Table 2 37 documents grouped under ECP providers

(Abdulghani, Karim & Irfan 2009)

Hospital Karachi, Pakistan.

Descriptive quantitative survey

45 faculty physicians (33%), residents (27%), medical officers (40%), 36% male and 64% female physicians; of them, the majority (64%) were married

To assess the knowledge of family medicine providers and their attitudes towards ECP

71% familiar with ECP, 40% prescribed in last year. Barriers noted ‘it will promote promiscuity’ (31%), religious/ethical reasons (27%), liability (40%), teratogenicity (44%), and inexperience (40%). 38% incorrectly chose menstrual irregularity as the most common side-effect, 33% answered that EC was not an abortifacient while 42% were unsure.

(Ahonsi et al. 2012)

Nigeria: Kaduna and Abuja.

Descriptive quantitative survey and qualitative interviews

407 providers: pharmacists (36%), followed by PMVs (30%), hospital and clinic staff private (22%), public sector (12%).

To document EC-related knowledge, attitudes, and practices among EC providers and opinion leaders

Providers: knowledge gaps, number of factors facilitated positive KAP.

13 stakeholders: government, professional associations, pharmaceutical companies religious leaders and NGOs

Public sector stakeholders less conversant with ECP than NGOs, Govt must take greater role in policy, procurement, management and monitoring

(Balakumar 2013)

Nepal: Kathmandu, Lalitpur, and Bhaktapur

Descriptive qualitative interviews content analysis

22 pharmacists

To examine pharmacists’ levels of knowledge surrounding EC and MA and their attitudes towards the use of these methods by adolescents

Generally supportive, more rural pharmacist more conservative attitudes

(Bibi et al. 2013)

India Hyderabad

Descriptive quantitative survey

270 general practitioners

To examine impact of physician ECP training

31.1% attended 5 days training course on FP in the past, 69.9% did not have any training. Source of training: government institutes 17%, NGO 14.1%. Significant positive difference was noted on EC knowledge, attitude and use in group who attended family planning training

(Byamugisha et al. 2007)

Uganda: Kampala

Descriptive quantitative survey

247 providers Midwives/nurses 74.9%, Clinical officer 6.5%, Doctor (medical officer) 10.9%, Gynaecologist 4.5%, Other.2%

To assess provider EC knowledge, attitudes and prescribing pattern

80% had knowledge of ECP, 25% was not sure about the time limit within which EC is effective, and 50% of the participants had obtained information from a physician (26.4%) or from a training school (24%). The Yuzpe regimen most commonly mentioned and prescribed method of EC. The HCWs attitudes to EC were generally positive, and the community should be sensitised about EC, significant difference between having had a family planning educational update or not in the last year and knowledge of EC (p = 0.005)

(Chowdhury 2013)

Kerala, India

Descriptive cross sectional survey

106 randomly selected Obstetrics and Gynaecology professionals

To develop and validate an Scale for measuring attitudes towards providing of MTP/ECP services and examine the influence of socio-cultural identities on these attitudes

Up to 60% of the OGPs had negative attitudes towards MTP/ECP provision and this is reflected in their practice that makes MTP/ECP services less accessible for women in many institutions. Personal beliefs and sector of worksite shape the stated attitudes of providers.

(Creanga et al. 2011)

Ghana: Kumasi

Descriptive quantitative survey

600 providers

To assess the theoretical and practical knowledge about EC among (FP providers

FP providers gave 4.1 correct answers to the 11 questions assessing theoretical knowledge and 5.6 correct answers to the 8 questions assessing their practical ability to provide EC. The health sector in which FP providers worked, their education and having received EC-specific training, the number of services offered, and the number of women seen during a week were all significant correlates of both theoretical and practical knowledge about EC. The 2 knowledge domains were significantly and positively associated.

75% providers worked in pharmacies and 83.7% in the private sector

(Dawit, Van der Merwe & Smith 2010)

Ethiopia: Addis Ababa

Descriptive quantitative survey

40 service providers

To determine pharmacists’ and drug vendors’ levels of knowledge, and attitudes towards and practices of ECP

Lack of knowledge about side-effects, contra-indications, and types of ECs. Most portrayed subjective attitudes towards easy EC access, especially for adolescent girls, since they believed that it would encourage promiscuity and unprotected sexual intercourse.

