Abstract
Teens from neighborhoods that have experienced historical and contemporary disinvestment have among the highest rates of teen pregnancy, yet they have less access to resources to reduce unintended pregnancies. In recognition of this, the New York City Department of Health and Mental Hygiene (NYCDOHMH) developed the Youth-Friendly Pharmacy Initiative. Over 7 consecutive months in 2015, educational materials and free NYCDOHMH condoms were placed strategically in independent pharmacies in the South Bronx. Refills were made monthly. Pharmacists were directed to order free refills from the NYCDOHMH after the project ended. To evaluate the feasibility of the study, a survey with teens (15-19 years) at the study midpoint and a 3-month post follow-up assessment were conducted. The retention rate over 7 months was 96.4% (27/28 pharmacies). Forty-three percent (2,068/4,830) of the booklets and 87.9% (43,841/49,850) of the condoms were taken by patrons. The posters and pamphlets were recognized by 63.6% and 27.3% of the teens, respectively. Forty-percent of the teens were aware of the free condoms, and one third had taken the free condoms. In the post assessment, 20% of the sampled pharmacies independently sought out resources for free condom refills. Pharmacies are positive sexual and reproductive health resources for underserved teens.
Keywords
Introduction
Teen pregnancy and birth rates are at a record low rate in the United States (Hamilton, Martin, Osterman, Curtin, & Mathews, 2015). Unfortunately, race/ethnic and neighborhood disparities persist (Centers for Disease Control and Prevention, 2016). The teen birth rate continues to be approximately twice as high for Latino and non-Latino Black teens (15-19 years) compared to non-Latino White teens. In 2014, the rates were 39.0, 34.9, and 17.3 births per 1,000 females, respectively (Hamilton et al., 2015). Moreover, communities with both a higher proportion of people of color and a higher prevalence of poverty have among the highest teen birth rates in the nation (Penman-Aguilar, Carter, Snead, & Kourtis, 2013).
Background
There is a growing consensus, as reflected in Healthy People 2020, that the disproportionate amount of unintended pregnancies among young Latinos and Blacks can be reduced by addressing the social determinants of teen pregnancy (Healthy People 2020, 2018). These social determinants of teen pregnancy include the root causes of poverty, disenfranchisement, and access to quality health care services (Healthy People 2020, 2018). As we work toward addressing the social determinants of teen pregnancy, which takes time, health promotion is needed. Health promotion can include enhancing the availability and accessibility of resources and services tailored for youth (Centers for Disease Control and Prevention, 2013). According to the Centers for Disease Control and Prevention (2013), modifying clinics to be more youth-friendly can assist youth in making informed healthy sexual and reproductive health (SRH) decisions (e.g., delay or reduce sexual activity). Youth-friendly clinics are characterized as providing confidential and private as well as having respectful and culturally competent services, information, and convenient office hours (Centers for Disease Control and Prevention, 2013).
Similar to clinics, community pharmacies could also be a potentially important setting where tailored SRH services are provided to youth. This is in largely due to the role and responsibilities of pharmacists. Pharmacists dispense hormonal contraceptives prescriptions, aid with the selection of nonprescription products, counsel patrons on new prescriptions, and educate clients on an as-needed basis (Farris et al., 2010). In addition, pharmacists are viewed as trusted health care professionals (Farris et al., 2010). Moreover, pharmacies are ubiquitous and are open at convenient hours (Farris et al., 2010).
There have been numerous interventions aimed at increasing the availability of emergency or oral contraceptives in pharmacy settings; however, none have focused on making pharmacies youth-friendly (Gonsalaves & Hindin, 2017). Also few occurred in low-resource settings, which are neighborhoods with the highest teen pregnancy rates (Beitz et al., 2003; Brittain et al., 2015; Gonsalaves & Hindin, 2017; Sampson et al., 2009; Wolfe 2005). Moreover, in a recent systematic review article, it was found that teen pregnancy interventions were attractive to and used by teens (Gonsalaves & Hindin, 2017).
Studies of condom distribution programs in pharmacies are also limited (Charania et al., 2011). Most condom distribution programs for youth occurred in schools, colleges, and clinic settings (Charania et al., 2011; Francis, Noar, Fortune & Adimora, 2018). The condoms were dispensed via condom machines, in bowls, or in person. In general, these interventions were shown to increase the availability and accessibility of condoms and increase condom use behaviors in these settings (Charania et al., 2011).
