Curricular Considerations for Preparing Student Pharmacists to Prescribe Hormonal Contraception

FINDINGS

In a 2020 survey by Rim and colleagues that assessed the contraception curricula taught in US pharmacy schools, 100% of schools that responded indicated they provided education on emergency contraception and hormonal contraception.⁷ The majority of respondents also offered non-hormonal nonprescription (over-the-counter [OTC]) contraception content (96%) and long-acting reversible contraception content (91%). On average, schools spent 6.8 ± 3.7 (mean ± SD) hours on contraception topics (range: 1.4-22 hours) with emergency contraception and hormonal contraception taking 0.9 ± 0.5 hours (range: 6 minutes-2 hours) and 2.9 ± 2.0 hours (range: 45 minutes-12 hours) of the curricula, respectively. Patient cases were the most frequent type of supplemental material used. Despite inclusion of content on routine and emergency contraception in the vast majority of PharmD programs, the curricula may not prepare all graduates to confidently prescribe hormonal contraception.^10-12

In 2007 Evans and colleagues was one of the first studies to evaluate learning outcomes associated with contraception content in pharmacy education (n = 752 from 18 colleges of pharmacy). This study evaluated general student knowledge of emergency contraception at different timepoints during the PharmD curriculum but did not assess a specific learning experience. The results found that students’ knowledge of emergency contraception increased with each year in pharmacy school, after taking a course covering contraception, or when emergency contraception was a specific topic in a course.¹³ Out of nine questions, students’ mean knowledge score was 5.9 (n = 65.5%). Scores improved with each academic year: first- and second-year students scored an average of 5.4, third-year students scored an average of 5.8, and fourth-year students scored an average of 6.4. Evans and colleagues did not address instructional time or quality of instruction as a determinant of student knowledge.

In 2018, Hohmann and colleagues conducted a cross-sectional survey of first-year student pharmacists (n = 110) regarding their contraceptive knowledge, perceptions, and counseling intentions among students.¹² The results of the survey suggested that student pharmacists early in training preferred to learn by watching examples of pharmacists counseling patients on contraception (56%) or through “role-playing” (30%). In 2014, Rafie and colleagues conducted a survey of student pharmacists (n = 502) in California prior to the state’s policy change. The survey was administered to student pharmacists who had completed pharmacotherapeutic coursework but not yet started advance pharmacy practice experiences (APPEs). Despite 94% of students feeling confident about counseling patients on the proper use of hormonal contraception, only 65% felt adequately educated to prescribe hormonal contraception in their pharmacy practice.¹⁰ In 2020, Stone and colleagues reported that 58% of pharmacists surveyed felt they had received adequate training to prescribe hormonal contraception. However, 42% did not feel that they were adequately trained and competent to prescribe hormonal contraception, and of these 21% reported that hormonal contraception was not covered in their pharmacy school curriculum. Finally, a majority of respondents indicated they desired additional training, specifically on switching patients from one contraceptive to another and selection of contraceptive products for a specific patient.¹¹

Pharmacists are not the only health care providers to report deficits in contraceptive training. Some surveys of primary care providers also reveal a reported lack of knowledge and comfort with contraception counseling,¹⁴ and surveys of graduating medical residents found that their knowledge of contraception varied widely.¹⁵ Provider knowledge about emergency contraception also varies widely. A 2016 survey of general practitioners who provided care for women of reproductive age did not know about more effective methods of emergency contraception (oral ulipristal acetate and copper intrauterine device) and rarely (4%) prescribed them.¹⁶ Establishing a standardized curricula for contraceptive training to address these knowledge gaps has been suggested for medical students.¹⁴

The amount of time dedicated to contraceptive training also varies in medical education. A 2003 survey of US and Canadian medical schools found that most taught three to 10 hours of sexual health education content and the majority was lecture-based.¹⁷ One review suggested that training in sexual health and assessment of students’ knowledge are lagging behind the clinical and scientific advancements in the field.¹⁸ A report issued in 2010 by the International Consultation of Sexual Medicine, an international, multidisciplinary expert panel, indicates that sexual health training of physicians is inadequate and standardized assessments of clinical skills are needed.¹⁸

There are limited studies that assess the quality of instructional methods and associated clinical competencies for emergency contraception and hormonal contraception curricula in pharmacy education. The available literature is described, and a summary of the study objectives, teaching modalities, type of course, study design, and assessment methods can be found in Appendix 1.