Pharmacists’ and drug vendors’

(Ebuehi, Ebuehi & Inem 2006)

Nigeria: Lagos State

Descriptive quantitative survey

256 health care providers

To assess provider knowledge and practice

9/10 providers had heard of emergency contraception, 50% knew the correct time frame for effective use 75% knew that the pills prevent pregnancy; >30% believed that they act as an abortifacient. <30% who had heard of the pills knew they are legal in Nigeria. Of those who had heard about emergency contraception, 58% provided clients with emergency contraceptive pills, 10% of these providers could correctly identify the drug, dose and timing of the first pill in the regimen. < than 1/10 who knew of emergency contraception said they always provided information to clients, whereas ¼ said they never did so

Physician 45.3%,Nurse 27.0%, Pharmacist 18.0%, Community health worker 9.8%

(Ehrle & Sarker 2011)

Nicaragua: Managua,

Descriptive quantitative survey

93 pharmacy employees

To access pharmacy personnel’s knowledge and attitudes

100% knew about emergency contraceptive pills and reported experience selling them. 92% sold them at least once a week without a prescription (97%). 45% knew that the pills can be taken up to three days afterward; none knew that the pills are effective up to five days afterward. 39% thought the pills can induce abortion, and overestimated contraindications and side effects. 75% believed the availability of emergency contraceptive pills discourages use of ongoing methods (encourages sexual risk-taking (82%) and increases transmission of HIV and other STIs (76%), 68% thought emergency contraceptive pills are necessary to reduce unwanted and unplanned pregnancy; 65% were willing to provide them to all women in need, 13% would provide them to minors.

(Fayemi et al. 2010)

Nigeria: Oyo and Ogun States

Descriptive quantitative survey

97 Patent Medicine Vendor (PMV), (60.8 per cent female

To assess knowledge, dispensing practices of PMVs, and referral for ECP

27.8% of respondents were not aware of ECP, and only half knew that ECP could prevent pregnancy, 40% had ever dispensed ECP. Reasons proffered by those who do not dispense ECP included barriers from the State Ministry of Health, police, other regulatory agencies, and religious beliefs. Only 50.5 per cent have referral arrangements for clients

(Gawade et al. 2009)

India: Mahaeshtra

Descriptive quantitative pre and post survey

102 auxiliary nurse midwives, lady health visitors, health assistants, multipurpose workers, pharmacists

To assess training outcomes and feasibility of paramedical to dispense ECP

Knowledge and attitudes significantly improved as a result of the training programme.

(Geidam, Kullima & Sadiq 2010)

Nigeria: Borno State

Descriptive quantitative survey

physicians, pharmacist and nurse/midwives

To determine the knowledge, attitudes and provision of emergency contraception

80.6% awareness, lower among nurse/midwives (69.8%), 49.5% of the respondent aware of Oestrogen as a method and 5.1% knew that Danazol can be used for emergency contraception, 10.2% were not sure of the correct timing of EC, 36.2% of the respondents had ever provided EC before. Physicians were more likely to approve the use while pharmacists were more likely to have provided EC before.

(Ibrahim, Ahmed & Shaaban 2013)

Egypt: Ismailia,

Descriptive quantitative survey

270 health care providers (obstetrics and gynaecology specialists and general practitioners or family physicians)

To explore the knowledge, attitude and practice of health care providers

Knowledge of specialists was significantly higher than general practitioners/family physicians regarding the three most commonly used methods of EC, viz; combined oral contraceptive (Yuzpe) method, progesterone only pills (plan B) method and IUCD. Only 39.5% of specialists and 24.0% of GPs/family physicians had good knowledge of EC (p = 0.01). 45.7% of specialists and 42.6% of GPs/family physicians had favourable attitude toward EC with no significant difference. 39.5% of specialists and 26.6% of GPs/family physicians reported ever prescribing EC. Yuzpe method was the most commonly prescribed method by specialists (31.5%) and GPs/family physicians (27.0%) with no significant difference. Knowledge and favourable attitude were significantly associated in both groups. Age and years of experience significantly affected the three outcome measures