To provide more information and resources to teens living in low-resource settings, the Youth-Friendly Pharmacy Initiative was initiated in 2015. It is an extension of the Bronx Teen Connection (BxTC), which is a program that uses a community-wide approach to enhance the ability of teens of color living in resource-deprived neighborhoods to make informed healthy SRH decisions (O’Uhuru, Santiago, Murray, Travers, & Bedell, 2017). Through the Youth-Friendly Pharmacy Initiative, community pharmacy personnel were engaged by the New York City Department of Health and Mental Hygiene (NYCDOHMH) to make their pharmacies more hospitable to teens by offering educational information, messages, and resources pertaining to SRH. This study assesses the feasibility and sustainability of conducting the Youth-Friendly Pharmacy Initiative. Consistent with the mission of the journal, this article focuses on the development, implementation, and evaluation of a health promotion intervention to reduce health inequities.
Method
Setting
The Youth-Friendly Pharmacy Initiative was conducted in the South Bronx. The South Bronx is a community of approximately 550,000 people, of which 96.5% are Latino or non-Latino Black and 43% live below the poverty line (U.S. Census Bureau, 2016). The South Bronx has among the highest teen pregnancy rates in New York City. The teen pregnancy rate in the South Bronx as of 2014 (the most recent data available) is higher than the citywide average (67.3 vs. 40.6 per 1,000 teen females) and more than double the national average (35.5 vs. 16.8 births per 1,000 females; Hamilton et al., 2015). As is the case citywide, 9 out 10 teen pregnancies in the South Bronx are unintended. Historic and contemporary segregation and systematic disinvestment of the South Bronx perpetuate this inequity.
Formative Evaluation
The findings from a formative evaluation conducted in 2011-2012 with 25 pharmacists operating in the South Bronx informed the development of the Youth-Friendly Pharmacy Program. Specifically, we were able to determine the following: (1) contraceptive availability in pharmacies, (2) type of services available to youth, (3) interest in providing youth tailored services and resources, and (4) previous and ongoing education received around youth SRH.
Outreach
The names and addresses of the independent pharmacies were identified from the Office of Emergency and Preparedness, which updates the list of pharmacies on a biweekly basis. Thirty-five pharmacies were identified through the Office of Emergency and Preparedness, of which 28 agreed to participate. From September 2015 to March 2016, NYCDOHMH personnel supplied each pharmacy with free SRH materials: (1) Lifestyles condoms, (2) lubricants, and (3) culturally and linguistically tailored booklets and posters. Materials were restocked in the participating pharmacies monthly or more frequently on request by NYCDOHMH personnel.
Condoms were given to the pharmacies in a clear fishbowl, which could hold up to 300 condoms, and placed in an easy-to-access area by NYCDOHMH staff. The maximum amount of condoms was delivered at each visit. A variety of condoms were included: Lifestyles Ultra Sensitive Strips, Lifestyles Blue, Lifestyles KYNG Gold, Lifestyles Ribbed, Lifestyles Ultra Thin, and Lifestyles flavored (strawberry and vanilla). The Lifestyles brand of condoms was specifically distributed because it is the brand of condoms that is available from the NYCDOHMH. Lubricants, 20 per store, were placed next to the condoms in the pharmacies starting at Visit 4.
The booklet, TeenSpeak About Sexual Health and Teens in NYC, was designed by teens participating from the Youth Leadership Team (YLT) affiliated with BxTC. The TeenSpeak About Sexual Health booklet consisted of information to help teens obtain information that can be hard to find about healthy relationships, effective methods of birth control, emergency contraception, and minors’ rights to sexual health services. The booklets were available in English, Spanish, French, and Arabic. The Teens in NYC booklet contained information about minors’ rights to sexual health services, and a citywide list of health care providers providing condoms, birth control, emergency contraception, testing and treatment for sexually transmitted infections (STIs), HIV testing, and pregnancy testing. The booklets were placed in an in-store health display in a prominent area. There is a link in the booklet to the electronic version of the booklet, The Teens in NYC mobile app, which is available through the NYCDOHMH and is offered for free to the public. Two educational posters, Dual Protection (Figure 1) and Your Talk, were informed by a Bronx population-based study and focused-groups with parents and teens. The messaging of the Dual Protection poster focused on promoting the use of dual protection (condoms by the male + contraception by the female), which is the optimal method to reduce both unintended pregnancies and STIs (Cates & Steiner, 2002; Centers for Disease Control and Prevention). The Your Talk poster encouraged parents and caretakers to speak to their teens about sex. Posters were placed in visible, prominent areas, such as store windows or column, by NYCDOH staff.
Educational Poster to Promote Dual Protection Among Teens Engaging in Sex
Tracking
The number of condoms, posters, and booklets taken by patrons were tracked at each visit by subtracting the number of items that were retrieved at each visit from the number delivered to each pharmacy. Eight visits were made, and the total of items taken by patrons was assessed and reported for Visits 1 to 7.