Young and colleagues (n = 189) found that approximately 25% of pharmacy students stated they were confident in counseling patients regarding emergency contraception prior to an active-learning exercise compared to 59% after (p < .01).²⁰ Students were asked to rate the degree to which certain barriers hindered their ability to counsel a patient regarding emergency contraception using a scale of 0 to 100, with 0 representing “not a barrier” and 100 representing “it’s a definite barrier.” The most common barrier to counseling identified by students on the pre- and post-workshop survey was lack of knowledge (presurvey mean score = 41.0 and postsurvey mean score = 19.8, p < .001). Student pharmacists’ knowledge of counseling patients regarding emergency contraception increased from 86% to 93% after the exercise (p < .001). The study concluded that active-learning exercises may be an effective way to increase student pharmacists’ knowledge and confidence regarding emergency contraception.

A few studies have evaluated teaching methods for contraception training in student pharmacists. Two studies in elective courses have been conducted. A 2018 study by Lynch and colleagues assessed student pharmacists enrolled in a women’s health elective (n = 11).²¹ The students underwent training on state hormonal contraception prescribing legislation and completed three simulated standardized-patient scenarios in which they used a prescribing algorithm to make clinical decisions and interacted with the simulated patients. Students received an average score of 27.6 out of 30 points, and all completed the activity within the allocated 20 minutes. Students reported overall satisfaction with the activity, generally agreed that the activity was realistic, and reported feeling prepared to prescribe contraceptives. A second study evaluating a women’s health elective was conducted by El-Ibiary and colleagues in 2018 and included contraception discussion activities and active learning in the form of reading journal article reviews and using drug information resources.²² Of the students enrolled (n = 33), 80% preferred workshops with OTC products as the mode of learning. Hormonal contraception workshops were the second most preferred (61%) mode of learning. Students’ confidence in counseling women about reproductive health significantly increased after the course (mean scores 2.62 pre-course vs 3.75 post-course; p < .01). Students’ perceptions of their overall knowledge in women’s health also increased (mean scores 2.63 pre-course vs 3.92 post-course; p < .01). Prior to the course, students were least confident in counseling patients about progestin-only implants and most confident in counseling patients about emergency contraception. After the course, students’ confidence increased for both products, respectively (mean score of 1.82 to 3.81; 3.70 to 4.29; p < .01 for both items).

Two larger studies evaluating teaching methods for contraception training in student pharmacists have been conducted. The first was by Harris and colleagues in 2020 and evaluated student knowledge of and confidence with prescribing hormonal contraception following participation in a simulated patient case activity.⁸ Student performance on an individual readiness assurance test was consistent, with a mean of 84% for two academic years sampled (2017-2018; n = 131 and 2018-2019; n = 112). Students scored an average of 84% (2017-2018) and 92% (2018-2019) on the documented assessment and plan (p < .001) and 96% (2017-2018) and 91% (2018-2019) on the post-activity quiz (p = .001). The tasks that students felt the most confident about completing included navigating and interpreting the patient’s prescription drug formulary, providing the patient with written documentation about the product, and notifying the patient’s primary care provider of any product prescribed to the patient. Students reported less confidence in their ability to select an appropriate hormonal contraception product based on patient-specific factors and provide education on managing missed doses. The second study by Lynch and colleagues assessed the impact of a stimulated activity on second-year student pharmacist readiness and confidence in prescribing contraception (n = 216).²³ The mean activity score was 86% (median 90%), with a significant change in students’ confidence in their ability to complete the process after the activity (p <  .01). There was a significant increase from pre-activity to post-activity in the number of students who agreed that the curriculum prepared them to prescribe hormonal contraception (increase from 15% to 29%; p < .01). However, at both baseline (52%) and follow up (53%) a majority of students still reported they would need more practice during advanced pharmacy practice experiences (APPE) before they would feel prepared to prescribe contraception.

Evaluation of teaching activities and learning assessments for contraception training in other health care professions is also limited, but available data indicate that active-learning activities may be effective in improving knowledge and comfort with contraceptive care. For example, one 2019 study provided internal medicine residents with a pocket card and one-hour didactic lecture and assessed their confidence in counseling on and prescribing contraception before and after the activity.²⁴ Forty-two students (56%) completed the pre-intervention survey and 40 students (53%) completed the post-intervention survey. Although there was a significant improvement in resident attitudes toward the applicability of contraception training (p = .03), there was no difference in confidence in prescribing or counseling patients regarding oral contraceptives (p = .05, p = 0.45). Another 2019 study evaluated internal medicine residents (n = 38) who completed a contraception case-based assessment using interactive online resources (CDC MEC and Reproductive Health Access Project websites) and smartphone applications (CDC Contraception and Contraception Point-of-Care applications).²⁵ The students’ mean knowledge score improved significantly after this learning activity, nearly doubling from 49% correct answers on the pre-survey to 85% correct on the post-survey. Students were asked to rate their confidence and comfort level with counseling patients and assessing their eligibility to use contraception using the following scale: 1 = very comfortable/confident, 5 = not at all comfortable/confident. Post-surveys demonstrated significant improvements in all categories (ie, comfort with counseling patients, confidence in evaluating their medical eligibility, and confidence in initiating contraception). Improvements in confidence were maintained on follow-up surveys administered four to six months later (evaluating patients’ medical eligibility, presurvey mean score = 3.2 and delayed postsurvey mean score = 2.7, p = .004; and initiating patient use of the pill, patch, ring, or injection, presurvey mean score = 3.6 and delayed postsurvey mean score = 3.0, p = .002).

