Iraqi J Pharm Sci, Vol.31(Suppl.) 2022 Emergency contraceptives
DOI: https://doi.org/10.31351/vol31issSuppl.pp141-152
141
Knowledge, Attitude, and Practices of Iraqi Community Pharmacists
Toward Emergency Contraceptives (Conference Paper )#
Juan Majid Shaukat* and Basma Zuheir Al-Metwali**,1
# 10th scientific conference sponsored by College of Pharmacy, University of Baghdad 2-3 June 2022
* Ministry of Health and Environment , Aladel Sector Primary Health Care Centre, Baghdad ,Iraq.
** Department of Clinical Pharmacy , College of Pharmacy, University of Baghdad, Baghdad, Iraq.
Abstract
Emergency contraceptives (ECs) are indicated for preventing the chance of unintended pregnancy that follows
unprotected sexual intercourse in cases of incorrectly used regular contraceptives and in sexual assault. It is considered
a safe choice to prevent pregnancy than abortion which is considered life threating. The aim of this study was to assess
knowledge, attitude, and practices (KAP) of community pharmacists towards emergency contraceptives and their
association with sociodemographic variables. This study was a cross sectional study conducted between August and
September 2021 on a convenient sample of community pharmacists from Iraq. The survey tool was an online, self-
administered questionnaire, in English language and a paper-based copy of the questionnaire was delivered face-to-face
to some of the study participants. The questionnaire consisted of four parts, sociodemographic characteristics,
knowledge, attitude and practices of community pharmacists toward emergency contraceptives. A total of 212
community pharmacists participated in the study. Of the study participants, 67.9% were in the age range of (24-29)
years, 61.8% were females,60% had less than 5 years of experience, the majority (73.1%) were from Baghdad. This
study showed that the majority of community pharmacists (74%) had good knowledge and 95% of them had a very
positive attitude. However, 51% of the participants had poor practice where 62.5% of the pharmacists did not make
counselling during dispending on mechanism of action. This study results have shown no significant relationship
between demographic characteristics and KAP of participants towards emergency contraceptives. The majority of the
study participants had good knowledge and very positive attitude too, whereas poor practice was observed in more than
half of the participants. Educational programs and training sessions are required to raise knowledge about the importance
of emergency contraceptives and also to improve the dispensing practice of these products.
Keywords: Emergency contraceptives, Knowledge, Attitude, Practice, Community pharmacists.
معرفة و مواقف وممارسات صيادلة المجتمع في العراق نحو استخدام وسائل منع الحمل
#) بحث مؤتمر ( الطارئة
** زهير المتولي بسمة و 1*،تجوان ماجد شوك
2202حزيران 3 – 2جامعة بغداد لكلية الصيدلة،العاشر # المؤتمر العلمي
األولية ، بغداد ، العراق قطاع العدل للرعاية الصحية والبيئة، زارة الصحةو*
، بغداد ، العراق جامعة بغداد ، كلية الصيدلة السريرية، فرع الصيدلة **
ةالخالص
موانع الحمل الطارئة تستخدم لمنع فرصة الحمل غير المقصود الذي يتبع الجماع غير المحمي في حاالت االستعمال غير الصحيح لوسائل منع
تقييم معرفة راسة هيالحمل االعتيادية و األعتداء الجنسي. يعتبر منع الحمل خيارا امنا مقارنة باإلجهاض الذي يعتبر خطرا على الحياة. كانت أهداف هذه الد
ارة عن دراسة و مواقف و ممارسات صيادلة المجتمع تجاه موانع الحمل الطارئة و عالقتها مع المتغيرات الديموغرافية األجتماعية. كانت هذه الدراسة عب
انت أداة المسح عبارة عن استبيان على عينة مالئمة من صيادلة المجتمع من العراق. ك 2021استقصائية مقطعية أجريت في الفترة من آب الى ايلول عام
من أربعة أجزاء: الكتروني يدار ذاتيا باللغة األنكليزية و تم تسليم نسخة ورقية من االستبيان وجها لوجه لبعض المشاركين في الدراسة. يتكون األستبيان
ه وسائل منع الحمل الطارئة. شارك في الدراسة ما مجموعه الخصائص األجتماعية الديموغرافية, و المعرفة, و المواقف, و ممارسة صيادلة المجتمع تجا
( من %73.1سنوات , و األغلبية ) 5من المشاركين لديهم خبرة أقل من % 60إناث, % 61.8( سنة, 29-24في الفئة العمرية ) % 67.9صيدلي مجتمع, 212
منهم لديهم مواقف جيدة جدا. و % 95ة عن وسائل منع الحمل الطارئة و أن ( لديهم معرفة جيد%74بغداد. أظهرت هذه الدراسة أن غالبية صيادلة المجتمع )
لم يقدموا المشورة بشأن آلية عمل وسائل منع الحمل. باإلضافة لذلك, % 62.5من المشاركين كانت لديهم ممارسات ضعيفة حيث أن %51مع ذلك, فإن
ين الخصائص الديموغرافية و المعرفة و المواقف و الممارسات تجاه وسائل منع الحمل أظهرت نتائج هذه الدراسة عدم وجود عالقة ذات داللة أحصائية ب
في حين لوحظت ممارسات تطبيقية ضعيفة في أكثر من نصف الطارئة،الطارئة. كان لدى غالبية المشاركين معرفة و مواقف جيدين تجاه وسائل منع الحمل
لتحسين ممارسة الصيادلة لصرف وكذلك يبية لرفع مستوى الوعي حول أهمية وسائل منع الحمل الطارئة تدر ودوراتالمشاركين. يقترح وضع برامج تعليمية
هذه المنتجات.