Follow-Up Assessment
NYCDOHMH staff follow-up
Three months following the last pharmacy visit, NYCDOHMH staff conducted in-store surveys and observations with one pharmacy staff member per randomly sampled pharmacy to ascertain whether pharmacy personnel reached out to the NYCDOH for a refill of condoms, the barriers and challenges in requesting the materials from NYCDOH, the perceptions of the project, and whether the posters and other educational materials were still on display. The number of pharmacies reaching out for free condom refills was validated with the records from the NYCDOH condom distributor.
Teen survey
Surveys with teens (15-19 years) were conducted outside of two of the participating pharmacies, 6 months after baseline to assess teen recognition and uptake of the project materials. Teen members of the YLT, a youth group affiliated with BxTC, contributed to the development and refinement of the survey. All surveys were conducted by NYCDOH personnel, who were accompanied by teens from the YLT. Pharmacies were selected based on proximity to a metro station and a high school.
Teens were eligible if they spoke English or Spanish and were walking past the pharmacy during afterschool hours, 4 p.m. to 6 p.m. Study participants received a round-trip metro card, a water bottle, and a booklet on minors’ rights on SRH for completing the survey.
Data Analysis
All data analysis was conducted in SAS Version 9.4. Ethical approval for the analyses in this study was given by the NYCDOHMH Institutional Review Board.
Results
Pharmacy engagement
Participation of the pharmacies remained high throughout the study, with only one pharmacy dropping out (Table 1). At baseline, 21 of the 28 pharmacies agreed to carry the free NYCDOHMH condoms. Twenty-three pharmacies carried the condoms and needed refills by the last visit. A total of 49,850 condoms were delivered, of which 43,481 were taken (87.9%). The average number of condoms taken by patrons ranged from 228.7 at the second visit to 249.5 at the seventh visit.
Total Number of Adolescent Sexual and Reproductive Health Materials Delivered and Taken by Patrons at Pharmacies, South Bronx, 2015-2016
The TeenSpeak booklets were placed in each of the 28 pharmacies for the first three visits, and 26 pharmacies were participating for a retention rate of 92.9% by the seventh visit. Of the 4,830 booklets delivered, 2,068 were taken. The average of number of booklets taken per store decreased over time from 22.5 per store to 3.4.
A total of 175 posters were posted or reposted in the pharmacies (results not shown).
Follow-up assessment
Twenty of the 28 pharmacies were assessed in the 3-month post assessment. Eight of the 20 pharmacies still had the posters on display, 9 had pamphlets, and 6 had a fishbowl of condoms accessible to clients. Twenty percent of the pharmacies reached out for additional free condoms (n = 4); 3 of the 20 pharmacies contacted NYCDOH, and 1 reached out to a local clinic. The personnel at these four pharmacies reported that both teen and adult customers were requesting the free condoms, and believed its availability helped their community, and attracted more customers. None of the pharmacies reached out for any additional project materials (i.e., pamphlets, posters, and lubricants). Pharmacy personnel reported being too busy to call (n = 2) or being unaware of the chance to receive additional free materials (n = 7) as reasons for not requesting refills. All of the pharmacy personnel (n = 20) believed that the Youth-Friendly Pharmacy Project was beneficial to the community.
Teen survey
Fifty-five teens were surveyed. More than half of the participants were male (n = 35), 71.8% were Latino, and 75% were born in the United States. Of the teens, 43.6% had been sexually active.
Approximately 40% reported shopping at the pharmacy at least once a month. Forty-percent (n = 22) teens were aware that free condoms were available in the pharmacy, of whom 33.4% (n = 8) had taken at least one. The majority of the teens recognized the Dual Protection and Your Talk posters (63.6%, n = 35). As a result of seeing the posters, 28.6% (n = 10) spoke with their parents afterwards about sexual health, 20.0% (n = 7) bought condoms, 5.7% (n = 2) bought birth control at the pharmacy, and 17.1% (n = 6) used dual protection (results not shown). More than a quarter (27.3%) recognized the Teen Speak pamphlets. Most of the teens found the posters and pamphlets to be helpful (69.1%; see Table 2).
Characteristics of Teens (15-19 Years, N = 55), the Youth-Friendly Pharmacy Project, Bronx, 2016
Discussion
This is one of the first studies to access the feasibility of distributing free SRH materials to teens in a nontraditional setting, pharmacies. With a retention rate of 96% over a 7-month period, we found that pharmacists in a disenfranchised neighborhood were supportive of serving as a resource to improve youths’ access to SRH resources. In addition, with nearly 45,000 free condoms and more than 2,000 booklets on teen sexual health taken by patrons over a 7-month period, we demonstrated that community members also support such efforts.
