Review

Pharmacy-­based sexual health services: a systematic

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review of experiences and attitudes of pharmacy
users and pharmacy staff
Julia Gauly ‍ ‍ ,1 Jonathan Ross,2 Isobel Hall,1 Irekanmi Soda,1 Helen Atherton1

►► Additional material is ABSTRACT pharmacists’ roles.9 For example, pharmacists in

published online only. To Background Pharmacies are increasingly providing England are now providing a range of public health
view, please visit the journal
online (http://​dx.d​ oi.​org/​10.​ services related to contraception and STIs. Identifying services such as smoking cessation and services for
1136sextrans-​2019-​054096). pharmacy staff’ and users’ experiences and attitudes drug misusers.10 11 Furthermore, they are increas-
relating to sexual health services is critical to understand ingly providing services such as contraception and
1
Warwick Medical School, users’ needs and examining how pharmacy staff can the screening and treatment of STIs.
Warwick University, Coventry, As a consequence of pharmacies’ service expan-
most effectively contribute to patient-­centred care. This
United Kingdom
2
Department of Sexual Health systematic review aimed to examine pharmacy staff and sion, the role of pharmacy staff is changing from
and HIV, University Hospitals pharmacy users’ experiences and attitudes towards the drug dispenser to patient-­centred care provider.7 12
Birmingham NHS Foundation delivery of a large range of sexual health services. Examining pharmacy staff experiences and attitudes
Trust, Birmingham, United Methods Seven electronic databases and the reference to sexual health services is critical to understand
Kingdom
lists of all included studies were searched in September whether they deliver a consistent and high-­quality
2018. Studies giving insight into pharmacy users’ and service.12 Furthermore, exploring pharmacy users’
Correspondence to
Julia Gauly, Warwick Medical pharmacy staff’s experiences and attitudes towards the experiences and attitudes may identify training
School, University of Warwick, delivery of services related to contraception and STIs needs and improve service delivery.7
Coventry CV4 7AL, UK; ​J.​ were included. The Mixed Methods Appraisal Tool was A recent systematic review focused on young
Gauly@​warwick.​ac.​uk used to assess the quality of included studies and a people’s experiences and found pharmacy-­ based
Received 23 April 2019 narrative synthesis applied to analyse evidence. sexual health services to be appealing to and used by
Revised 2 July 2019 Results Nineteen studies were included. Eleven studies this group, although some pharmacy staff created a
Accepted 17 July 2019 looked at pharmacy staff, four at users and four at both barrier to service access or refused access.13 Another
Published Online First groups. Users found services accessible and convenient review has explored the acceptability of and barriers
5 August 2019 to chlamydia testing and included both user and staff
and staff found service provision feasible. However, several
barriers to service delivery were identified including lack of perspectives.14 This review showed that chlamydia
privacy for delivering services, lack of trained staff available screening is feasible, accessible and convenient and
to provide services and subjective judgements being made that incentives can increase access to testing. Another
on who should be provided or offered a service. review on pharmacy-­ based sexual health services
Discussion Barriers to service delivery need to looked at emergency contraception (EC) and found
be addressed to allow pharmacies to deliver their that women liked the service but had concerns about
full potential. Future research on pharmacy-­based the advice provided on future contraception and
gonorrhoea and syphilis screening, and hepatitis B STIs.15 Previous reviews have focused particularly on
vaccination is needed. EC and chlamydia screening.
PROSPERO registration number CRD42018106807. Therefore, our review aimed to systematically
summarise and critically appraise pharmacy users’
and staff experiences and attitudes towards the
delivery of a large range of pharmacy-­based sexual
Introduction health services.
