clients received more culturally
competent care at clinics because bilingual administrative
and medical staff were available. Providers’ observations
included the following:
“Most of our pharmacies here only have techs that
speak Spanish; they don’t have a pharmacist [who speaks
Spanish].…Generally, their first line is to [tell clients to]
come to the clinic.…My receptionists and doctors all
speak Spanish.…It’s a pretty open environment here. We
try not to put up any barriers.”—Rural clinician
“You know, if English isn’t your first language…then you
aren’t going to advocate for yourself [at the pharmacy] so
much. You know, you’re just going to say ‘Okay, bye.’ ”
—Rural community outreach worker
䊉 Rationale for deciding whether to provide emergency
contraception. Some pharmacists did not get certified in
the pharmacy-access program because they did not believe
that pharmacists should prescribe medication or because
of concerns about time constraints or limited space to provide adequate counseling, liability, emergency contraception’s health effects on young females and on those who
took it too often, or lack of community physician support.
Most of the interviewed pharmacists assumed that it was
easiest for women to obtain emergency contraception at
large pharmacies or at clinics. Moral, religious or ethical
concerns were not explicitly stated as reasons for not getting certified; however, pharmacists may not have been
comfortable expressing such concerns to the interviewer.
The following responses demonstrate why some pharmacists had not gotten certified:
“I don’t feel the pharmacy is the right place to counsel
about emergency contraception—we can’t keep the proper
records, [and] we’re not set up to counsel and take the
time to do this properly. It’s a decision that has to be made
between the patient and her doctor; it is not something
pharmacists should be doing….If someone comes in, then
I give them the number and the address of the clinic.”
—Rural pharmacist
“I had really thought about signing up to certify when
[pharmacy access] first came out…, but because of my
workload, and because I didn’t see the need for it, I didn’t
see the reason to certify and deal with all the red tape until the service demands it. The main reason I’m not certified is that there are bigger chains across the street and
around the corner, and two community clinics nearby,
Perspectives on Sexual and Reproductive Health
and I assume they are giving out Plan B….[But] I feel
bad when it’s Sunday and I have to turn someone away.”
—Rural pharmacist
“I don’t think there’s a problem with younger pharmacists, or the middle-aged pharmacists. I think it’s more the
older pharmacists….I don’t think it’s a moral thing here….
It’s just sometimes you get those pharmacists who are in
their comfort zone, and they don’t want to take on something new.”—Rural pharmacist
Viewing emergency contraception as easy to dispense
and wanting to help young women prevent unintended
pregnancy emerged as themes in interviews with pharmacists who expressed interest in the training or who were already trained to dispense it. These pharmacists wanted to
improve access to the method, thought that provision did
not take up too much of their time, wanted to be involved
in counseling and pregnancy prevention, and believed
pharmacists had a role that went “beyond counting pills.”
For pharmacists, getting certified to dispense emergency
contraception takes additional training and requires selfmotivation. In the mystery-shopper survey, professional
self-motivation was demonstrated by the fact that many
uncertified pharmacists provided phone numbers to help
the caller obtain the method, and callers noted that some
staff even called another pharmacy to make sure the method was in stock and that someone there could dispense it.
One certified pharmacist noted:
“[The] problem for pharmacists is that you have to believe in counseling…because it takes time and backs other
things up. Not all pharmacists are willing to sacrifice the
time.”—Urban pharmacist
䊉 Pharmacists’ knowledge and clinical comfort. Pharmacists knew that emergency contraception could be taken
effectively within 120 hours after unprotected sex, but
were uncomfortable providing it beyond 72 hours. They
emphasized the importance of women’s receiving regular
reproductive health care, and preferred that adolescents be
seen at a clinic. Pharmacists said they would refer an adolescent to a clinic instead of providing her with emergency
contraception if she had diabetes, smoked, had irregular
periods or reported repeated use of the method. Several
pharmacists explained why they would refer more “complicated” situations to a clinic:
“At least there’s a doctor there to consult with in regards
to medical conditions. I don’t know if I can make the correct choice for them.”—Rural pharmacist
“I knew…there was a five-day window period, but the
percentages go down.…[I would] tell them most of the
manufacturers recommend not [taking the method] after
72 hours.…I would also refer them to the clinic.”—Rural
pharmacist
Callers noted that some pharmacists’ comments, such
as “three days is too late for the morning-after pill,” demonstrated a lack of knowledge about the method. In light
of the in-depth interviews, some of these comments appear to have been motivated by pharmacists’ discomfort.