. صيادلة المجتمع ، ممارسات،مواقف ،معرفة ،الطارئةالكلمات المفتاحية: وسائل منع الحمل
Introduction
Emergency contraceptives (ECs) are
indicated for preventing the chance of unintended
pregnancy that follows unprotected sexual
intercourse in cases of contraceptive failure and
sexual assault. The ECs are considered as a last
choice since they cannot be used as a regular method
of contraception and they cannot provide protection
against sexually transmitted diseases (STDs)(1) .
1Corresponding author E-mail: Basma.Naji@copharm.uobaghdad.edu.iq
Received: 13/7/2022
Accepted: 23/10 /2022
Iraqi Journal of Pharmaceutical Science
https://doi.org/10.31351/vol31issSuppl.pp141-152
Iraqi J Pharm Sci, Vol.31(Suppl.) 2022 Emergency contraceptives
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ECs do not terminate the pregnancy if it has already
occurred. Also, they have no harmful effects neither
on the fetus nor on the mother compared to methods
used in abortion which have adverse effects like
maternal death and infertility(2). Unintended
pregnancy and induced abortion can be a significant
problem in the community, both from the health and
economic point of view. A cross sectional study
conducted on 500 pregnant women in Erbil/ Iraq has
shown that about 39.4% of women had unintended
pregnancy which was significantly higher in those
aged ≥35 years and those with insufficient income(3).
Another study carried out in Mosul/Iraq on 1302
married women showed that 13.5% of women tried
to induce abortion by physical activity, herbal
remedies or pharmacological preparations(4). This
can impose a significant risk on the mother’s health.
The same study had shown that induced abortion
was significantly higher in women with unemployed
husbands, those who were housewives and those
who were not using contraceptives (4). Therefore, the
use of ECs can reduce both the health and economic
consequences of unintended pregnancy and
subsequent induced abortion.
There are four types of ECs which vary in their
mechanisms of action and efficacy. Available types
of ECs include emergency hormonal contraceptives
(EHC) pills, also known as morning after pill, which
include two major types: ulipristal acetate (Ella)®
and levonorgestrel (plan B) ®. In addition, many
types of combined oral contraceptives (COC) that
contain progesterone and ethynyl estradiol can be
used as ECs. Other non-hormonal ECs include
copper intrauterine device (IUD). Ulipristal acetate
(Ella)®, a progesterone receptor modulator, acts by
delaying or preventing the ovulation process. It is
effective until five days (120 hours) of unprotected
sexual intercourse, however, as a general principle
for all types of EC, it is best to be given as soon as
possible (5) . The possible side effects of ulipristal
acetate include abdominal pain, headache, dizziness,
nausea, vomiting and dysmenorrhea. Other less
common side effects include bloating and uterine
cramping(6).Levonorgestrel is a progesterone only
tablets. It should be taken within 72 hours after
unprotected intercourse(7). The mechanism of action
of levonorgestrel is inhibiting or delaying the
ovulation process by inhibiting rupture of follicle
and release of ova that prevents fertilization and
pregnancy (8). The possible side effects related to
levonorgestrel include heavy or light menstruation,
nausea, vomiting, abdominal pain, most women
show their cycle within few days with expected
date(9). Combined Oral Contraceptives containing an
estrogen and a progestin can also be used for
emergency contraception in method called Yuzpe
regimen. It should be taken within three days (72
hours) after unprotected sexual intercourse (8) .The
mechanism of action of COCs as ECs is by
inhibiting implantation of a fertilized egg, delaying
or suppressing ovulation, interfering with corpus
luteum function and making changes in the
endometrium that prevents implantation(8) . The
possible related side effects of COCs include
nausea, vomiting in higher proportion than ulipristal
or levonorgestrel, headache and abdominal
cramping (8). Copper Intrauterine Device (IUD) is
the most effective method of EC. It is used within
five days of unprotected intercourse. Although
copper IUD has high efficacy, many studies showed
that it had low recommendation from physician
related to its practice and the presence of oral
emergency contraceptives(10).The mechanism of
action of copper IUD involves releasing copper ion
from this device which can have toxic effects on
both sperm and ova, so preventing fertilization and
preventing implantation if fertilization has occurred.