Worldwide, more than a million people acquire
an STI daily1 and around 44% (99.1 million) of
Methods
all pregnancies in 2010–2014 were unintended.2
This review is reported using the Preferred
Unintended pregnancies can cause worse health,
Reporting Items for Systematic Reviews and Meta-­
economic and social outcomes for women3 4 and STIs
Analyses (PRISMA) reporting framework.16 The
can have severe reproductive, sexual and maternal-­
PRISMA checklist can be found attached (see
child health consequences.1 Hence, STIs and unin-
research checklist). The protocol was published in
tended pregnancies are major concerns5 6 and the
August 2018 on PROSPERO and is available from:
provision of sexual health services addressing STIs
© Author(s) (or their https://​bit.​ly/​2QIegjv
employer(s)) 2019. Re-­use and unintended pregnancy are highly important.
permitted under CC BY-­NC. No Pharmacies have the potential to improve
commercial re-­use. See rights access to sexual health services by virtue of their Inclusion and exclusion criteria
and permissions. Published numerous locations; and since industrialised coun- The review included qualitative studies (interviews,
by BMJ.
tries face new challenges associated with rising focus groups, ethnography), quantitative studies
To cite: Gauly J, Ross J, costs and demand, limited financial resources and (randomised controlled trials (RCTs), cross-­sectional
Hall I, et al. Sex Transm Infect a shortage of human resources,7 8 several coun- studies, cohort studies) and mixed method studies.
2019;95:488–495. tries have recently implemented policies to expand The population of interest was users and providers
488 Gauly J, et al. Sex Transm Infect 2019;95:488–495. doi:10.1136/sextrans-2019-054096
 Review
ensure findings would inform current practice, which is consis-

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tent with previous reviews in the same field.10 14
The search strategy was informed by previous reviews in the
field13–15 and compiled by JG in collaboration with HA, JR and a
librarian. The search was adapted for each database by mapping
the keywords ‘pharmacy/pharmacies’ with terms associated with
contraception and STIs. The search strategy used for Medline is
presented in online supplementary appendix 1.

Selection of studies
All articles initially identified were deduplicated and the
remaining titles and abstracts screened against the inclusion
criteria by two researchers independently. Disagreements were
resolved through discussion with another researcher. The full
texts of potentially relevant articles were retrieved and dual
screened against predefined criteria. If an article was excluded at
this stage, the reason was recorded. Discrepancies between the
reviewers were resolved by another researcher.

Data extraction
A data extraction sheet was developed and piloted. Data were
extracted by two researchers independently, with agreement
reached through discussion with a third reviewer if required.
Outcomes were extracted according to our prespecified
framework.

Quality assessment
The methodological quality of included studies was assessed
using the Mixed Methods Appraisal Tool (MMAT) V.2018,19
which is designed for reviews where study designs are mixed
and individual studies use mixed methods. The assessment was
Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-­ completed independently by two researchers and disagreements
Analyses flow diagram. were resolved with another researcher. Studies were catego-
rised as high, medium or low quality, depending on how many
MMAT criteria were met. Quality assessment was used to
provide context for the study findings.
of pharmacy-­based sexual health services. Only studies based in
countries within the Organisation for Economic Co-­ operation
and Development (OECD) were included. This was to ensure that Data synthesis
results could inform current practice in OECD member countries. A narrative synthesis was conducted by JG in collaboration with
A wide range of pharmacy services were included in this review as HA and JR. Due to the methodological heterogeneity of included
being relevant to the research question.17 These were: condoms, studies, conducting a statistical meta-­analysis was not possible.
EC, chlamydia, gonorrhoea, syphilis and HIV screening, chla- Narrative synthesis allowed for the combination of qualitative
mydia treatment, contraceptive pill/oral contraceptives, contra- and quantitative evidence through the comparison of similarities
ceptive injection, hepatitis B vaccine and partner notification for and differences between studies and is a method commonly used
chlamydia. Studies with and without a comparator group were to synthesise data in systematic reviews.20–23 Elements of guid-
eligible for inclusion. The outcome groupings of interest were ance by Popay et al on the conduct of narrative synthesis were
broad to reflect the wide range of possible relevant outcomes for followed.24
the review question. The characteristics and key findings of studies were summa-
The Cochrane Effective Practice and Organisation of Care rised and patterns across studies presented according to the
outcome framework was used to categorise the outcomes of population type. Next, factors offering explanations for rela-
interest18: service user outcomes (eg, experience, barriers and tionships within and between studies were sought.