However, other underlying personal reasons may have
Volume 41, Number 2, June 2009
affected the refusal to dispense emergency contraception
beyond 72 hours. Some callers noted comments such as
the following, from staff whom they considered rude and
dismissive:
“It will not work after 72 hours.…It’s called the morningafter pill—haven’t you heard? You just have to wait. It
won’t work!”—Rural pharmacy staff
“We have it here without a prescription, but it’s too late
for you. It’s been too long, so there’s nothing you can do.
You can only take the pill the day after the unprotected
act.”—Rural pharmacy staff
䊉 Pharmacist-clinician
communication. Most clinicians
and pharmacists felt that at the community level, communication was lacking between the professions in dispensing emergency contraception. Although pharmacists do
not require authorization from a clinician to dispense the
method, they expressed a desire to consult with clinicians.
For their part, clinicians did not know which pharmacies
in their communities provided emergency contraception
without a prescription, and some were not even aware that
California had a pharmacy-access program. Both pharmacists and clinicians appeared to be confused about pharmacy access: Some clinicians thought all adolescent clients
had to pay for the method when using pharmacy access
(those enrolled in Family PACT get it free), and some
pharmacists thought they could dispense with prescriptive authority only if they had an agreement with a collaborating physician, and did not seem to know there was
a statewide protocol for certified pharmacists.
One urban pharmacist reported regularly collaborating with a community clinic. When an adolescent had
requested the method but had no insurance, the pharmacist immediately referred her to a nearby clinic, where she
registered for Family PACT; the adolescent then returned
to the pharmacy to obtain the emergency contraception
for free.
䊉 Clinics or pharmacies as dispensing sites. The interviewed clinicians worked in public health or community
clinics and preferred on-site dispensing of emergency contraception for a number of reasons: They felt pharmacies
were not committed to providing access to the method,
believed pharmacists were telling clients they had to pay
for the method, were concerned that adolescents were not
comfortable negotiating the necessary interaction with a
pharmacist and thought that adolescents were more comfortable obtaining the method at a community clinic. Rural pharmacists felt that local adolescents did not come
to them for emergency contraception, and assumed that
adolescents were visiting clinics instead. Several clinicians
remarked on adolescents’ access:
“They come [to the community clinic] and get it for
free….You know, kids are just not used to the whole prescription thing, and how they work. So I think it’s just
easier to give them the pills.”—Rural clinician
“I don’t know what’s going on with the pharmacies....
They were telling people they had to pay. And that just
scares a teen away.”—Rural clinician
115
Barriers to Adolescents’ Getting Emergency Contraception in California
DISCUSSION
Before an adolescent can gain access to emergency contraception, she must perceive herself to be at risk of getting
pregnant, want to prevent the pregnancy, know about
the method and where to obtain it, be able to afford it
or obtain it at reduced or no cost, and be able to negotiate her needs with a health care provider or pharmacist.
Furthermore, our study indicates that some adolescents
face significant barriers because of language, inadequate
pharmacist-clinician collaboration, inconsistent availability of pharmacists certified to prescribe the method and
lack of clear referral protocols. In California, these barriers
appear to be larger in rural areas and for Spanish speakers
than in urban areas and for English speakers. We found
that access to emergency contraception was hampered by
poor or nonexistent Spanish-language services, and believe that the impact of language barriers on unintended
pregnancy among Latinas needs to be further explored.
Because pharmacies are often an initial access point in the
health care system,23 strategies need to be developed to address language barriers and improve cultural competency
in all pharmacies in California.
As other studies have found,40 interviews revealed factors
that influenced a pharmacist’s motivation to get certified to
dispense emergency contraception. While some pharmacists had vague concerns that use of the method would
have a negative impact on adolescents’ health or sexual
behavior, a more common concern was that adequate
counseling about the method would take too much time.