The possible related side effects of IUD include
uterine cramping, dysmenorrhea and increasing
duration of menstruation (7).
The role of the pharmacists is very important
in dispending EC. This involves providing
consultation about the use and side effects and
answering related questions on EC use. Different
studies were conducted to assess knowledge,
attitude and practice of pharmacists toward EC. A
study conducted in Kathmandu/Nepal on a sample
of community pharmacists has shown that about
65% of participant pharmacists had good
knowledge, about 93% of them had positive attitude
and 75% of them good practice in dispending ECs
(11) . In Ethiopia, a study conducted on pharmacy
professionals found that overall participants had
very good knowledge, attitude and dispensing
practice regarding ECs (12). In Iraq, knowledge about
ECs was investigated among primary healthcare
doctors (obstetrics and gynecology specialists,
general practitioners and family physicians) in
Baghdad. The results showed that there was a defect
in primary healthcare physicians’ knowledge which
led to EC underuse (13). In addition, knowledge,
attitude, and practice about EC among women in
primary healthcare centers was investigated in
Baghdad. The study has shown that participants had
little knowledge about ECs and that only 12% of
them used EC to prevent unwanted pregnancy(14). To
our knowledge, there is no study conducted in Iraq
that has evaluated the level of knowledge, attitude
and dispensing practices of ECs among community
pharmacists.
The aim of this study was to assess knowledge,
attitude, and practices of community pharmacists
towards emergency contraceptives and their
association with sociodemographic variables.
Iraqi J Pharm Sci, Vol.31(Suppl.) 2022 Emergency contraceptives
143
Subjects and Methods
The current study was approved by the
Ethical and Scientific Committee at College of
Pharmacy/University of Baghdad. The pharmacists
were informed of the research objectives and
confidentiality of their responses.
This was a cross sectional study
conducted between August and September
2021. The inclusion criteria were pharmacists
of both genders who were working in
community pharmacies and consented to
participate in this study. Community
pharmacists who were excluded from this study
were those who did not consent to participate in
the study and those who provided incomplete
responses.
The survey tool was an online self-
administered questionnaire in Google form
distributed through medical groups on social media,
in English language, that was used to collect study
data from eligible participants. In addition, a paper-
based copy of the questionnaire was delivered face-
to-face to some of the study participants due to
limited time of study and also small sample size who
responded to the online questionnaire. The
questionnaire was adopted from a previous study
with some modifications that were made according
to the local practice(11). The questionnaire consisted
of four sections. The first section included
sociodemographic questions, whereas the other
three sections included questions about knowledge,
attitude, and practices; respectively. The
questionnaire was first pretested on ten community
pharmacists to ensure the clarity of the questions.
Then it was distributed to other community
pharmacists.
The statistical analyses were performed
using Microsoft Excel (2010) and Statistical
Package for Social sciences (SPSS) version 15
(SPSS Inc., Chicago, IL, USA). Descriptive
statistics were used to summarize the characteristics
of the study population. The categorical variables
were expressed as frequencies and percentages. For
the assessment of knowledge and practice scores,
each correct response was given a score of one,
whereas each incorrect response was given a score
of zero. Then the cumulative and mean scores were
calculated. Participants whose scores above the
mean score were considered to have good
knowledge and good practice, whereas those who
had scores below mean score were considered to
have poor knowledge and poor practice (11) . The
attitude of participants was calculated using five-
point Likert scale ranging from strongly agree with
a score of 5, to strongly disagree with a score of 1,
while a reverse scoring was used in questions one,
three and six. Then, both of the cumulative and
median score were calculated. Those participants
who had scores equal and above median score were
considered to have positive attitude while those who
had scores below the median score were considered
to have negative attitude (11). The data was not
normally distributed. Therefore, for the detection of
the relationship between sociodemographic
variables and the participant knowledge level and
practice level, Chi-square and Fischer Exact tests
were used where relevant. Additionally, for the
assessment of the relationship between the attitude
level and the sociodemographic variables Mann -
Whitney U and Kruskal-Wallis H tests were used
where relevant. A P- value of less than 0.05 was
considered to be significant.