Previous pharmacy interventions aimed at improving SRH resources for youth in the United States have infrequently occurred in low-income settings, and rarely included Blacks and Latinos (Sampson et al., 2009). It is particularly important for youth of diverse racial/ethnic backgrounds residing in marginalized neighborhoods to be the focal point for research and programs that provide free and easily accessible SRH resources because teen pregnancy rates are disproportionately high in these groups. This is in part due to limited resources in these neighborhoods, such as family planning services (Dehlendorf, Rodriguez, Levy, Borrero, & Steinauer, 2010), youth involvement programs (Manlove, Franzetta, McKinney, Papillo, & Terry-Humen, 2004), employment opportunities (Rosenbaum, Zenilman, Rose, Wingood, & DiClemente, 2012), and robust sexual health education in schools (Kohler, Manhart, & Lafferty, 2008). In addition, the emphasis in previous U.S. studies was largely on pharmacists prescribing and dispensing emergency and oral contraceptives to youth (Gonsalves & Hindin, 2017). Although that is a serious concern and a legal right that should not be impeded by pharmacy personnel, messaging and educational materials are also needed to assist teens in feeling welcomed into the pharmacy environment in order to communicate their SRH needs to the pharmacists as in this study.
There were some limitations. While the proportion of 15- to 19-year-olds who took the condoms cannot be confirmed, it is positive to note that 40% of the teens sampled were aware that free condoms were available in the pharmacy and that more than a third of these had taken at least one. Another limitation is that a small sample size of teens were surveyed, which prevented any stratified analysis by gender or sexually activity status. While we were unable to determine the effect of providing free condoms on the sale or price of condoms, the number of pharmacies wanting free condoms delivered increased with time. In addition, three to five pharmacies per month requested condom refills before the next visit. Thus, it is most likely that the availability of free condoms did not adversely affect the sales of the stores’ condoms in a detrimental way. Another limitation is that the impact of the intervention in youth who spoke French or Arabic was not assessed given a lack of staff who are fluent in either language. Last, viewership of the electronic version of the booklet was not tracked.
One major goal of the project was to educate and enable pharmacy personnel to understand that NYCDOHMH can provide free educational materials and condoms, and that the NYCDOHMH has expertise in SRH that can support the work of pharmacies. Only 3 of the 20 pharmacies sampled for follow-up called for additional condoms within 3 months of the project completion. One independently sought out free condoms from a neighboring clinic. Thus, although pharmacists welcomed the materials in the pharmacy, we need to explore how to encourage pharmacy clerks/pharmacists to independently contact NYCDOHMH for free materials and support.
The availability of SRH information, messaging, and free condoms in pharmacies might delay or reduce sex, especially unprotected sex, among teens. However, this may not result in pharmacists being more confident about engaging youth around their SRH needs or dispensing contraceptives. To address the fear or uncertainty that pharmacists may have, the NYCDOHMH developed a comprehensive online continuing education curriculum around youth SRH that covers the epidemiology of SRH, minors’ rights, contraceptives recommended for teens, and key communication tips. The curriculum is available through the New York State Society of Pharmacists.
The study had several strengths. Pharmacies have convenient hours and are locations, which, made it readily easy to conduct outreach to youth. Findings from a formative evaluation with pharmacists in the priority areas informed the design of the Youth-Friendly Pharmacy project. Education materials, messages, and condoms can be protective against unintended pregnancies and the transmission of STIs, and were relatively simple to display in the pharmacies. Another strength of the study was that all of the educational materials displayed in the pharmacies were informed by focus groups with teens and parents, and a population-based study of parents and caretakers in the Bronx. In addition, information was provided in the Teens in NYC booklet about the Teens in NYC mobile app, which connects teens with electronic SRH resources. It is possible that parents, caretakers, and other trusted adults may have also taken the informational materials, thus increasing the knowledge of adolescent SRH among residents in the community.
Despite having a small sample size of teens in the study, the teens sampled had similar characteristics to those in the NYC Youth Risk Behavior Survey, which is a study designed to be representative of teens in NYC public schools (NYCDOHMH, 2017). In addition, most of the independent pharmacies in the community district of interest participated in the study. Given that the neighborhoods in the South Bronx are similar in terms of demographics, the findings are generalizable to other pharmacies in the geographical area.
Conclusions
To reduce inequities in unintended teen pregnancies and HIV/STIs, teens from neighborhoods with historical and contemporary disinvestment need as much positive information and quality resources as possible provided to them in trusted health care settings. Our findings demonstrate that both teens and community pharmacists are supportive of the provision of SRH educational materials and free condoms in pharmacies. Moreover, the results indicate that placing youth-friendly SRH materials in pharmacies is highly feasible and fairly sustainable. Thus, the provision of SRH materials in pharmacies can be expanded beyond emergency contraception. We recommend DOHs and interests groups engage community pharmacies in promoting best sexual practices by providing informational materials, messages, and free condoms that are available through local DOHs, clinics, or organizations. Importantly, future outreach programs need to include diverse ethnic youth groups in and/or from resource-deprived neighborhoods in order to reduce inequities in the teen birth rates.
