The present study was done to assess the knowledge, attitude, and practice (KAP) of ECP and their associated factors among dispensers of community pharmacies of Kathmandu valley. In this study more than half of the respondents were male (57.7%) which was similar to the study conducted in Gondar Town, Northwestern Ethiopia (60%) and Nigeria (57.3%) [14, 19].
Practice of dispensers of community pharmacy on ECP
A large majority of the respondents in the present study had ever dispensed ECP and the majority of the product was sold on patient requests without a prescription which was similar to the study carried out in Managua, Nicaragua and Ibadan and Lagos Metropolis, Nigeria.[14, 17]
Only 35.3% of the respondents in our study had received formal training/ education on dispensing of ECP which was consistent with the study conducted in Gondar Town, Northwestern Ethiopia (38.3%) but was lower than the findings by Ehrle et al., and Belachew et al., in which 50% of respondents had received information about the method in the past year [17, 19]. This contrast may be due to the difference in the training facilities in two settings and the lack of awareness of the place and time where the training is conducted.
In this study, 30.8% of respondents felt ECP should be categorized under OTC drugs. This result was slightly lower than the study conducted in Jamaica and Barbados in which 50.3% and 40.3% of respondents voted for the provision of making it available without prescription respectively [20]. This difference may be due to the unsubstantiated belief of the dispensers that ECP without prescription would increase promiscuity towards sexual behavior and result in unsafe sex along with repeated use of ECP. Therefore, positive aspects of ECPs should be highlighted during training with proper educational messages.
Counseling was reported to be an essential facet of dispensing by 92.1% of respondents and quite evidently, 70% of the respondents did counsel all the users while dispensing ECP. This statistic was somewhat lower than the studies carried out in Turkey and Ethiopia in which counseling was offered as an indispensable service by almost all of the pharmacists [19, 21]. This difference may be due to lack of private counseling areas in the community pharmacies of Kathmandu Valley which was reportedly present in 75% of the pharmacies in Turkey
Most of the dispensers in our study were willing to dispense ECP to men seeking ECPs for their partner (77.5%) which was similar to the study conducted in Nicaragua (83.9%) [17].
Knowledge of the respondents towards ECP
This study illustrated that about 149 (65.6%) of the respondents possessed a good knowledge of ECP. The result of the present study was slightly lower than the study conducted in New Mexico in which the pharmacists had overall knowledge scores of 71.2± 11.3 [22]. This contrast may be due to differences in training facilities and no systematic continuing medical education regarding ECP in Kathmandu valley. Regarding the mechanism of action of ECP, 63.4% gave the correct answer which was consistent with the study done in Managua, Nicaragua in which more than half of the respondents (59%) knew how the emergency contraceptive pills worked [17].
Despite WHO assertion, 57% of respondents in Managua, Nicaragua, and 68% in New Mexico incorrectly believed that ECP could cause harm to the developing fetus versus 63.4 % in the present study. In this study, the majority (81.5%) of the respondents reported that ECP should be taken after unprotected sexual intercourse to be clinically effective which is in agreement with the findings of research conducted on Nicaraguan pharmacists in which this awareness was observed in 79% of the respondents [17, 22]. Most of the partakers reported that ECP should be taken within 72 hours after unprotected sexual intercourse but very few knew that it was also effective if taken within 120 hours of unprotected sexual intercourse. This corroborates the findings of studies conducted in Jamaica and Barbados and South Africa [20, 23]. A study conducted in South-Eastern Hungary which reported that nearly all (97%) pharmacists were aware of the active agent of the ECP reflects a higher statistic than our study where only 76.7% of the respondents voted for levonorgestrel as the active constituents of ECP. Side effects mentioned by the dispensers in this study were no different from those stated by another author [24]. In the present study, 67.4% of the respondents knew about the side effects of ECP and 68.3% reported the right dosing which was lower than the study carried out in South Africa. The reason for this result may be due to the difference in educational level. Only pharmacists were interviewed in the study conducted in South Africa whereas all the dispensers of community pharmacy irrespective of their degree or level of education were enrolled in the present study. This may be the reason that the present study may have lower knowledge regarding the side effects and dosing schedule of ECP compared to the study conducted in South Africa [23]. A good proportion of the respondents (75.3%) correctly believed that ECP does not offer protection against sexually transmitted infections (STI), underpinning the findings of Szucs et al. [24].
It was found that despite the good overall knowledge, dispensers lacked specific information about ECP such as side effects, dosing schedule, time frames and so on. This could eventually affect the information given during counseling by the dispensers to their users. For instance, very few respondents knew that ECP can be taken up to 120 hours which can lead to the delivery of misinformation to the ECP users that pills would no longer be effective and can result in unwanted pregnancy or abortion. Hence, educational and awareness programs should be designed to address these issues.