enablers), provider outcomes (eg, experience, workload, work
morale), social outcomes (eg, empowerment), attitudes (eg, service
users’, providers’), satisfaction (eg, service users’, providers’). Results
Literature search
Of 4778 articles identified in the literature database search,
Search strategy 110 were identified at title and abstract stage and the full text
Cochrane, Embase, Medline, Popline, PsycINFO, Scopus and was screened. Of these, 16 studies met the inclusion criteria. A
Web of Science and the reference lists of all included studies further three studies were identified through the screening of
were searched without language restrictions on 17 September the reference lists of included studies. A total of 19 studies were
2018. Only literature from the past 10 years was included10 to included (figure 1).
Gauly J, et al. Sex Transm Infect 2019;95:488–495. doi:10.1136/sextrans-2019-054096 489
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Table 1 Characteristics and quality of included studies
Study component(s) Relevant pharmacy
Study of interest Setting Type of intervention Comparator population type Quality
25
Black et al Survey England Emergency Yes (family planning clinic; GP) Pharmacy users (n=50) Low
contraception
Chaumont and Foster43 Interviews and survey Canada Emergency No Pharmacists (survey: n=198; High
contraception interviews: n=17)
Cooper et al39 Interviews England Emergency No Pharmacists (n=23) High
contraception
Dabrera et al37 Interviews England Chlamydia screening No Pharmacists (n=10) Medium
Darin et al26 Survey USA HIV screening No Pharmacy users (n=69) Low
Debattista57 /Emmerton58 Interviews Australia Chlamydia screening No Pharmacists (not reported) Low
Deeks30 /Parker31 Interviews, focus groups Australia Chlamydia screening No Pharmacy users (survey: Medium
and survey n=945; interviews: n=18)
and pharmacy healthcare
assistants (survey: 20; focus
group=10)
Downing et al38 Interviews and survey Australia Emergency No Pharmacists (survey: n=34; Low
contraception interviews: not reported),
non-p­ harmacists such
as pharmacy healthcare
assistants and pharmacy
managers (survey: n=111;
interview: not reported)
Gudka et al27 28 Survey and focus groups Australia Chlamydia screening No Pharmacy users (survey: High
after emergency n=91; focus group: n=5)
contraception and pharmacists (focus
group: n=6)
Gudka et al29 Survey Australia Emergency No Pharmacy users (n=113) Medium
contraception
Heller et al32 Survey and interviews Australia Contraceptive injection No Pharmacy users (survey: Low
n=50) and pharmacists
(interviews: not reported)
Hussainy et al42 Survey Australia Emergency No Pharmacists (n=427) High
contraception
Michie et al33 Interviews Scotland Oral contraception Yes (two types of pharmacy Pharmacy users (n=12) and High
after emergency care; family planning clinic) pharmacists (n=10)
contraception
Ragland et al34 35 Survey USA Emergency Yes (women’s clinic) Pharmacy users (n=87) High
contraception
Rodriguez et al45 Survey USA Hormonal Pharmacists (n=121) Medium
contraception
Ryder et al40 Interviews USA Condoms No Pharmacists (n=5) and High
pharmacy healthcare
assistants (n=4)
Thomas et al36 Interviews New Zealand Chlamydia screening Yes (schools; health and youth Pharmacists (n=12) High
after emergency centres)
contraception
Whelan et al41 Survey England Emergency No Pharmacists (n=422) High
contraception
Wong et al44 Interviews Canada Copper IUD No Pharmacists (n=20) High
consultation as
part of emergency
contraception
counselling
GP, general practitioner.