Results
Sociodemographic characteristics of the study
population
A total of 217 responses were received
form the participants. Five responses were excluded
because of incomplete answers and 212 responses
were included in the final analysis. There were 162
online and 50 paper-based responses received from
the study participants. Table (1) presents the
sociodemographic characteristics of community
pharmacists who participated in the study. Most of
the participants (67.9%) were in the age group (24-
29), were females (61.8%), had bachelor degree
(79.2%), had less than 5 years of experience (60.8%)
and were from Baghdad (73.1%). Most of the
participants (83%) had another work in addition to
the community pharmacy from whom 48.1% were
working in a hospital.
Table 1. Sociodemographic characteristics of the study participants.
Characteristic Percentage distribution of
respondents, Number (%) Age (years)
24-29 144 (67.9%)
30-35 40 (18.9%)
36-41 16 (7.5%)
42> 12 (5.7%)
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144
Continued table 1
Characteristic Percentage distribution of
respondents, Number (%)
Gender
Male 79 (37.3%)
Female 131 (61.8%)
Missing 2 (0.9%)
Degree of education
Bachelor 168 (79.2%)
Diploma 8 (3.8%)
Master 27 (12.7%)
PhD 9 (4.2%)
Years of Experience:
<5 129 (60.8%)
5-10 48 (22.6%)
>10 35(16.5%)
Governorate in which pharmacy is located
Baghdad 155(73.1%)
Babil 10(4.7%)
karbala 9(4.2%)
Others a 38(17.9%)
Do you have additional work?
Yes 176 (83.0%)
No 36 (17.0%)
if yes please specify:
Hospital 102 (48.1%)
Hospital, medical representer 2 (0.9%)
Primary health care center 26 (12.3%)
Academia 24 (11.3%)
Others b 18 (8.5)
missing 4 (1.8)
Location of the pharmacy
Near the hospital 24 (11.3)
Near gynecology clinic 37 (17.5)
None of them 151 (71.2)
a : Al-Anbar, AL-Najaf, Al-Qadisiya, Basra, Dhi Qar, Diyala, Erbil, , Kirkuk, Maysan, Nineveh, Saladin,
Sulaimaniya, Wasit.
b : medical representer, supervisor.
Knowledge of the community Pharmacists
towards Emergency contraceptives
Table (2) shows the participants responses
about knowledge questions. Regarding the
mechanism of action of ECs, 59.4% of the
participants stated that ECs act by preventing or
delaying ovulation. Only 39.6% of the community
pharmacists indicated that they received information
about ECs more than once, with about half of those
who received information (51.8%) stated that they
received it from undergraduate/postgraduate study.
In contrast, 22.6% of them indicated that they did
not receive any information in previous years. More
than one-third of the participants (37.7%) indicated
that levonorgestrel should be taken within 72 hours,
and more than half of them (56.6%) stated that
levonorgestrel is the major ECs constituent. Only
48.6% of all participants showed that EC have no
harmful effects on fetus development. Most of the
participants (83.9%) stated that condom leak was the
main cause of ECs use. The majority of the study
participants (90.9%) indicated that ECs do not
Iraqi J Pharm Sci, Vol.31(Suppl.) 2022 Emergency contraceptives
145
protect from sexually transmitted diseases (STDs).
The most commonly reported side effects of ECs
were nausea and vomiting (Figure 1).
Regarding the knowledge level of the
community pharmacists, results showed that the
mean knowledge score was 0.55 and that about 74%
of the participants had good knowledge, while 26%
had poor knowledge (Figure 2).
Table 2. Knowledge of community pharmacists towards emergency contraceptives
Knowledge questions Number (%)
Mechanism of action of ECs:
Prevent or Delay Ovulation (release of ovum from an ovary) 126 (59.4%)
Induce Abortion 9 (4.24%)
Prevent an already established pregnancy 73 (34.4%)
Don’t Know 15 (7.07%)
How many times in the past years have you received information about ECs?
Yes, once 80 (37.7%)
Yes, more than once 84 (39.6%)
No 48 (22.6%)
Sources of information:
Undergraduate/postgraduate study 110 (51.8%)
Medical Representative 16 (17.5%)
Textbook 47 (22.1%)
Training 39 (18.3%)
Internet 212 (38.2%)
Within how many hours after unprotected sexual intercourse should the levonorgestrel
pills be taken?
120 9 (4.2%)
72 80 (37.7%)
48 22 (10.3%)
24 36 (16.9%)
Don’t know 14 (6.6%)
Mention the constituents of ECs.
Levonorgestrel 120 (56.6%)
Levonorgestrel plus Ethinyl Estradiol 17 (8.01%)
Cupper IUD 22(10.3%)
Don’t Know 5 (2.3%)
ECs can harm a developing fetus
Yes 58 (27.4%)
No 103 (48.6%)
Don’t Know 51 (24.0%)
Situations where ECs can be used
Missed Injection due date and had unprotected sex 140 (66.3%)
Condom leaked/slipped 178 (83.9%)
Victims of sexual assault 172 (81.1%)
Intercourse without any family planning method 143 (67.4%)
Don’t Know 16 (7.5%)
Do you know the side effects of ECs?