(Judge, Peterman & Keesbury 2011)

Kenya: Nairobi, Coast, Rift Valley, Nyanza and Western. provinces and Ethiopia: Addis Ababa, Amhara, Oromiya, Tigray Southern Nations, Nationalities and People’s Region

Descriptive quantitative survey bivariate analyses and multivariate logistical regression models

524 health care providers in 199 government health care facilities in Kenya

To gain and understanding of the impact of provider biases and gaps in provider knowledge on EC counselling

54% and 31% of Kenyan and Ethiopian providers, respectively, display strong EC counselling behaviour, while 61% and 55%, respectively, and report having ever provided EC. Bivariate and multivariate results show that, in Kenya, increased EC counselling and provision behaviours are associated with higher levels of provider knowledge.

121 health care providers in Ethiopia nurses (73%),

followed by midwives (14%); 3 doctors

(Kassa, Hiwot et al. 2009)

Ethiopia Addis Ababa, hospitals

Mixed methods- Descriptive Cross sectional survey of all health facilities in Addis Ababa to assess EC provision after sexual assault. In-depth interview were conducted with key informants at police stations.

576 health facilities in Addis Ababa

To examine the potential barriers to accessing ECP among sexual assault survivors

Five public hospitals and one model clinic give 1.04% of all facilities treatment to victims of sexual assault and provide ECP. No private hospital provides treatment. Low police knowledge of ECP and referral usually to model clinic. Lengthy processing times and cost to women make court action difficult

4 police stations

(Kassaye & Dwizedi 2009)

Ethiopia: Addis Ababa

Descriptive quantitative survey

445 physicians at government hospitals

To assess attitudes of physicians towards routine counselling and advance prescription

55.3% received a very good and good knowledge score. Physicians of ObGyn dept. were more knowledgeable than others (p < .0001.). Attitudes of physicians were favourable (64%) towards EC. Being a member of ObGyn dept. showed a very good knowledge score, and past counselling and prescribing EC had favourable attitudes. 72.4% have never prescribed EC. Physicians who ever counselled and prescribed EC before the survey were more likely to have a very good knowledge score (181 p < 0.0001), favourable attitudes (176 p < .001) and past prescribing (124 p < 0.15) than others. 83.6% agreed on the role of routine counselling and advance prescription supply of EC, in provision, promotion and information dissemination, and among them 68.8%, were willing to prescribe EC in the future. 90% had concerns like it might encourage repeated use. 84% mentioned mass media, printed materials, women organization and telephone including text messages and involvement of male partners as better options for EC advocacy, information dissemination, and provision.

(Kestler & Ramirez 2004)

Guatemala

Descriptive quantitative survey

120 people who completed ECP training physicians (20%), nurses (17%), public employees (police officers - 16%), and social workers (11%), other 37%

To examine the awareness of and access to emergency EC among the medical community

14% prior to the workshop had ever recommended EC. After the workshop, 62% reported having recommended EC. 14% reported having given an information talk, trained counsellors on EC, 8% gave talks or provided information in organizations different from their own, and only 4% replicated the workshop

(Khan et al. 2012)

India: Lucknow, Aligarh, Agra and Delhi in Uttar Pradesh

Descriptive quantitative survey and qualitative interviews

315 providers: Drs (83), pharmacists (199), others (33)

To document EC-related knowledge, attitudes, and practices among EC providers and opinion leaders

Despite providers saying safe and effective they were incorrectly informed about ECP’s mechanism of action. Pharmacists do not provide any information on ECP to customers, for fear of embarrassing customers due to lack of privacy in their shops, lack time for any real client counselling. Appropriate for married women and that a minimum age restriction of 18 to 20 should be instituted. Drs felt it should be prescription only. Opinion leaders supported access but had reservations about promoting or mainstreaming ECP