Description of included studies Two qualitative and two quantitative studies included a
Quantitative (n=7), qualitative (n=5) and mixed methods (n=7) comparator group.
studies looking at pharmacy staff (n=11), users (n=4) and both
users and staff (n=4) were included. Interviews (n=11), surveys Quality of included studies
(n=12) and focus groups (n=2) gave insight into users’ and staff ’ Ten studies were of high, five of low and four of medium quality.
experiences and attitudes. The characteristics of included studies Most studies (n=18) had clear research questions and appro-
are presented in table 1. Studies reported on at least one of the priate data collection methods (n=16). While most qualitative
following services: EC, oral contraception, contraceptive injection, studies were of high quality, most quantitative studies had a high
chlamydia screening, HIV screening and condom distribution. risk of non-­response bias and most mixed methods studies failed
490 Gauly J, et al. Sex Transm Infect 2019;95:488–495. doi:10.1136/sextrans-2019-054096
 Review
to adequately integrate results. The detailed quality assessment is to discuss sexual health in private consultation rooms27 28; where

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attached as online supplementary file 1. none was available, they tried to counsel in private areas away
from other users.37 38 42
Experiences and attitudes of pharmacy users and staff
Pharmacy users Counselling
Three key areas of importance to pharmacy users were identi- Staff were generally comfortable counselling users and tried
fied: suitability, privacy and counselling. The main findings are to be youth-­ friendly and non-­ judgemental. Dealing with
summarised in table 2. groups and asking sensitive questions were perceived as diffi-
cult.27 28 30 31 36 38 40 43 44 According to staff, pharmacy users
Suitability with the exception of young users and women counselled by
Users found pharmacies convenient, easy and quick to access and male staff felt comfortable during counselling.40 44 While staff
use. They liked that compared with other providers, no appoint- agreed that side effects, dosages, efficacy and future contra-
ments needed to be organised.25–33 However, a barrier to service ception should be included in EC counselling, they had mixed
delivery experienced by some users was that trained staff were views on the provision of counselling for STIs.38 42 According
not always available to provide the service.32 to one study, fewer pharmacy users (28%; 14/50) than users
of clinical services (90.4%; 75/83) reported receiving counsel-
Privacy ling for contraception after receiving EC.25 Furthermore, staff
All five studies evaluating ‘privacy’ did so in relation to EC or tended not to dispense EC to a person requesting the service on
chlamydia screening. Users’ perceptions of experience conflicted behalf of someone else38 42 43 and made subjective judgements
within and between studies: while some were not concerned and on whom to provide or offer services such as EC and chlamydia
stated that privacy was something they liked about pharmacies, screening. For example, some were likely to refuse EC to young
others had privacy concerns and were worried about being over- people.38 39 42 With regard to chlamydia screening, staff were
heard at the counter.25–31 In one study, 98.9% of users of clinical sometimes hesitant to offer it to young users, those presenting
services such as family planning services and general practices for a non-­sexual health services and users thought to be married
(82/83) were satisfied with the level of privacy provided, a or in a long-­term relationship.36 37
significantly lower percentage (p≤0.001) of pharmacy users
(44%; 22/50) were satisfied.25 Workload
Although staff found the provision of sexual health services
Counselling feasible overall,36 37 45 they admitted that the counselling and
With the exception of some younger individuals, pharmacy users paperwork added to workload.27 28 30 31 41 42 Some staff were
generally had a positive counselling experience, felt comfort- concerned about long waiting times and that trained staff were
able discussing sexual health26–35 and found that appropriate not always available to provide services.30 31 36 41
advice was provided.26–28 30 31 33–35 However, in two quantita-
tive studies, pharmacy users found counselling on EC less infor- Impact
mative and satisfactory compared with users of other sexual Staff felt that the provision of sexual health services benefited
health providers25 34 35: whereas 95% of users of clinical services their profession and improved their job satisfaction.30–32 39 40 45
(78/83) agreed that adequate advice on EC was provided, fewer However, some staff felt conflicted in their roles as a healthcare
pharmacy users (82%; 41/50) did so.25 While both clinic users professional and drug dispenser, feeling pressured to provide
(86.6%; 100/116) and pharmacy users (81.4%; 71/87) were services quickly rather than thoroughly.44
generally satisfied with the counselling, pharmacy users were
slightly less satisfied than users of clinical services.34 35 Discussion
Main findings
We aimed to examine pharmacy staff ’ and pharmacy users’ atti-
Pharmacy staff
tudes and experiences of pharmacy-­based sexual health services.