Yes 92 (43.3%)
No 89 (41.9%)
Not sure 31 (14.6%)
Does EC protect from Sexually Transmitted Infections (STI)?
Yes 6 (2.83%)
No 191 (90.09%)
Don’t know 15 (7.07%)
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146
Figure 1. Community pharmacists’ responses on side effects.
Figure 2. The knowledge level of the study participants.
Relationship between sociodemographic
characteristics and the knowledge level of the
community Pharmacists
Results of the current study showed that
none of the sociodemographic characteristic of the
participants had a significant effect on the
knowledge level (p > 0.05) (Table 3). However, a
higher knowledge level was found in the age group
of (30-35) (82.5%), those with master degree
(81.5%), and those with 5-10 years of experience
(79.2%).
Table 3. Association between sociodemographic characteristics and community pharmacists’ knowledge
level.
Variables Good knowledge N(%) Poor knowledge N (%) P value
Age
24-29 104 (72.2%) 40 (27.8%) a 0.144
30-35 33 (82.5%) 7 (17.5%)
36-41 13 (81.3%) 3 (18.8%)
42> 6 (50%) 6 (50%)
Gender
Male 58 (73.4%) 21 (26.6%) b 0.983
Female 96 (73.3%) 35 (26.7%)
Degree of education
Bachelor 123 (73.2%) 45 (26.8%) a 0.485
Diploma 6 (75.0%) 2 (25.0%)
Master 22 (81.5%) 5 (18.5%)
PHD 5 (55.6%) 4 (44.4%)
Years of experience
<5 93 (72.1%) 36 (27.9%) a 0.174
5-10 38 (79.2%) 10 (20.8%)
>10 25 (71.4%) 10 (28.6%)
Location of the pharmacy
Near the hospital 14 (58.3%) 10 (41.7%) a 0.174
Near gynecology clinic 29 (28.4%) 8 (21.6%)
None of them 113(74.8%) 38 (25.2%)
a: Fishers Exact test
b: Chi-square test
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147
Attitude of the community pharmacists toward
emergency contraceptives
Table (4) shows the attitude of the
community pharmacists towards ECs. Results
showed that 46% of participants expressed their
disagreement on giving easy access for teenagers in
using ECs, and 50.7% showed their agreement that
adolescents should be discouraged to use ECs. Also,
78.9% showed their agreement that routine
information on ECs should be included in the ECs
counselling, and 31% of participants agreed that
they were uncomfortable with ECs dispending for
moral or religious reasons. In addition, 76.1%
showed their agreement on the importance of formal
training in enabling pharmacists to appropriately
dispense ECs and 55.4% agreed that ECs without
prescription will promote unsafe sexual intercourse.
Table 4. Attitude of community pharmacists towards emergency contraceptives.
Attitude questions Strongly
disagree N (%)
Disagree N
(%)
Neutral
N (%)
Agree
N (%)
Strongly
Agree N
(%)
Adolescents (Teenagers) should
be given an easy access to ECs.
*
45 (21.1) 53 (24.9) 42 (19.7) 51(23.9) 20 (9.4)
Adolescents (Teenagers) should
be discouraged to use ECs.
14 (6.6) 45 (21.1) 45 (21.1) 68 (31.9) 40 (18.8)
ECs can be used as a regular oral
routine contraceptive method.
73 (34.3) 78 (36.6) 21 (9.9) 28 (13.1) 12 (5.6)
ECs discourage regular
contraceptive method use among
youth.
16 (7.5) 49 (23.0) 56 (26.3) 73 (34.3) 17 (8.0)
Routine information about ECs
should be included in
contraceptive counseling.
5 (2.3) 7 (3.3) 32 (15.0) 103(48.4) 65 (30.5)
Are you uncomfortable
dispensing ECs for moral or
religious reason? *
29 (13.6) 42 (19.7) 75 (35.2) 50 (23.5) 16 (7.5)
Formal training is needed to
enable the dispensers to
appropriately dispense ECs.
2 (.9) 12 (5.6) 36 (16.9) 89 (41.8) 73 (34.3)
ECs without prescription will
promote unsafe sexual
intercourse.
13 (6.1) 30 (14.1) 51 (23.9) 71 (33.3) 47 (22.1)
*Reverse scoring was adopted.
Results of the participants’ attitude showed
that about 95% of them to have positive attitude,
while only 5% of them to have negative attitude
(Figure 3).
