Pharmacists' attitudes, knowledge, and practices in providing emergency contraception and medical abortion to adolescents in three districts of the Kathmandu Valley, Nepal, 2012 Open Access

Balakumar, Kavitha (2013)

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Background: Nepal has made incredible strides in reducing maternal deaths and bringing down fertility; however, for this progress to continue, family planning policies must also address the reproductive and sexual health needs of adolescents. This paper details research conducted by Ipas Nepal that explores how adolescents access emergency contraception (EC) and medical abortion (MA) from pharmacies. Specifically, we examine pharmacists' levels of knowledge surrounding EC and MA and their attitudes towards the use of these methods by adolescents. We also discuss how pharmacists' knowledge and attitudes to EC and MA may impact the quality of "care" adolescents receive at pharmacies, and provide recommendations for future research and policies.

Methods: We conducted structured, open-ended interviews with a convenience sample of 22 pharmacists from Kathmandu, Lalitpur, and Bhaktapur, three districts within the Kathmandu Valley. Interviews were conducted in Nepali by local researchers trained in qualitative research methods. An independent consultant translated the interview data from Nepali back to English. Upon receiving the translated data, we conducted a detailed content analysis using MaxQDA and Epi Info software.

Results: Pharmacists' levels of knowledge surrounding emergency contraception and medical abortion varied across the three study areas, with pharmacists in Kathmandu having the least complete knowledge of each method. Additionally, an attitude assessment revealed that pharmacists generally support adolescents accessing contraceptives including EC, and support adolescents' use of medical abortion. Pharmacists in Kathmandu, however, carried more conservative attitudes than those in the two smaller study regions of the Valley.

Conclusions: Pharmacists require additional education for the safe provision of emergency contraception and medical abortion. Their training should include a Values Clarification and Transformation (VCAT) workshop. We also encourage partnerships with youth organizations in the community to increase pharmacists' capacity to manage the needs of their adolescent clients with greater sensitivity. Finally, additional research is needed to develop systematic evaluation tools to assess family planning services rendered in pharmacies.

Table of Contents


I. Introduction 1

Problem Statement 1

Statement of Purpose 1

Statement of Significance 2

II. Background 3

Geography & Population 3

Government 3

Family Planning Policies and Programs 4

Key Stakeholders 4

History of Abortion Reform 5

Millennium Development Goals (MDGs) 7

Reproductive Health Indicators 8

III. Review of the Literature 10

Adolescents 10

--Define adolescence 10

--Demographic significance 11

--Delayed Youth Transition 11

--Burden of unintended pregnancy 12

--Drivers of unintended pregnancy 13

--Consequences of unintended pregnancy 17

--Need for EC & MA 18

--Paucity of data 18

Pharmacists 20

--Role of pharmacists 20

--Current practices 21

--Reviewing pharmacists' knowledge 21

--Reviewing pharmacists' attitudes 22

IV. Manuscript 24

Contributions of student 24

Abstract 25

Introduction 25

Methods 27

--Study population & design 27

--Data collection 28

--Data preparation & analysis 28

--Emory University IRB 29

Results 29

--Topic 1: Assessing pharmacists' knowledge and training about EC and MA 29

--Topic 2: Assessing pharmacists' attitudes towards youth accessing MA 34

Discussion 38

--Most important findings 38

--Comparisons with existing literature 40

--Limitations 42

--Implications of findings for future research 44

--Recommendations 45

Conclusion 46

Acknowledgements 46

References 47

V. Additional Results 48

Topic 1: Characteristics of pharmacists in the Kathmandu Valley 48

Topic 2: Characteristics of adolescents visiting pharmacies in the Kathmandu Valley 50

Topic 3: Availability of contraceptive methods and MA in pharmacies in the Kathmandu Valley 54

Topic 4: Contraceptive preferences of Adolescents 60

Topic 5: Dissemination of information regarding EC & MA 66

Topic 6: Pharmacists' process of referring abortion and post-abortion clients 69

VI. Additional Discussion 73

Relevant Results 73

Limitations 76

VII. Conclusions and Recommendations 78

Implications of findings for future research 78

Recommendations 79

Implications for public health 80

VIII. References 83

IX. Tables

Table 1: Pharmacists' knowledge of medical abortion (MA), stratified by district in the Kathmandu Valley, 2012 34

Table 2: Pharmacists' attitudes towards adolescents accessing medical abortion (MA), stratified by adolescents' marital status and gender, Kathmandu 2012 35

Table 3: Respondent's role in the pharmacy, stratified by district in the Kathmandu Valley 49

Table 4: Availability of contraceptive methods, stratified by district in the Kathmandu Valley 55

Table 5: Contraceptive methods by brand name 56

Table 6: Provision of MA, stratified by district in the Kathmandu Valley 58

Table 7: Weighing pharmacists' original responses to carrying MA against the answers provided for what brand of MA they carry 60

Table 8: Contraceptive methods most requested by female and male youth, stratified by district in the Kathmandu Valley 63

Table 9: Most popular selling items among youth, stratified by district in the Kathmandu Valley 65

Table 10: Least popular selling items among youth, stratified by district in the Kathmandu Valley 66

Table 11: CAC providers listed by pharmacists in Kathmandu, Lalitpur, and Bhaktapur 72

X. Appendix 86

Open-ended interview guide 86

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