Five key areas were identified as being of importance in rela-
The studies we identified indicate that pharmacy-­based sexual
tion to pharmacy staff and three of these were the same as those
health services are perceived as accessible and convenient to use
important to pharmacy users: suitability, privacy and counsel-
by both pharmacy users and pharmacy staff. However, lack of
ling. The two further areas identified were workload and impact.
availability of trained staff was perceived to be a barrier for some
The main findings are summarised in table 2.
pharmacy users. Furthermore, some pharmacy users and staff
had privacy concerns. With the exception of young users and
Suitability women counselled by male staff, pharmacy users and staff were
Staff believed that pharmacies were well suited for the provision generally comfortable with the counselling offered. However,
of sexual health services because of their large clientele, accessi- two quantitative studies comparing the satisfaction on EC coun-
bility and convenience.32 36–39 However, some staff thought that selling of pharmacy users and users of other service providers
pharmacies might not be ideal for condom distribution40 as they showed that pharmacy users were less satisfied with EC counsel-
were not frequently used by young men, and that young men ling than users of other service providers.
may be hesitant in approaching female pharmacy staff to request Most staff found the provision of sexual health services practi-
sexual health services.40 cally feasible, although some felt under time pressure, and ques-
tioned the suitability of pharmacies for condom distribution to
Privacy young males.
While some pharmacy healthcare assistants generally thought
that users appeared unconcerned about their privacy, most Strengths and limitations
pharmacy staff felt that privacy was highly important to users This review provides a timely overview of the literature relating
requesting sexual health services.30 31 37 38 41 Thus, staff preferred to experiences of pharmacy-­based sexual health services using
Gauly J, et al. Sex Transm Infect 2019;95:488–495. doi:10.1136/sextrans-2019-054096 491
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Table 2 Key findings of included studies
Study Key findings
Qualitative studies
Cooper39 ►► Some pharmacy staff were more likely give out EC to older users and were not willing to give EC to under 25 s.
Dabrera37 ►► Pharmacists were supportive of pharmacy-­based chlamydia screening and found service provision feasible.
►► Some pharmacists were concerned about privacy outside of a consultation room.
►► Pharmacists were concerned about approaching young people (under 16 years) and found it more challenging to offer STI screening to users
attending for non-­sexual health complaints.
Michie33 ►► Women used the pharmacy because they had difficulties accessing contraception elsewhere and did not want to plan an appointment ahead.
►► Women felt that the information given to them about contraception was clear.
Ryder40 ►► According to pharmacists, young users were uncomfortable when requesting condoms.
►► Pharmacy staff felt that dealing with groups of people together is problematic.
►► Some pharmacy staff felt that young males do not use the pharmacy for condoms as the pharmacy might be seen as an intimidating
environment due to having to talk to female staff.
Wong44 ►► Some pharmacists felt conflicted in their roles as a healthcare professional and a drug dispenser (pharmacists felt pressured by users to provide
fast services rather than detailed counselling).
►► Most pharmacists were comfortable during counselling and believed that users were also comfortable.
►► Some pharmacists felt that women might feel uncomfortable being counselled by male pharmacists if there is not enough privacy provided;
pharmacists felt that it is difficult to ask users sensitive questions.
Quantitative studies
Black25 ►► 74% (37/50) pharmacy users and 83.1% (69/83) of users of clinical services found it easy to obtain EHC from the pharmacy (p=0.163).
►► 98.9% (82/83) of clinic users compared with only 44% (22/50) of pharmacy users agreed that adequate privacy had been provided (p≤0.001).