Attitude of the respondents towards ECP
The present study found that a large majority of the respondents (93.4%) have a positive attitude. More than half of the study respondents agreed that ECPs are safe to use (53.4%) which is similar to the study conducted in Ethiopia [19].
Only 25.6% agreed whereas 45.4% disagreed that adolescents should be given easy access to ECPs. This result was in agreement with research conducted in South Africa in which a significant number of pharmacists doubt their appropriateness for women younger than 18 years of age [23].
Regarding the Medicalization of ECP, 36.5% of the respondents agreed that the government of all countries should medicalize ECPs while more than two- thirds (68.3%) of the study respondents of Ethiopia favored de-medicalization of ECPs and proposed it to be OTC drug. [19]. This difference in result may be due to the concern of dispensers of the pharmacy of Kathmandu Valley regarding unwise use of ECP by the adolescents and the risk of an increase in unsafe sex, which is evident from the proportion (65.2%) of dispensers consenting to the statement that ECP without prescription will promote unsafe sex. This finding was in line with the study conducted in South Africa in which the majority stated that the use of pills promoted promiscuity, repeat use and increased risk of contracting HIV and other STIs [23].
In the present study, a large proportion of respondents agreed that routine information about ECP should be included in contraceptive counseling (87.7%) as well as all sexually active women should be aware of ECP (91.6%). These results were higher in comparison to the study conducted in Ethiopia with a percentage of (75%) and (58.3%) respectively [19] and similar to the study conducted in Turkey with a percentage of (85%) and (92%) respectively [21]. Majority of the respondents (94.3%) believed that ECP should be a part of comprehensive sexuality education in schools. This data was higher than the study carried out in Turkey in which only 73.1% of the respondents agreed with the above statement [21]. Approximately 86.4% of respondents were in the favor of conducting formal training focused on enabling the dispensers to appropriately dispense ECP which reflects the opportunity to design and run educational campaigns that can aid in mainstreaming ECP use. In the same vein, Kishore et al. pointed out a significant improvement in knowledge, attitude and dispensing practice of the providers after attending training programs on ECP (p <0.05) [25]. Due to growing awareness of the existence of ECP and people’s willingness to use it, ECP users should be counseled properly by the dispensers of the community pharmacy since lack of counseling can result in inappropriate and ineffective use of the drug. Despite their positive attitude towards ECPs, our study respondents have more conservative beliefs about the OTC availability of ECP in comparison to another study conducted in Sweden [26].
Determinant factors associated with knowledge and practice of ECP
Age, primary position, years of experience, location of pharmacy and district of pharmacy were found to be the determinant factors statistically associated with dispensing practice. Age and years of experience shared a positive relationship with dispensing practice in bivariate analysis and a district in which pharmacy was situated was found to be a statistically significant factor for dispensing practice in the multivariate analysis. There was no significant association of gender, religion, and level of education with dispensing practice. In the study conducted in Delhi, India, age, years of experience were found to have statistical significance with the dispensing practice of ECP which was consistent with the present study [25]. Years of experience was found to have a positive relation with dispensing practice in the study conducted in Ethiopia which was in agreement with the present study [19].
Age, degree, primary position, years of experience, location of pharmacy and district of pharmacy were found to be statistically significant factors for the level of knowledge. In bivariate analysis, age and years of experience were found to show positive relation with the level of knowledge. In multivariate analysis, age showed a positive relationship with the level of knowledge of dispensers about ECP whereas years of experience and location in which pharmacy was situated were found to share negative relation with their level of knowledge. There was no significant association between gender and religion with their level of knowledge. The result is similar to the study conducted in South Dakota in which years of experience was found to be statistically significant with the level of knowledge [27].
The extent of knowledge of respondents towards ECP was a statistically significant factor for the good dispensing practice of respondents and had a positive relation [AOR= 11.86, 95% CI (5.821-24.190)]. This result was consistent with the studies conducted in India [25] and Florida [26] in which the dispensing practice of providers was found to be positively correlated with their knowledge (p< 0.05).
Even though the majority of the participants possessed a positive attitude, demographic variables, dispensing practice and knowledge level of the respondents towards ECP did not show any significant association with their level of attitude. However, this result was not consistent with the studies done in Sweden [28] and India [25] in which the older group, aged 45–64 years, were more positive towards routine information of ECP in contraceptive (p=0.001) and a significant association of attitude was observed with dispensing practice (p<0.05) respectively. This contradiction may be accounted to the possibility that some of the respondents may have filled in responses they perceived to be desirable rather than their actual perceptions. Despite having a significant association between attitude and dispensing practice, a positive attitude without adequate knowledge does not correspond at all with the level of dispensing practice. It is the knowledge that holds a great role in decision making in dispensing practice. [25]