19 Key stakeholders: MoH, professional associations, NGOs, donors

(Kishore, Misro & Nandan 2010)

India: south district in Delhi,

Descriptive quantitative survey

428 providers 72 Lady Health Visitor/

To assess knowledge, attitude and dispensing practices of ECP

Medical officers were observed to be most knowledgeable about E-pills and the pharmacists were the least. The correct prescribed dose of E-pill was known only to 32% of the providers while 49% knew about its right time of intake. Misconceptions and apprehensions for promoting its use were very much prevalent even among medical officers as majority felt that open access to E-pills would increase promiscuity. The dispensing practice of providers was found positively (p < 0.05) correlated with their knowledge. Training resulted a significant (p < 0.05) improvement in knowledge, attitude and dispensing practice of the providers. Knowledge and training combined together contributed 35% to the dispensing practice (R² = 0.35)

Staff Nurse, 164 Auxiliary Nurse Midwife (ANMs) and 67 were Pharmacists

(Lemma 2009)

Ethiopia: Addis Ababa

Descriptive quantitative survey

40 licensed pharmacists and drug vendors

To determine pharmacists and drug vendors' level of knowledge, attitude towards and practice on

Service providers were knowledgeable on the purpose and dosing schedule of EC, they lacked knowledge on side-effects, contra-indications, and types of ECs. Most respondents portrayed a subjective attitude towards easy EC access of especially adolescent girls, since they believed that it will encourage promiscuity and unprotected intercourse.

(Liambila, Obare & Keesbury 2010)

Kenya: Nairobi,

Experimental design baseline and endline assessments of EC provision through the use of mystery clients. Survey and qualitative interviews

9 intervention and control 8 pharmacies. Intervention pharmacies received weekly updates on EC, fliers with three key messages on EC, and information, education, and communication materials

To evaluate the provision of reproductive health information and services to users of ECs by private pharmacists

The differences between the control and intervention pharmacies with respect to the provision of additional information on EC and regular family planning services are in the expected direction but statistically insignificant. In contrast, the likelihood of providing information or referral for counselling or testing for sexually transmitted infections or HIV was lower in the intervention than in the control pharmacies but the difference was also not statistically significant.

(Mané et al. 2012)

Senegal: Dakar and Thiès urban areas

Descriptive quantitative survey and qualitative interviews

34 opinion leaders and 155 providers (doctors, midwives, nurses/ nurse assistants, pharmacists, and pharmacy counter staff)

To document EC-related knowledge, attitudes, and practices among EC providers and opinion leaders

Providers (38%) have not received any EC training.

41% of trained providers were comfortable with ECP sold without prescription, while the majority preferred tighter controls. preferred EC provision limited to conventional health facilities such as hospitals, health centres, private clinics, and pharmacies: They do not favour extending EC at community and school levels through other supply means; more than others, are at greater risk of acquiring STIs, have multiple sexual partners, and not use regular contraception; Over two-thirds of providers indicated providing instructions on ECP use. Few KOLs are informed about ECP’s mode of action; most are in favour of integrating EC in the national guidelines for FP service provision Legislation should be revised similarly to other contraceptive products: urged caution in expanding EC access to the community level.

(Mayhew, Osei & Bajos 2013)

Ghana and Burkina Faso

Qualitative interviews

31 Providers Nurse/midwife 18, Drs. 5, Pharmacists 4, Pharmacist assistant 4

To assess providers’ EC attitudes and delivery practices

Result on two dimensions reflecting providers’ “acceptance” and “provision” of EC. Provider attitudes broadly favoured EC, although most in Burkina Faso were cautious about providing it (fearing that regular use might displace condom use, thus increasing HIV risk), while in Ghana, many highlighted useful role of EC in reducing unwanted pregnancy. Overall, respondents wanted to limit distribution to health facilities and pharmacies and were reactive, rather than proactive, EC providers. Their attitude towards people seeking emergency contraception varied: those suffering contraceptive method failure or provider failure were seen as deserving, while those who came because they had used their contraceptive method incorrectly or not used one at all were regarded less favourably.

