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

Background and Purpose: Rural communities 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. 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 local implementation of pharmacist-prescribed contraception. Stakeholder interviews occurred over Zoom, lasted between 46-68 minutes, and were audio recorded. We used the Sort and Sift, Think and Shift qualitative analytic approach to guide coding and theme development.

Results: We interviewed 20 stakeholders (11 community and 9 healthcare). Community stakeholders included representatives from churches, youth organizations, schools, and social service programs. Healthcare stakeholders included providers who worked in large health systems, reproductive health clinics, and pediatric clinics.

Participants described Tulare County as a rural, farm-worker community, with a large population of Latinx and Asian communities and people with lower levels of income and education. Stakeholders recognized that the conservative nature of the community posed access barriers for youth to both accurate sex education and contraception. Due to the rural landscape, access to healthcare is limited for those without personal transportation, and pharmacies were likely more accessible.

Awareness that pharmacists could prescribe hormonal contraception varied among participants but was higher among healthcare stakeholders. Even when stakeholders had awareness about pharmacist-prescribed contraception, there was confusion about what methods and how pharmacists could prescribe–even among healthcare stakeholders. Most importantly, no one interviewed was aware of a pharmacy in the local area offering this service.

Support for pharmacist-prescribed hormonal contraception was mixed. Many stakeholders recognized the importance of increasing contraceptive access locally, but discussed scenarios for when they believed pharmacist-prescribing hormonal contraception was appropriate (e.g., only for adults, oral contraceptives but no other methods). Stakeholders had concerns about process and logistics, as pharmacists were not physicians, likely did not have existing clinical relationships with potential service users, did not have access to health records, and may not have access to a private consultation space. Many stakeholders did not conceive of 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. All stakeholders thought that youth would benefit most from this service. Ultimately, stakeholders expressed the importance of offering contraception in ways patients prefer, noting that pharmacists prescribing hormonal contraception may be one such mechanism.

Conclusions and Implications: Pharmacist-prescribed hormonal contraception offers an additional avenue for access to contraception, which is important in rural communities that have disparate contraceptive access. These findings suggest that addressing the barriers and facilitators suggested by community and healthcare stakeholders would influence implementation of pharmacist-prescribed contraception. Raising awareness about this service along with details around the process and logistics may help ensure this service will be used by the community, especially youth.