Figure 3. Attitude of community pharmacists
toward ECs.
Relationship between sociodemographic
characteristics and attitude level.
In the current study, none of the
sociodemographic characteristics of the study
population was found to have a significant relation
with attitude (Table 5). However, a higher positive
attitude was found in participants aged more than 42
years (83.3%), female pharmacists (79.4%), those
with PhD and Bachelor qualification (77.8%) and
(77.4%) respectively, those who have more than 10
years of experience (82.9%), and where the location
of their pharmacies being near a hospital (83.3%).
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148
Table 5. Association between sociodemographic characteristics and community pharmacists’ attitude
level.
Variables Positive Attitude Negative Attitude P value
Age
24-29 136 (94.4%) 8 (5.6%) a 0.7
30-34 38 (95.0%) 2 (5.0%)
35-41 16 (100.0%) 0 (0.0%)
42> 12 (100.0%) 0 (0.0%)
Gender
Male 73 (92.4%) 6 (7.6%) b 0.5
Female 128 (97.7%) 3 (2.3%)
Degree of education
Bachelor 160 (95.2%) 8 (4.8%) b0.1
Diploma 7 (87.5%) 1 (12.5%)
Master 26 (96.3%) 1 (3.7%)
PhD 9 (100%) 0 (0.0%)
Years of experience
<5 125 (96.9%) 4 (3.1%) a 0.2
5-10 43 (89.6%) 5 (10/4%)
>10 34 (97.1%) 1 (2.9%)
Location of the pharmacy
Near the hospital 23 (95.8%) 1 (4.2%) a0.07
Near gynecology clinic 36 (97.3%) 1 (2.7%)
None of them 143 (94.7%) 8 (5.3%)
a: Kruskal-Wallis H test
b: Mann-Whitney U test
Practice of community Pharmacists toward ECs
Table (6) shows the responses of
participants towards the practice of ECs. Most of the
participants (79.2%) stated that they have dispensed
ECs in their pharmacy. More than half of them
(56.1%) thought that ECs should not be categorized
as OTC drugs whereas 43.3% stated that they should
be. For the participants who dispensed, 71.4% of
them indicated that levonorgestrel (I- pill) ® tablet
was the most sold brand of ECs. In addition, 90.4%
of the community pharmacists indicated that
dispensing ECs was upon their recommendation and
75% of them stated that they have provided ECs for
girls under 18 years old.
Regarding counseling about ECs 70.2% of
the pharmacists stated that they counsel all ECs
users while dispensing, whereas 62.5% of them
indicated that they do not make counselling on ECs
mechanism of action. Also, 86.9% of the
pharmacists indicated that they make counselling on
the time ECs should be taken, on other hand, about
61.3% of the pharmacists stated that they provide
counselling about ECs side effects.
Table 6. The practice of the community pharmacist toward EC
Practice questions Percentage distribution of
respondents, Number (%)
Have you ever dispensed Emergency Contraceptives?
Yes 168 (79.2%)
No 44 (20.7%)
Do you feel ECs should be categorized under Over the Counter (OTC)
drug?
Yes 92 (43.4%)
No 119 (56.1%)
Don’t know 1 (0.47%)
Which brand of ECs is sold the most?
Levonorgestrel (I pill) 120 (71.4%)
Ulipristal (Ella One) 17 (10.11)
Combination oral contraceptives 29 (17.2%)
Iraqi J Pharm Sci, Vol.31(Suppl.) 2022 Emergency contraceptives
149
Continued table 6.
Practice questions Percentage distribution of
respondents, Number (%)
Intrauterine device (IUD) 5 (2.9%)
Most often the products are sold on:
Patient request 2 (1.1%)
Patient approaches with prescription 79 (47.02%)
On your recommendations 152 (90.4%)
To whom you have provided ECs:
Girls aged under 18 years 126 (75%)
Victims of sexual assault 15 (8.9%)
Women whose partner’s barrier contraception method fail 5 (2.9%)
Women who did not use any contraception method 70 (41.6%)
Do you counsel all ECs users while dispensing?
Yes 118 (70.2%)
No 50 (29.8) %)
Do you counsel on mechanism of action of ECs?
Yes 63(37.5%)
No 105 (62.5%)
Do you counsel the time at which the ECs should be taken?
Yes 146 (86.9%)
No 22 (13.09%)
Do you conceal side effect of EC?
Yes 103(61.3%)
No 65(38.7%)
Figure (4) shows the practice level of the
community pharmacists based on their responses.
The mean practice score was 0.6, and 82 (48.8%) of
the participants were found to have good practice
while 86 (51.1%) of them were found to have poor
practice.