This led some pharmacists to avoid certification. These
same factors may also influence pharmacists’ referrals for
emergency contraception. For example, a pharmacist’s belief about whether pharmacies or clinics should be dispensing the method, as well as knowledge of its effectiveness beyond 72 hours and comfort in dispensing it during
that extended period, probably guide whether a client is
referred to a clinic or to another pharmacy. Rural pharmacists may feel that referring clients to clinics is a better way
to ensure their access to emergency contraception where
fewer participating pharmacies exist; this may explain our
finding that English-speaking callers who asked for the
method beyond 72 hours were less successful when they
called rural pharmacies than when they called urban pharmacies. More studies are needed to explore the constraints
that rural pharmacies face when deciding whether to dispense emergency contraception, and to determine how to
support them in doing so.
Rural clinicians and pharmacists suggested that adolescents might receive better care and counseling at clinics, on
the assumption that clinics have more Spanish-language
services and that adolescents in rural communities may feel
more comfortable seeking confidential care at these sites.
A large number of low-income adolescents in California,
especially Latinas, lack a regular source of health care.41–43
Pharmacy staff cannot assume that adolescent clients have
a regular doctor, and telling them to “call your doctor”
could further delay access to emergency contraception. To
116
shorten delays, pharmacy staff should guide adolescents
to a specific clinic by giving them a phone number or an
address.
Pharmacies are well positioned to help connect adolescents with community family planning clinics for
ongoing care. Our study, however, found that few clinic
referrals included specific contact numbers or addresses;
this could be because pharmacy staff did not know which
clinics adolescents could go to in their community, or because staff assumed that adolescents already had a family
planning provider. Strategies are needed to link community clinics with pharmacies and to improve pharmacies’
referral protocols. In addition, insurance coverage protocols for adolescents need to be clarified to pharmacy
staff, so they can guide adolescents to publicly funded
providers to obtain services at no cost. Pharmacists also
need to be reminded that emergency contraception can
be offered until five days after unprotected sex, and those
who are uncomfortable prescribing it beyond 72 hours
should know where to direct adolescents to avoid delays. Furthermore, innovative and ongoing education for
pharmacists and support staff would be beneficial, especially to those in isolated rural communities. Qualitative
studies are needed to better understand how rural adolescents, especially Spanish speakers, feel they would be
best served.
In California, adolescents are legally permitted to obtain
confidential family planning services from clinic and pharmacy providers. Contrary to some national media criticism
of pharmacists,44 our study showed that few pharmacists
cited age as the reason they would not provide emergency
contraception, or told callers that parental notification was
required. Although this is encouraging, barring access to
emergency contraception services for even one adolescent
could lead to one more unintended pregnancy.
Limitations
One limitation of our study is that it did not assess pharmacies’ actual provision of emergency contraception; no
U.S. mystery-shopper studies in which Spanish speakers
enter a pharmacy and request emergency contraception
have yet been published. In addition, our callers were
in their early 20s, and they may have been more assertive than actual adolescent clients; hence, our results may
overestimate callers’ success. Another limitation is that
we cannot determine whether access differed by callers’
age, because age was linked to the timing of the request.
Furthermore, because the data were drawn from responses generated by mystery shoppers, we cannot be certain
that pharmacy staff volunteered all of the reasons why the
method was not made available to callers. Also, we compared access on the basis of rural and urban region rather
than zip code; looking at access by zip code might yield
different results.37
The qualitative data are limited because they were drawn
from a convenience sample, a small number of pharmacists were interviewed and the interviews were conducted
Perspectives on Sexual and Reproductive Health
in English. The interviewer’s profession and language
may also have affected the data collected. For example,
pharmacists may have been uncomfortable sharing underlying moral concerns, whereas clinicians—who may have
felt less targeted as a professional group for their views
on emergency contraception—may have been more open
about their thoughts on provision of the method.
Conclusions
Ensuring timely access to emergency contraception is one
effective strategy for preventing unintended pregnancy,
and though pharmacy access is a critical element in improving the method’s availability to adolescents, several
logistical issues continue to complicate their access. Our
study points out that access to emergency contraception is
dependent on a number of factors, and that policy changes
alone are not enough to guarantee access at pharmacies.
The expansion of Spanish-language services at pharmacies
would likely improve timely access, but adolescents must
feel comfortable negotiating their needs at these sites.
Encouraging and advertising on-site dispensing at clinics, and providing advance prescriptions to adolescents,
should not be ignored as important options in improving
access to the method, even with its current availability behind the counter. Clinics will probably remain a primary
source for access to emergency contraception, but stronger
collaborative efforts within the health care community and
recognition of pharmacists as key members of the health
care system could further improve access. Finally, ensuring that Spanish-language services are widely available at
pharmacies would improve access not just to reproductive
health care, but also to broader health care services.