►► 95% (78/83) compared with 82% (41/50) of pharmacy users felt that adequate advice was provided (p=0.015).
►► Only 28% (14/50) of pharmacy users compared with 90.4% (75/83) of clinic users reported that future contraception was discussed after
accessing EC (p≤0.001).
Darin26 ►► Speed (22/52) and convenience (16/52) were the most favourable features of pharmacy users experience.
►► Lack of privacy at check-­in was something users (3 out of 15) did not like about the pharmacy, ‘private’ and ‘confidential’ was something that
users (7 out of 52) liked about the pharmacy.
Gudka29 ►► Most women (69%; 73/113) found it very easy/easy to get to the pharmacy and felt very comfortable/comfortable discussing EC with the
pharmacist.
►► 48% (54/113) of women were unconcerned/very unconcerned about privacy in the pharmacy; 29% (33/113) were unconcerned/very
unconcerned about privacy.
Hussainy42 ►► 59.7% (256/427) of pharmacists refused EC when the person presenting was not the person needing EC.
►► 59.5% of pharmacists preferred to counsel on EC in an area of pharmacy where confidentiality could be assured or in a separate area away
from other pharmacy users.
►► Most pharmacists counselled on EC side effects (90.2%), dosage (91.8%), efficacy in relation to time since unprotected sexual intercourse
(88.8%); 81.9% (345/421) of pharmacists felt that it is their role to counsel on regular contraception but only 54.5% (229/420) felt that
pharmacists should counsel on STI.
Ragland et al34 35 ►► The majority of both clinic users (86.6%; 100/116) and pharmacy users (81.4%; 71/87) rated ‘strongly agree’ on being satisfied with counselling
(p=0.523).
►► Pharmacy users (mean±SD: 3.6±0.6) rated significantly lower (p=0.034) the statement that the counselling helped them understand EC use
better than clinic users (mean±SD:3.8±0.4).
Rodriguez45 ►► 87.6% of (106/121) pharmacists felt comfortable during counselling.
Whelan41 ►► The factors interfering most with pharmacists’ ability to provide EC were lack of privacy (46.1%; 195/422) and lack of staff (50.9%; 219/422).
Mixed methods studies
Chaumont and Foster43 ►► 70.9% (134/189) of pharmacists were comfortable providing EC.
►► For 23.3% (10/43) of pharmacists, the primary reason to refuse EC was that the person presenting was not the patient.
Debattista57 (2017)/ ►► While pharmacy staff were supportive of pharmacy-­based chlamydia screening, some were concerned about the workload.
Emmerton (2011)58
Deeks et al30 /Parker31 ►► Pharmacy users were highly satisfied with chlamydia screening service and liked the accessibility, convenience and that there was no need to
(2013) book an appointment or travel a long distance.
►► A lack of privacy in the pharmacy was stated as a barrier by some participants.
►► Some users were concerned about confidentiality and privacy (because of other people around; fear of being overheard).
►► Most pharmacy users felt that appropriate advice was provided.
►► While most users felt comfortable discussing chlamydia with pharmacy staff, a few young people felt uncomfortable.
►► Pharmacy assistants felt that offering sexual health services increased their job satisfaction.
►► Pharmacy assistants were anxious about longer waiting times for users due to offering chlamydia screening.
►► Users presenting in groups were concerning to pharmacy staff.
Downing et al38 ►► Pharmacy staff were aware of the importance of privacy and tried to seek a quiet consultation area away from the counter/other customers, if
no consultation room was available.
►► Young age (65%; 28/43) and person presenting not being the patient needing EC (32%/ 14/43) were reasons for staff refusing EC provision.
►► 85% of pharmacists (109/128) and 72% of non-­pharmacist staff (271/295) agreed that advice on STI and future contraception should be
provided after EC.

Continued

492 Gauly J, et al. Sex Transm Infect 2019;95:488–495. doi:10.1136/sextrans-2019-054096

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Table 2 Continued
Study Key findings
27 28
Gudka et al ►► 87% (79/91) of pharmacy users stated in a survey that they were not concerned about privacy; however, in a later survey, almost half of the
same participants stated that they experienced a lack of privacy and in a focus group, users said that they would not feel comfortable discussing
sexual health at the counter and preferred a private consultation area.
