Patient-Centred Counselling Tools for Dispensing Contraceptives in Community Pharmacy Settings: A Systematic Review

Introduction

Community pharmacy settings could ensure access to contraception services in line with Sustainable Development Goal 3 to contribute to good health and well-being.¹ This includes family planning, information, education, and the integration of reproductive health into national strategies and programmes. Hormonal contraceptives are readily available at community pharmacy for women’s reproductive health and overall well-being. It could be used to control their fertility, allowing the informed decision for a wanted child and providing various health benefits, such as reducing the risk of ovarian and endometrial cancers and regulating the menstrual cycle.²

The use of hormonal contraceptives may be not suitable for all women as it has the risk and has to be evaluated carefully before dispensing. In Malaysia with various cultural diversity, consumers may face many barriers and concerns related to stigma mainly in sexual and reproductive healthcare.³ Community pharmacists play an important role in comprehensive reproduction health education. Community pharmacists are one of the interprofessional personnel who can promote access to contraceptive services with their availability in most areas and long hours for operating the services.⁴ Community pharmacy is suitable for patient-centred care and lack of need for appointments which are good for many consumers with limited time. This commentary suggests specific ways for pharmacies to improve access to contraception, emergency contraception, and abortion in line with national quality recommendations.⁵ Particular focus can be given to the intersection of sexual and reproductive health resources and referrals within the pharmacy profession, as well as the training and technical assistance tools that can help address unmet patient needs.⁵

Certainly, educational interventions play an important tool in increasing the awareness and knowledge about the right contraceptive choice given by the community pharmacist. Contraceptive counselling plays a crucial role and can help individuals to make informed decisions about their needs and preferences. Key aspects of contraceptive counselling include information and education, assessment of needs and preferences, risk assessment, side effect management, continuous support, method continuation, and switching. All this requires collaboration between individuals and healthcare providers, thus a patient-centred approach. This aimed to empower the individuals to make choices aligned with their appropriate health reproductive goals. The Bruce framework identified six dimensions for quality family planning (FP) services, including choice of methods, information given to clients, and interpersonal relations.⁶

Patient-centred counselling tool is meant to facilitate an effective interactive process between provider and client. Patient-centeredness refers to providing care that is respectful of, and responsive to, individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.⁷ Contraceptive counselling tools available such as interactive decision-making aids using mobile apps, charts and infographic brochures, and comprehensive method guides using the WHO Medical Eligibility Criteria wheel or online tools. Such tools aim to engage the community pharmacist with patients in the decision-making process, taking into consideration preferences and needs with complete assessment of patients and developing personalised treatment plans. It was predicted that a well-designed patient-centred counselling tool could enhance the quality of provider and client interactions which would contribute to better reproductive health outcomes and alert the community pharmacist for risk factors to refer the patient to a physician.

Dispensing contraceptives in community pharmacy settings to date requires standardised guidelines or adherence to the best practices to ensure the safe provision of services given. Pharmacists should utilize a collaborative practice agreement to expand their scope of practice and provide clinical preventive services to patients.⁴ Community pharmacists should receive proper continuous updates or training on deciding the choice of contraceptives for dispensing or switching contraceptives. Community pharmacists should actively involve their consumers in the decision-making process to ensure the risk factors involved were identified to tailor the suitable contraceptives for the consumer before dispensing.

Several systematic reviews have been conducted to identify the counselling intervention tools in various other countries.^8–10 There was limited documentation on the referral of high-risk category patients to doctors. The current review therefore aimed to identify and select suitable tools used by community pharmacists with targeted patient-centred outcomes for dispensing contraceptives. Certainly, using educational interventions plays an important tool in increasing the awareness and knowledge about the right contraceptive choice given by the community pharmacist. Thus, the results of this review will inform about the importance of patient-centred counselling tools to guide the dispensing of contraceptives in community pharmacy settings.

Methods

Development of Key Questions and Analytical Framework

An analytical framework was developed to identify the link between the population of interest (community pharmacist with the client/patient), and the interventions that could provide the primary and secondary outcomes of interest (Figure 1). The key questions were developed through literature reviews and inputs from the experts.^5,11,12 Ten key questions (Q) were addressed on the patient-centred counselling tools for dispensing contraceptives in community pharmacist settings (Supplementary Table 1). The first seven (Q1-Q7) asked whether any tools were used to increase the awareness of contraceptive choice based on risk and benefit, participation in the decision-making, attitude towards contraceptives, selection of more effective choice of contraceptives and level of comfort with the dispensed choice. The final two questions were for long-term outcomes for community pharmacy settings and more on quality of services with appropriate referral to physicians for high-risk patients.