REFERENCES
1. Singh S and Darroch JE, Adolescent pregnancy and childbearing:
levels and trends in developed countries, Family Planning Perspectives,
2000, 32(1):14–23.
2. Child Trends Databank, Teen births, 2008, <http://childtrends
databank.org/indicators/13TeenBirth.cfm>, accessed Apr. 5, 2009.
3. Constantine NA and Nevarez CR, No Time for Complacency: teen
births in California, Public Health Institute, 2003, <http://teenbirths.
phi.org/TeenBirthsFullReport.pdf>, accessed Apr. 4, 2009.
4. Constantine NA, Nevarez CR and Jerman P, No Time for Complacency: teen births in California, Public Health Institute, 2008 update, <http://teenbirths.phi.org/2008TeenBirthsReport.pdf>, accessed
Apr. 5, 2009.
5. Martin JA et al., Births: final data for 2005, National Vital Statistics
Reports, 2007, Vol. 56, No. 6.
6. Santelli JS et al., Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use, American Journal of Public Health, 2007,
97(1):150–156.
9. Jones RK, Darroch JE and Henshaw SK, Contraceptive use among
U.S. women having abortions in 2000–2001, Perspectives on Sexual
and Reproductive Health, 2002, 34(6):294–303.
10. Hofferth SL, Reid L and Mott FL, The effects of early childbearing on schooling over time, Family Planning Perspectives, 2001,
33(6):259–267.
11. Public Health Institute, Teen births and costs by California counties, 2006, <http://teenbirths.phi.org/2008CountyTable.pdf>, accessed Apr. 7, 2009.
12. U.S. Bureau of the Census, State and county quick facts, California, 2009, <http://quickfacts.census.gov/qfd/states/06000.html>,
accessed Apr. 7, 2009.
13. California Department of Finance, Population projections for
California and its counties 2000–2050, by age, gender and race/
ethnicity, 2007, <http://www.dof.ca.gov/HTML/DEMOGRAP/Reports
Papers/Projections/P3/P3.php>, accessed Sept. 25, 2008.
14. Trussell J, Rodríguez G and Ellertson C, Updated estimates of
the effectiveness of the Yuzpe regimen of emergency contraception,
Contraception, 1999, 59(3):147–151.
15. Ellertson C, Evans M and Ferden S, Extending the time limit for
starting the Yuzpe regimen of emergency contraception to 120 hours,
Obstetrics & Gynecology, 2003, 101(6):1168–1171.
16. Rodrigues I, Grou F and Joly J, Effectiveness of emergency contraception pills between 72 and 120 hours after unprotected sexual intercourse, American Journal of Obstetrics & Gynecology, 2001,
184(4):531–537.
17. von Hertzen H et al., Low dose mifepristone and two regimens
of levonorgestrel for emergency contraception: a WHO multicentre
randomized trial, Lancet, 2002, 360(9348):1803–1810.
18. Pharmacy Access Partnership, Models for EC pharmacies,
<http://www.go2ec.org/ModelsForECPharmacies.htm>,
accessed
Mar. 27, 2009.
19. Kaiser Family Foundation and SELF magazine, National Survey of
Women About Their Sexual Health, 2003, <http://www.kff.org/womens
health/3341-index.cfm>, accessed Sept. 20, 2005.
20. Kaiser Family Foundation, Emergency Contraception in California—Findings from a 2003 Kaiser Family Foundation Survey, 2004,
<http://www.kff.org/womenshealth/upload/Emergency-Contracep
tion-in-California.pdf>, accessed Aug. 15, 2005.
21. Foster DG et al., Knowledge of emergency contraception among
women aged 18 to 44 in California, American Journal of Obstetrics &
Gynecology, 2004, 191(1):150–156.
22. Foster DG et al., Trends in knowledge of emergency contraception among women in California, 1999–2004, Women’s Health Issues,
2007, 17(1):22–28.
23. Monastersky-Madres N and Cohen-Landau S, The continuum of
care: a case for pharmacists as key members of the reproductive health
care team, editorial, Contraception, 2008, 77(3):139–142.