Association between sociodemographic
characteristics and practice level
Table (7) shows the results of the
relationship between sociodemographic
characteristics of the study population and the
practice level. No significant relationship was found
between any of the sociodemographic and practice
level of the participants. However, a good practice
was found within the age group (24-29) (51.4%),
participants with Diploma degree (83.3%), those
with 5-10 years of experience (57.6%), and those
who had location of the pharmacies near hospital
(58.8%).
Figure 4. The community pharmacists’ practice level
Table 7. Association between sociodemographic characteristics and community pharmacists’ practice level.
Variables Good practice Poor practice P value
Age
24-29 56 (51.4%) 53 (48.6%) a 0.4
30-35 17 (50.0%) 17 (50.0%)
36-41 6 (37.5%) 10 (62.5%)
≥42 2 (25.0%) 6 (75.0%)
Iraqi J Pharm Sci, Vol.31(Suppl.) 2022 Emergency contraceptives
150
Continued table 7.
Variables Good practice Poor practice P value
Gender
Male 30 (44.8%) 37 (55.2%) a 0.4
Female 47 (48.0%) 47 (48.0%)
Degree of educating
Bachelor 62 (48.8%) 65 (51.2%) b 0.3
Diploma 5 (83.3%) 1 (16.7%)
Master 11 (42.3%) 15 (57.7%)
PHD 3(37.5%) 5 (62.5%)
Years of experience
<5 47 (48.0%) 51 (52.0%) a 0.3
5-10 20 (57.6%) 18 (47.4%)
>10 14 (45.2%) 17 (54.8%)
Location of the pharmacy
Near hospital 10 (58.8%) 7 (41.2%) a 0.3
Near gynecology clinic 10 (37.0%) 17 (63.0%)
None of them 61 (49.6%) 62 (50.4%)
a: Chi-square test
b: Fishers Exact test
Discussion
Community pharmacists play an essential
role in dispensing of ECs. In addition, looking at the
significant numbers of unintended pregnancies and
induced abortions reported in Iraq (3), it has become
very imperative to conduct a study to evaluate the
knowledge, attitude and dispensing practice of
community pharmacists towards these medications.
The results of this study have shown that 74% of
community pharmacists had good knowledge about
ECs. Other studies have shown that pharmacists had
very good knowledge (12) or had good knowledge (11)
about ECs. In comparison, another study has shown
a low level of the knowledge among community
pharmacists (15).
Having good knowledge could be attributed to
receiving information about ECs from various
sources. This was shown in the results of this study
where the majority of participants indicated that they
had received information about ECs, with about half
of them had received the information during their
undergraduate/postgraduate studies. This reinforces
the important role of the undergraduate/postgraduate
curriculum to provide essential information to
pharmacists. The overall good knowledge level
obtained in this study came from the participants’
responses. The majority of participants provided
correct responses about the major ECs constituents,
situations where ECs can be used and whether ECs
can protect from STDs. However, a fewer number of
participants have provided correct information about
the mechanism of action of ECs, the time within
which ECs should be used after sexual intercourse,
whether ECs can harm a developing fetus, and side
effects of ECs. Additionally, some participants gave
inaccurate side effects of ECs. This may be related
to receiving information from internet (38.2%)
which may be inaccurate or not receiving any
information about ECs (22.6%). Possessing correct
information about ECs, particularly that regarding
the mechanism of action, timing of use and side
effects is very essential for the community
pharmacists to enable them to properly dispense
these medications. For example, giving inaccurate
information about the side effects of ECs may result
in fear of women from using these products and
using other risky ways to terminate pregnancy.
The currents study’s results had shown that
there was no significant relationship between
sociodemographic characteristics of the community
pharmacists and knowledge score. However, a
higher knowledge level was observed in the age
group of (30-35) and those with 5-10 years of
experience. This may implicate that as pharmacists
had more years of work, they gain more experience
and knowledge about ECs. This came in agreement
with a study conducted in Iran which found non-
significant association between pharmacists’
knowledge and their demographic variables (15). On
the other hand, the study of Ethiopia found a positive
relationship between knowledge and years of
practice (12) . Also, in Nepal study pharmacists’ age
had a significant effect on level of knowledge (11) .