Figure 1 Analytic framework for systematic review of patient-centred counselling tools for dispensing contraceptives in community pharmacy settings.

Search Strategies and Study Identification

A systematic study of published literature was done following the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines.¹³ The review assesses the primary data of patient-centred counselling tools for hormonal contraceptives published between January 1990, since the publication of the Bruce framework in 1990 to June 2023 will be included regardless of the language. The studies using patient-centred counselling tools as interventions on the choice of contraceptives suitable for pharmacists were included. They must be also free to access in full online or accessible through university libraries. Reviews must have a primary focus on patient-centred tools used to select hormonal contraceptives or guidance used for the practice of dispensing contraceptives with any of the short-term outcomes highlighted in Figure 1. Inclusion criteria were developed, and the study included had to address one of the key questions. To meet the inclusion criteria, studies had to suit community pharmacists or had to describe an intervention that could be implemented feasibly in community settings for pharmacists to choose the contraceptives for dispensing. Studies focusing on counselling tools only or assessing knowledge only were excluded. Other exclusion criteria were interventions or outcomes focused solely on barrier methods. Studies focusing on long-acting reversible contraceptives including contraceptive implants and intrauterine devices (IUDs) were also excluded.

The search was conducted through a manual comprehensive literature on the Web of Science, The Cochrane Library, PubMed, Scopus, and Google Scholar as an additional source for published and unpublished studies. The lack of outcome data was traced by contacting the authors of the study. The proposed search matrix is chosen using the Population, Intervention, Comparator and Outcome (PICO) model (Table 1). The populations are set at pharmacists with the intervention of patient-centred counselling tools or healthcare providers suitable for pharmacists as a population. The comparison with other types of contraceptives dispensing with or without tools. The outcome is determined by the enhancement of a guide for pharmacists. Thus, the search keywords used such as “contracepti*”, “family planning”, “counselling OR counselling” OR “educational strategies” OR “patient-centred interventions” OR “tool* OR guide for pharmacist” OR “decision aid” OR “family planning quality” OR “quality of family planning” OR “patient-provider interaction” OR “patient-provider interaction” OR “client-provider interaction” OR “client-provider interaction” or “client-provider communication” OR “client-provider communication” OR “patient-provider communication” or “patient-provider communication AND pharmacist*” OR “community pharmacist”. Boolean operators such as “AND” and “OR” were used to increase the sensitivity and specificity of the search. Specific search terms used for each topic are presented in the appendix for complete search of keywords.

Table 1 Population, Intervention, Comparator and Outcome (PICO) Model

Selection of Studies

All uniquely identified publications in which patient-centred contraceptive tools were used among pharmacists or healthcare providers suitable for pharmacists were screened by one author (PV) based on title and abstract. All selection processes were undertaken by one reviewer that will complete both screening, eligibility, and inclusion. The selection process and screening of the results were validated by three reviewers AMA, CWW, and AA. Rayyan QCRI software was used for this study for the screening part.

Data Extraction and Data Synthesis

Extracted data included detailed information on study design, patient-centred contraceptive tools used, general healthcare providers and suitable for pharmacists to use the tools. The studies identified were examined thoroughly, selected study has answered any of the key questions outlined as per the analytic framework in this review. Data were extracted from included studies in an Excel data extraction sheet. The results were reported according to the intervention type and suitable for the target population with specific attention paid to community pharmacists or pharmacists. The substantial variability in contraceptive tools used as interventions and the outcomes prevented them from conducting a meta-analysis. We summarised the findings on the Patient-Centered Counselling Tool for dispensing contraceptives in community pharmacy settings in summary Table 2.^14–33 In this review, PRISMA reporting guidelines were followed.¹³

Table 2 Baseline Characteristic of Included Studies

Assessment of Study Quality

Study quality was assessed using a quality risk-of-bias assessment. In this study, the Robvis tools (RoB, 2023) were used for visualising the assessment of the risk of bias in individual studies.³⁴ A convenient “traffic light” plot tabulates the judgement for each study in each domain. Risk of bias domains consist of bias due to randomisation, deviation from intended intervention, missing data, outcome measurement, and finally selection of reported results. The overall risk of bias is weighted in the bar plots of the distribution of the risk of bias judgements within each bias domain (Figure 2).