►► Pharmacy users liked that the service was convenient to use, and no appointments needed to be booked.
►► Pharmacy users felt that pharmacists handled consultations professionally and provided clear and concise information.
►► Pharmacists were supportive of service provision but found that paperwork and documenting of services was time consuming.
Heller et al32 ►► Although most pharmacy users had a positive experience with the service delivery, some experienced difficulties (no trained staff available in
chain pharmacies).
►► Pharmacy users found it easy to use the service and were supportive of pharmacy-­based contraceptive injection.
►► Pharmacists acknowledged that features of the pharmacy were appealing for users when compared with other providers and felt that the
pharmacy was an appropriate place for contraceptive services.
Thomas et al36 ►► Pharmacists are concerned to offer screening to ‘older’ individuals because they might be in a long-­term relationship and might feel offended
by being offered the service.
►► No pharmacists wanted to approach clients in long-­term relationships, married people or people with children (pharmacists perceived ethnic
minorities to be more likely to be married and faithful).
►► Most pharmacists believed that pharmacies are well placed to deliver chlamydia screening because of their large clientele and felt that is was
feasible within their practice; some pharmacists were concerned that increasing the use of locums could hinder service expansion since locums are
often untrained.
EC, emergency contraception.

a systematic and robust approach. One potential limitation is and future contraception is often not provided.47 51 Findings in
that only studies published after 2007 and conducted in OECD this review suggest that time pressure and mixed views on the
member countries were included. appropriateness of counselling in relation to STIs contribute to
Removing these restrictions might have revealed a different this and highlight the need for high-­quality training which is
picture; however, they ensured that our findings can inform reviewed regularly.
current pharmacy practice in high-­ income countries. The Pharmacy staff were concerned that men may be less comfort-
included studies were of variable quality and were not always able when counselled by women.
reported in line with study reporting frameworks, having Also that women prefer to be counselled by female staff is
missing data and risk of bias. This limited the conclusions that supported by one study in which almost half of all women wanted
could be drawn from these studies within this review. Mystery to be counselled by a woman.52 Furthermore, staff believed that
shopper studies were excluded from this systematic review to young males were not frequently using a pharmacy to obtain
capture experiences from ‘real’ pharmacy users only. Mystery condoms, because they did not want to approach female staff.
shoppers who are not in need for the service arguably experience This belief is in line with a study which found that young males
the delivery of services differently from people who are in real between 16 and 17 years were less likely to access retail settings
need of the sexual health service. However, these studies may including pharmacies for condoms than older men between 18
have added more detail to the review. and 34 years.53
In contrast to our review and another review on STI testing,46
Comparisons with existing literature two previous reviews on pharmacy-­based sexual health services
As identified in another recent review, we found that there is did not identify privacy as being of concern to patients.14 15
insufficient evidence on pharmacy-­ based syphilis screening,46 However, we found that privacy concerns were raised in several
and also on gonorrhoea screening and hepatitis B vaccination, of our included studies both in relation to EC and STIs, whereas
as no study on these services met our inclusion criteria. Further- this was not the case for ongoing contraception. Similarly,
more, our review included studies which reported on one or one previous study on EC found that privacy was a concern,54
more sexual health services. However, since only three studies whereas a study on regular oral contraception did not.55 It is
reported on two sexual health services which were offered as likely that the stigma around EC and STIs may cause users to be
a package, research evaluating several pharmacy services being more sensitive about privacy.56
delivered as part of an integrated sexual health service is required.
