21. Assessment of Adolescent Decision-Making Capacity For Pharmacist Access To Hormonal Contraception

Abstract

Multiple states allow pharmacists to prescribe combined hormonal contraception. In many cases, pharmacy access is restricted or unavailable for minors due in part to concerns about minor’s decision-making capacity. Our objective was to examine adolescents’ decision-making capacity for contraception after a simulated pharmacist prescribing process. As part of a larger study of minor access to contraception in a pharmacy setting, we recruited 53 females, ages 14-21, from primary care and subspecialty clinics (neurology, rheumatology, cardiology, oversampled for contraindications). Participants underwent a simulated pharmacist prescribing process, which included completion of a self-screener for medical contraindications, providing the participant with a menu of available options based upon their screener, and method specific counseling. The simulation was followed by a validated, semi-structured capacity assessment using the MacArthur Competency Assessment Tool - Treatment (MacCAT-T). The tool assesses four components of decision-making: (1) understanding of the treatment, (2) appreciation for how the decision will affect the young person personally, (3) logical reasoning and balancing risks/benefits, and (4) making a voluntary choice. Questions are open-ended with follow-up probes to elucidate decision-making processes. Interviews are scored out of 20 using a pre-determined scoring rubric, with a higher score indicating a greater level of decision-making capacity. Predictors included demographics, health literacy (rapid assessment of adult literacy in medicine (REALM), socioeconomic status (Family Affluence Scale II), sexual behavior, presence of a chronic illness (Children with Special Health Care Needs questionnaire). Quantitative data were analyzed using correlation, t-tests and ANOVA. Multiple regression was not done as there was not sufficient variation in the outcome. The open-ended questions were analyzed qualitatively using thematic analysis to identify key concepts related to decision-making capacity and opinions regarding contraception and pharmacy access. Of the 53 participants, 58% were from primary care clinics, 42% subspecialties; 70% were under 18 years of age; 38% African American, 36% white, 11% Latina. Participants scored high on the MacCAT-T, with little variation in the scores (18.8 (+/- 1.9)) and no correlation with any hypothesis variables. Examining differences by age below or above 18 showed no differences between sub-scores in understanding (5.5 v. 5.6), appreciation (3.9 vs. 4.0), reasoning (7.7 vs. 7.6) and choice (1.6 vs. 1.6). In bivariate analysis, neither age, ethnicity, clinic type, insurance, family affluence, sexual activity or chronic illness were statistically significant with total MacCAT-T scores. One variable found to be significantly associated was medical literacy (p<0.001). Key themes included stigma around contraception use and sexual activity. Some found discussing heavy or painful menstrual cycles as a strategy for more acceptable contraceptive use—both with parents and their larger community. Participants found pharmacy access to be a convenient and discreet option. However, they did raise concerns about pharmacists’ knowledge and understanding of their chronic illness. Furthermore, some participants preferred their clinical provider due to their already established relationship and knowledge of medical history. Minors demonstrated high levels of decision-making capacity regarding contraception, comparable to young adults. These data support expansion of pharmacy access to hormonal contraception to adolescents of all ages.