24. Pharmacy Access Partnership, EC protocols, <www.pharmacy
access.org/ECProtocols.htm>, accessed May 15, 2008.
25. Foster DG et al., Pharmacy access to emergency contraception
in California, Perspectives on Sexual and Reproductive Health, 2006,
38(1):46–52.
26. Gardner JS et al., Increasing access to emergency contraception
through community pharmacies: lessons from Washington State,
Family Planning Perspectives, 2001, 33(4):172–175.
7. Finer LB and Henshaw SK, Disparities in rates of unintended pregnancy in the United States, 1994 and 2001, Perspectives on Sexual and
Reproductive Health, 2006, 38(2):90–96.
27. Schwarz EB et al., Knowledge of and perceived access to emergency contraception at two urgent care clinics in California, Contraception, 2007, 75(3):209–213.
8. Kids Count Data Center, California teen births (rate per 1,000
females ages 15–19), 2005, <http://datacenter.kidscount.org/data/
bystate/Map.aspx?state=CA&ind=416>, accessed Mar. 31, 2009.
28. Espey E et al., Emergency contraception: pharmacy access in
Albuquerque, New Mexico, Obstetrics & Gynecology, 2003,
102(5):918–921.
Volume 41, Number 2, June 2009
117
Barriers to Adolescents’ Getting Emergency Contraception in California
29. French A and Kaunitz AM, Pharmacy access to emergency hormonal contraception in Jacksonville, FL: a secret shopper survey,
Contraception, 2007, 75(2):126–130.
38. Creswell JW, Research Design: Qualitative, Quantitative, and Mixed
Methods Approaches, second ed., Thousand Oaks, CA: Sage Publications, 2003.
30. Bennett W et al., Pharmacists’ knowledge and the difficulty
of obtaining emergency contraception, Contraception, 2003,
68(4):261–267.
39. Morse JM, Read Me First for a User’s Guide to Qualitative Methods,
Thousand Oaks, CA: Sage Publications, 2002.
31. Free C, Lee RM and Ogden J, Young women’s accounts of factors influencing their use and non-use of emergency contraception:
in-depth interview study, BMJ, 2002, 325(7377):1393–1396.
32. Karasz A, Kirchen NT and Gold M, The visit before the morning
after: barriers to preprescribing emergency contraception, Annals of
Family Medicine, 2004, 2(4):345–350.
33. Wallace JL et al., Emergency contraception: knowledge and
attitudes of family medicine providers, Family Medicine, 2004,
36(6):417–422.
34. Harper CC et al., Over-the-counter access to emergency contraception for teens, Contraception, 2008, 77(4):230–233.
35. Gold MA et al., The effects of advance provision of emergency contraception on adolescent women’s sexual and contraceptive behaviors, Journal of Pediatric and Adolescent Gynecology, 2004,
17(2):87–96.
36. Raine TR et al., Direct access to emergency contraception through
pharmacies and effect on unintended pregnancy and sexually transmitted infections: a randomized control trial, Journal of the American
Medical Association, 2005, 293(1):54–62.
37. Bigbee JL et al., Pharmacy access to emergency contraception
in rural and frontier communities, Journal of Rural Health, 2007,
23(4):294–298.
118
40. Sable MR and Schwartz LR, Using the theory of reasoned action
to explain physician intention to prescribe emergency contraception,
Perspectives on Sexual and Reproductive Health, 2006, 38(1):20–27.
41. Guendelman S et al., Overcoming the odds: access to care for immigrant children in working poor families in California, Maternal and
Child Health Journal, 2005, 9(4):351–360.
42. Rew L, Access to health care for Latina adolescents: a critical review, Journal of Adolescent Health, 1998, 23(4):194–204.
43. Solorio MR et al., A comparison of Hispanic and white adolescent
females’ use of family planning services in California, Perspectives on
Sexual and Reproductive Health, 2004, 36(4):157–161.
44. Wall LL and Brown D, Current commentary: refusals by pharmacists to dispense emergency contraception, Obstetrics & Gynecology,
2006, 107(5):1148–1150.
Acknowledgments
The authors are thankful for the support provided through the Department of Family and Community Medicine and the Department
of Obstetrics, Gynecology and Reproductive Sciences, University of
California, San Francisco.
Author contact: oli.sampson@yahoo.com
Perspectives on Sexual and Reproductive Health