In line with the existing literature, pharmacy-­ based sexual Implications for service delivery and future research
health services were perceived as acceptable, convenient Our findings suggest that to further improve pharmacy-­based
and accessible, compared with other health providers.13–15 46 sexual health services, more transparency is required on whether
However, staff sometimes created barriers to access through appropriate trained staff are available, and if female or male
refusing EC to young users or not offering chlamydia screening. pharmacists are present in the pharmacy. This could help users
Several mystery shopper studies confirm that young users may be to find a pharmacy that provides appropriate services where
refused access to EC.47–50 Young people are at particularly high they can feel comfortable attending. Improvements to pharma-
risk for sexual ill-­health and denying EC or not offering screening cist training would help to increase pharmacy users’ counselling
for STIs can have severe consequences, such as unwanted preg- satisfaction on EC. Finally, ensuring more privacy within a phar-
nancy and the spread of STIs. macy setting might make people feel more comfortable and facil-
Pharmacy users in two studies perceived EC counselling as less itate condom uptake in young men.
informative or satisfactory than users of other providers and one Consequently, areas that would benefit from future research
of the included studies showed that few pharmacy users were include clarifying appropriate privacy requirements and coun-
counselled on future contraception. Several mystery shopper selling preferences for pharmacy users. These factors may influ-
studies have shown that counselling on side effects of EC, STIs ence uptake and use of sexual health services. Other areas for
Gauly J, et al. Sex Transm Infect 2019;95:488–495. doi:10.1136/sextrans-2019-054096 493
 Review
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systematic review protocol. XA provided feedback on the systematic review protocol.
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JG designed the literature search with support from HA, JR and SJ. JG carried out
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the literature search and deduplicated the records. JG, IH and IS screened records
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for their eligibility. Where no consensus could be reached, HA and JR made a
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included records. Where no consensus could be reached, the study was discussed conduct of narrative synthesis in systematic reviews: effectiveness of interventions to
with Dr Helen Atherton and Professor Jonathan. The analysis and interpretation was promote smoke alarm ownership and function. Evaluation 2009;15:49–73.
conducted by JG with support by HA and JR, who also supported the write up and 24. Popay J, Roberts H, Sowden A. Guidance on the conduct of narrative synthesis in
critical revision of the systematic review. The version to be published was approved systematic reviews: a product from the ESRC methods programme, 2006.
by JG. JR, IH, IS and HA. 25. Black KI, Mercer CH, Kubba A, et al. Provision of emergency contraception: a pilot
Funding This study was funded by the University Hospitals Birmingham NHS study comparing access through pharmacies and clinical settings. Contraception
Foundation Trust. 2008;77:181–5.
26. Darin KM, Klepser ME, Klepser DE, et al. Pharmacist-­provided rapid HIV testing in two
Competing interests None declared. community pharmacies. J Am Pharm Assoc 2015;55:81–8.
Patient consent for publication Not required. 27. Gudka S, Marshall L, Creagh A, et al. To develop and measure the effectiveness and
acceptability of a pharmacy-­based Chlamydia screening intervention in Australia. BMJ
Provenance and peer review Not commissioned; externally peer reviewed. Open 2013;3:e003338–9.
Open access This is an open access article distributed in accordance with the 28. Gudka S, Marshall L, Creagh A. To develop and pilot a best practice community
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which pharmacy Chlamydia screening model. Contract no. IIG-003. Canberra: Pharmacy
permits others to distribute, remix, adapt, build upon this work non-­commercially, Guild of Australia, 2009.
and license their derivative works on different terms, provided the original work is 29. Gudka S, Bourdin A, Watkins K, et al. Self-­Reported risk factors for Chlamydia: a
properly cited, appropriate credit is given, any changes made indicated, and the use survey of pharmacy-­based emergency contraception consumers. Int J Pharm Pract
is non-­commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/. 2014;22:13–19.
30. Deeks LS, Cooper GM, Currie MJ, et al. Can pharmacy assistants play a greater role
ORCID iD in public health programs in community pharmacies? lessons from a Chlamydia
Julia Gauly http://o​ rcid.​org/​0000-​0002-7​ 835-​0882 screening study in Canberra, Australia. Res Social Adm Pharm 2014;10:801–6.
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