Rethinking the Pharmacy: Stakeholder Perceptions of Pharmacist-Prescribed Hormonal Contraception in Rural California

Background and Purpose

Rural communities nationally and in California experience sexual and reproductive health inequities and inadequate access to healthcare, including contraceptive care. Pharmacies are an important source of healthcare in rural America, particularly as pharmacists’ scope of practice is expanded to prescribing medication, chronic disease management, and preventive health services. This study investigated barriers and facilitators to implementing pharmacist-prescribed contraception in Tulare County, a rural, agricultural county in California’s Central Valley.

Methods

Using an implementation science framework, we interviewed community and healthcare stakeholders to investigate external influences that could promote or hinder the implementation of pharmacist-prescribed contraception in Tulare County. Stakeholder interviews occurred over Zoom, lasted between 46-68 minutes, and were audio recorded for transcription. We used the Sort and Sift, Think and Shift qualitative analytic approach to identify emergent themes.

Results

Community stakeholders included representatives from churches, youth organizations, schools, and social service programs in Tulare County. Stakeholders recognized that the conservative, religious nature of the community posed access barriers for youth to both accurate sex education and contraception. Many stakeholders were unaware that pharmacists could prescribe hormonal contraception but were supportive, recognizing the importance of increasing contraceptive access locally. Some stakeholders cited the potential for opposition to this service from the conservative community but did not view this as a significant barrier. Despite their support, stakeholders had concerns about process and logistics, specifically pharmacists’ access to patient medical records to identify hormonal contraception contraindications and the ability to provide a private consultation space. Many of the stakeholders did not view pharmacists as “patient-facing” providers, emphasizing the importance of pharmacists altering their practice to build more patient rapport and informing the community about this service through targeted advertising.

Healthcare stakeholders included providers who worked in large health systems, reproductive health clinics, and pediatric clinics. Perceptions of pharmacist-prescribed hormonal contraception were generally favorable, yet several concerns emerged, specifically the potential for fragmented care. Providers described the general benefits of the medical home model, wondering if and how visits to the pharmacy for hormonal contraception would be communicated to them. In addition, providers were unsure if pharmacists had the skills and capacity to screen for other social and health issues, such as intimate partner violence. All providers interviewed thought that youth would benefit the most from this service. Ultimately, providers expressed the importance of offering contraception in ways patients prefer, noting that pharmacist prescribing of hormonal contraception may be one such mechanism.

Conclusions and Implications

Pharmacist-prescribed hormonal contraception offers an additional avenue for access to contraception, which is especially important in rural communities that have disparate contraceptive access. Community stakeholders emphasized pharmacists changing their practice to be more “patient-facing,” focusing on building pharmacist-patient rapport, whereas healthcare stakeholders stressed the importance of pharmacists fostering interprofessional relationships with other providers to ensure smooth integration of patient care within a medical home model. Pharmacists who prescribe hormonal contraception and practice in rural communities should take these considerations into account when designing this service.