Figure 2 Risk of bias and overall risk for the selected studies. Adapted from McGuinness LA, Higgins JPT. Risk-of-bias VISualization (robvis): an R package and shiny web app for visualizing risk-of-bias assessments. Res Synth Methods. 2021;12(1):55–61. © 2020 The Authors.Research Synthesis Methods published by John Wiley & Sons Ltd.34

Result

Systematic Search Results

The electronic search yielded a total of 5466 articles (Figure 3). Title and abstract screening excluded 4857 articles due to the inappropriate nature of the literature, not suitable for pharmacists, no tools being used to dispense or counsel contraceptives and duplicated records. Potentially relevant articles were screened and out of these 609, further 40 articles were duplicated and excluded using Rayyan software. Full-text assessment excluded 16 articles due to conflicts in the population and did not meet the inclusion criteria.

Figure 3 Systematic review flow diagram. *Rayyan Automation tools were used to help expedite the initial screening of abstracts and titles using a semi-automation process to indicate how many records were excluded. Adapted from Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339(7716):332–336. Creative Commons.13

The characteristics of all studies are presented in Table 2. The studies included populations involved in family planning (FP), who were categorised as service providers, healthcare providers, pharmacists, community pharmacists, practitioners and academicians, and community health workers. The tools used for patient-centred contraceptive counselling included mobile base, computerised aid, WHO wheels, written aid, and counselling kit. The outcomes of the studies were selected based on the key questions developed and largely correspond to shared decision-making and tools that serve as interactive aids for personalised patient care.

The participating studies provided an overview of the interventions used in the different populations (Table 3). The majority of studies were aimed at users of FP service. There were only three studies targeting community pharmacists, which was important to identify the tools used by community pharmacists. The appropriateness of patient-centred interventions in community pharmacy settings was tabulated according to the acceptability in community, patient care, time taken for consultation, cost, requirement for training, referral point to physician, risk factor alert, and involved culture aspect (Table 4)

Table 3 Mapping of Study Interventions Across the Population in Included Studies

Table 4 Summary of the Suitability of Patient-Centred Interventions in Community Pharmacy Settings

Discussion

Aligned with the current trend of family planning vision in sight, which is access to information and services on reproductive health, this systematic review provides a timely analysis of the patient-centred counselling tools available for dispensing contraceptives in community pharmacy settings. Patient-centred counselling approach for dispensing contraceptives in community pharmacy is a crucial aspect that focuses on tailored advice and personalized individual needs. By using a patient-centred counselling tool, pharmacists can effectively engage with clients, address their specific needs and concerns, and help them make informed decisions about contraceptive options.³⁵ This review provides new knowledge on detailed screening on patient-centred counselling tools by utilizing evidence-based resources, the source that could be used by community pharmacists to ensure they are providing accurate information on contraceptives and the risks of the different contraceptives evaluated before dispensing.

This review helps to identify any misinformation regarding contraceptive choices provided by community pharmacists to empower patients that the right choice was given accordingly. As community pharmacists strive to optimize the appropriate contraceptives, by incorporating patient-centred tools, community pharmacists can proactively provide comprehensive advice on contraception, ensuring that high-risk patients are adequately screened and referred to physicians. Patient-centred counselling tools serve and encourage active participation of patients or consumers in the counselling process, as they build rapport, relate contraceptive information to their situation, and reward their attempts to participate in a shared decision-making process.³⁶ This systematic review on patient-centred counselling tools for community pharmacists showed the importance of exploring the specific components such as risk factors, referral points by pharmacists to physicians, cultural inputs, and strategies that have been proven effective in enhancing patient engagement and empowerment. By implementing these patient-centred counselling strategies and providing comprehensive education on contraceptive options, healthcare providers can support women in making informed choices about their reproductive health.³⁷