Regarding the attitude of community
pharmacists towards ECs, this study’s results have
shown that 95% of participants had very positive
attitude towards ECs. Similarly, the studies
conducted in Turkey and Ethiopia have shown that
pharmacists had positive attitudes towards ECs(12,16)
. In addition, the study done in Nepal showed that
high percentage of pharmacists (93.4%) had positive
attitude towards ECs (11). This level of positive
attitude may have come from the responses obtained
from the participants. Half of the study participants
(50.7%) agreed that adolescents should be
Iraqi J Pharm Sci, Vol.31(Suppl.) 2022 Emergency contraceptives
151
discouraged from using ECs, and about half (46%)
of them expressed their disagreement in giving an
easy access for teenagers in using ECs as this may
be decrease the use of regular contraceptive methods
among youth (42.3%), also may encourage some
teenagers on illegal relationships. Attitudes about
the use of ECs by adolescents and youngest people
may be subject to cultural backgrounds. The study
of Nepal has shown that 48.9% of participants
disagreed that adolescents should have an easy
access to ECs (11) whereas studies of Turkey and
Ethiopia have shown that 40% and 63.3% of
participants, respectively, thought that teenagers and
youngest people can take responsibility of using
ECs(12,17).
Another positive attitude was shown when the
majority of the participants indicated the importance
of including routine information on ECs during
counselling and felt that formal training is important
to enable pharmacists to appropriately dispense ECs.
Besides, more than half of the participants believed
that dispensing ECs without prescription will
promote unsafe sexual intercourse. Therefore,
56.1% of them felt that ECs should not be
categorized under over-the-counter drugs.
The current study’s results showed non-
significant relationship between sociodemographic
characteristics and attitude score. That coincides
with Nepal study where the relationship between
sociodemographic characteristics and attitude score
was non-significant (11) .
Regarding the dispensing practice of
community pharmacists towards ECs, the current
study’s results have shown that only 48.8% of the
participants had good practice. These findings
contradict the results that showed that most of the
study participants had good knowledge and very
positive attitude. Having good knowledge and
attitude does not necessarily mean applying it in
practice. This could be due to the finding that some
participants did not dispense ECs in their
pharmacies or the dispensing was improper as will
be discussed later. Similar findings were obtained
from a study conducted in United Arab Emirates
where the dispensing practice of ECs was rated as
suboptimal (18), and the Turkish study which
concluded that some aspects of the dispensing
practice of ECs needs to be improved (17). However,
in Nepal study, 74.9% of pharmacists had good
practice (11) and in Ethiopia study, the practice level
was described to be very good (12)..
In the current study, only 79.2% of the participants
indicated that they had dispensed ECs which may
indicate underuse of ECs in our community. This
was shown in a study conducted in Baghdad/Iraq
where only 12% of women used ECs to prevent
unwanted pregnancy(3). In the current study,
dispensing of ECs was mostly based on the
pharmacists’ recommendations. This may reflect the
level of knowledge of customers who request ECs,
where it has been shown that women had limited
information about ECs in the study done in Baghdad
(14). An interesting finding in the current study where
more than half of the participants stated that they
have provided ECs to girls under 18 years old, which
was contradicting to their attitude where about half
of them disagreed that adolescents should have easy
access to ECs.
Regarding counseling during dispensing,
only 70.2% of the participants indicated that they
counsel all EC users while dispensing. This is
comparable to the finding that 79% of the
participants thought that providing information on
ECs during counselling is essential. Counselling was
mostly about the time of taking ECs, and the ECs’
side effects, with only a minority of participants who
counselled about the mechanism of action of ECs.
Counseling is a very essential role of the pharmacist
and it enables women to make the right choice of
which EC product to use and the proper way to use
it. Providing inadequate counseling may be
attributed to the lack of time due to the work load or
lack of private areas in the pharmacies to discuss
such sensitive issue. Similarly, only 58.2% of the
pharmacists in the study done in United Arab
Emirates provided spontaneous counseling about the
use of ECs(18). In contrast, the Nepal study has
shown that 70% of the participants provided
counseling to all EC users(11) .Additionally, 85% of
the respondents in Ethiopia study stated that they
counsel all women while dispensing ECs (12).
This study’s results showed that there was
non-significant relationship between demographics
variables and practice level. In comparison, the
results of the Nepal study showed a significant
association between age, years of experience and
location of the pharmacy with the dispensing
practice (11). On the other hand, the Ethiopian study
results showed that dispensing practice had positive
relation of years of experience (12).
The limitation of this study was the small
sample size due to the short time of data collection.
Conclusions
This study detected that community
pharmacists in Iraq had good knowledge and
positive attitude but poor practice especially about
counselling about ECs during dispending.
Additionally, the sociodemographic variables had
non-significant relationship with the knowledge,
attitude and dispensing practice of ECs.
Recommendations of the current study were:
1. Future educational programs are very important
like regular training programs by the
Pharmacists Syndicate.
2. Necessity of inserting the subject of ECs in the
Continuing Education System in Ministry of
Health to the pharmacists especially in general
hospitals, and Primary Health Care Centers in
which family planning department is present.
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152
3. Necessity of educating the community education
about the importance of ECs and their safe and
effective use.
Conflict of interest
Authors of the study declare no conflict of interest.
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