One major limitation in evaluating teaching activities for student pharmacists regarding contraception prescribing and patient education is the understanding that there is a discordance between methodologies used in the classroom and those described in the literature. Robust literature related to active learning techniques, applied skills laboratory time within the curriculum, and simulation scenarios is lacking. Educators are likely using these techniques to deliver the contraception curriculum; however, they are not publishing papers about their experience or research in this area. This can be because of a variety of reasons, including lack of time or concerns of lack of rigor or high enough degree of innovation for peer consumption.

Faculty may face barriers that impact successful implementation and expansion of advanced contraception education into pharmacy curricula.^7,26,27 Some of the overarching concerns that commonly impact curricular development include faculty resources or resources for activity development and curricular design. School curricula often are already strained for space and time, and inserting a new activity can be challenging. Additionally, having the faculty resources for development of new activities may be difficult depending on the institution and faculty expertise. Also, an institution may place limitations on faculty in terms of how in-depth contraception content can be delivered, discussed, and applied. When extrapolating data from other health professions, similar barriers have been documented.^24-28 Reported barriers in delivering sexuality content, including contraception, within nursing curricula include: time constraints in the curriculum, less priority compared to other topics, comfort and capability to teach the topics, and importance not seen by faculty.^26,27 Aaberg found 40% of responding nursing programs identified time constraints as the primary barrier in 2016, which aligns with a study conducted nearly 50 years prior in which 45% identified lack of time as a barrier.^26,28 Pharmacy schools also identified time as a barrier to contraception education curricula incorporation in the 2020 study by Rim and colleagues, although 68% felt the curriculum was adequate. Only 29% of pharmacy schools agreed that incorporating six to eight hours of hormonal contraception education into the required didactic curriculum would be easy. Interestingly, 61% agreed that providing six to eight hours of contraception education within the elective curriculum would be easy.⁷ Although expanding women’s health education within any part of a curriculum should be lauded, expansion in elective areas of the curriculum alone would not contribute to the practice-readiness of all students in a pharmacy program.

The optimal duration of instructional time needed to deliver contraceptive content is unknown, and instructional time may not directly correlate with an increase in practice-readiness. Typical assumptions often include the idea that additional instruction time results in increases in performance outcomes. A 2017 study by Cattaneo and colleagues in secondary education illustrated that an additional hour of instruction only delivered 30%-40% of the expected learning impact that is typically associated with the first hour of instruction.²⁹ Lavy, and Rivkin and Schiman found that increasing instructional time modestly increased students’ performance on examinations in secondary education.^30,31

Depending on state regulations and current contraception prescribing practices, pharmacy faculty, preceptors, and students may have different expectations of the importance of advanced student learning activities within the curriculum with regard to contraception. Theoretically, students and educators located in states that allow pharmacists to prescribe may place a greater emphasis on active learning and simulated activities and devote more time to the topic. Additionally, lack of support for these types of activities from other health care providers may exist as well, which could impact interprofessional education experiences. The most commonly used learning technique for contraception in the 2020 study by Rim and colleagues was the use of case studies, but the lowest used method was patient interviews.⁷ The use of active learning techniques allows students to apply the information they have learned and grow in their comfort level with prescribing contraception. Rim and colleagues suggested that patient interview utilization could be increased to aid with student confidence. As practicing pharmacists often cite training as a barrier to providing this service, robust activities using a variety of teaching techniques can best help equip students for practice.³²

Student attitudes towards contraception prescribing also play a role in the intent to perform this action. In 2018, Hohmann and colleagues discovered that, among first-year student pharmacists who had not yet learned about contraception, those with more positive attitude scores regarding contraception counseling had a higher intent to counsel. Perceived importance of contraceptive education may vary among students, schools of pharmacy (ie, religious vs secular institutions), and states (ie, pharmacist prescribing vs non-prescribing). These factors may ultimately affect an individual pharmacist’s decision to prescribe contraception.

States that allow pharmacist-prescribed contraception mandate that the provider complete a training course, the content of which varies among states. However, some states waive this requirement for pharmacists who graduated from a school in the state after the bill went into effect (Appendix 2). It is unclear whether receiving this prescriptive authority as part of earning a PharmD degree instead of by completing postgraduate training increases the number of pharmacists who choose to provide this service.