The studies included, although targeting all family planning users, the digital decision-making tools and provider training (including paper-based decision-making aids and video aids) did not find evidence of effect on contraceptive behaviour or satisfaction at community pharmacy. However, the exceptions to this included the training from the search for this review in the Population Council’s Balanced Counselling Strategy and WHO Decision-making Tool effective in some community settings.^29,30,33 There were three studies targeting particularly only for community pharmacists which were important to identify the tools that have been used among community pharmacists for future suitability.^22–24 Collaborative drug therapy protocol that has a self-administered screening tool effectively screens women for the safe use of hormonal contraceptives and selects the appropriate contraceptives.²² However, the limitation of this study was only 65% of participants completed the study, possibly due to the long length of the service time and the different practices of pharmacists at other community pharmacy settings. The notable gaps include evidence on interventions targeting new users at community-based, women with high-risk factors in the community, and decision-making tools with referral points to physicians. The evaluation forms, checklist, and questioning score achieved appropriate outcomes and significantly correlated with the appropriate counselling and dispensing behaviour of community pharmacists which could minimize the serious consequences such as unwanted pregnancy.²³ Community pharmacists had good retention of family planning knowledge post-training reinforcement and providing them with job aid.²⁴

This review further summarises the available evidence on the comparative advantages and disadvantages across the target populations and suitability for community-based pharmacists (Table 4). Focus on comparing the intervention tools is critical to help identify successful interventions to improve contraceptive dispensing in community pharmacy settings. The outcomes examined that were directly affected (awareness of contraceptive choice based on risk and benefit, knowledge of suitable choice, participation in decision-making, attitude towards contraceptives level of comfort), or indirectly affected (quality of service, referral to physician, and database at community level) by patient-centred counselling tools. Although preventing the unmet need for contraceptive use and unwanted pregnancies is the main objective, the knowledge and participation of patients over the long run are equally important.

This review has identified three limitations; the keywords for counselling interventions are not well defined, and this lead to the identification of relevant studies through a wide range of search synonyms and extensive searches. The advantages, disadvantages, and unavailable data were assessed based on information reported by the authors and subjective assessment of intervention to suit the community settings, thus subject to individual contexts suitability. There are a few limitations to the evidence base. One of them included the study type as a variable, particularly among the non-randomised, survey and qualitative. Although the risk of bias is assessed, some studies have some concerns with inconsistency mostly due to deviation from intended intention and imprecision from missing outcome data. Selection biases likely overestimate the strength of association with the intervention used and are more likely to use contraception in chosen participants and likely to hide the “true” population effect. Understanding these key elements of “true patient” may be the contribution to successful patient-centred counselling and can provide valuable insights for the development and refinement of patient-centred counselling tools that are tailored to the needs of community pharmacists.

Secondly, the study settings, interventions, and outcomes have limited comparability. For instance, interventions were effective in some settings and with some populations may not be suitable to be used, although they have positive implications. Family planning settings or wards at hospitals dealing with women may not explore the impact of patient-centred counselling on various patient populations, including those with chronic conditions, polypharmacy, or complex medications for multiple comorbids. The effectiveness of similar interventions may be limited and shed on the adaptability and applicability of the interventions in community pharmacy settings.^26,27,32 Some papers only highlighted the use of WHO tools for determining the contraceptives for consumers, however, they did not specify the suitable tools for community pharmacy settings in choosing the contraceptives which targeted patients centred with identifications of the risk factors and screened for suitability of the hormonal contraceptives by the community pharmacist. The effectiveness of adapting the evidence-based recommendation even from WHO may contribute to reduced intensity of best practices in community settings due to the suitability of the studies. Overall, patient-centred counselling is a crucial aspect of community pharmacy practice that can significantly improve patient outcomes and enhance the pharmacist–patient relationship.³⁸

Third, many studies fail to mention the specific intervention to be used for targeting initiating, switching, or continuing suitability for dispensing contraceptives. This could be used to address the gap in contraceptive intervention studies. This lack of information in the studies included hinders the adaptability of effective intervention strategies in improving contraceptive dispensing at community pharmacy. Future studies need to develop appropriate patient-centred counselling tools with detailed information on deciding the contraceptives tailored to patients’ needs with appropriate cultural touch and point of referral to physicians for high-risk patients in community settings.

Conclusion

Patient-centred counselling tools showed promising results in improving the contraceptive choices tailored to patients’ needs and enhancing the patient’s understanding of the contraceptive instructions. Long-term outcome answering all the key questions and empowering patients for overall contraceptive outcomes. Furthermore, patient-centred contraceptive tools ensure effective communication and collaboration between community pharmacists, patients, and physicians if required. Thus, community pharmacists will be able to be an important aspect in improving dispensing of contraceptives by enhancing patients’ contraceptives understanding. Improved and novel interventions are needed for future studies.