(Mir & Malik 2010)

Pakistan: Rawalpindi district

Descriptive quantitative survey

67 Lady Health Supervisor

To explore the ECP knowledge, attitudes and practices of the Lady Health Supervisor

Insufficient knowledge, high misinformation and strongly negative attitudes. > 50% did not know that ECP do not cause abortion. About 4/5 believed that emergency contraceptive pills will lead to ‘evil’ practices in society. > 4/5 recognized that the clients of National Program for Family Planning need ECP. The attitudes significantly associated with knowledge

(Mishra & Saxena 2013)

India: Delhi

Descriptive quantitative survey

60 pharmacies

To evaluate the knowledge and over-the-counter services provided by the pharmacists in

2 to 500 packs sold per month. 62% of the pharmacists claimed that majority of the clients repeated use during the same month, 18% of the clients were referred by doctors, and 82% directly approached the pharmacists. 1/3 clients were adolescents. 67% of the pharmacists had adequate knowledge about EC, 3.3% asked about the last menstrual period or the time elapsed since the last unprotected intercourse. No pharmacist asked if one or multiple unprotected acts of intercourse, if any regular contraceptive method was being used, or the reason for EC intake. 91.7% explained the dosage schedule to clients. 50% explained client may experience side effects. No pharmacists suggested STI screening, 35% counselled the clients regarding regular contraception.

(Mondal et al. 2006)

India Kolkata, RG Kar Medical College and in the district of 24 Parganas

Descriptive quantitative survey

140 healthcare providers and 480 beneficiaries

to evaluate the knowledge, attitude and practice

Providers and beneficiaries lacked knowledge of the concept of ECP. Paramedical providers were more likely to recommend ECP after unprotected sex and to prevent abortion than Gynaecologists and Obstetricians.

(Obare, Keesbury & Liambila 2009)

Kenya

Descriptive quantitative survey and qualitative interview

103 Mystery client visits to 20 randomly selected pharmacies with mystery clients acting out two scenarios: an experienced client, and a non-experienced client.

To assess pharmacists and others provider knowledge and practices regarding EC

Some providers insist on doctors’ prescriptions before they can dispense EC. There are variations among providers on the recommended dosage and possible side-effects of EC pills. MCs presenting as inexperienced clients were significantly more likely to be given additional information on EC than the experienced ones. There was no significant difference in the provision of additional reproductive health (RH) information/services by the scenario presented.

(Okonofua et al. 2009)

Nigeria from 11 States

Descriptive quantitative survey

174 private medical practitioners

To determine knowledge and practices of EC by private medical practitioners

79.9% of the respondents correctly described emergency contraceptive methods; only 23% reported that they had emergency contraceptives in their clinics, while only 13.8% of the practitioners used the correct brands and dosages of emergency contraceptives currently available in the country. Similarly, a large proportion of the practitioners did not know the exact timing of emergency contraceptives in relation to sexual intercourse, while only a few gave correct names and dosages of administration. The results show inadequate knowledge and poor use of emergency contraceptives by private medical practitioners in Nigeria

(Onwuhafua et al. 2005)

Nigeria: Kaduna State

Descriptive quantitative survey

232 community health extension workers

To determine knowledge, attitude and practice of family planning amongst community health extension workers

All could recall at least one modern method of family planning. The oral contraceptive pill (OCP) (85.8%), injectable contraceptives (85.3%), and the intra-uterine contraceptive device (IUCD) (56.0%), were most widely known about. Emergency contraception was not known about. A high percentage of female Chews have practised family planning: 115 (74.7%) have used at least one method and this is more among the married women. Methods ever used included injectable contraceptive (57.4%), OCP (47.0%), and IUCD (22.6%). Fifty percent of females were current users. Non-current users were likely to be between the ages of 25–29 years especially when not married, and 35–39 years when married. Reasons for the non-use of family planning by female Chews were side effects, not being married, not being sexually active and religious beliefs

(Oriji & Omietimi 2011)

Nigeria: Port Harcourt

Descriptive quantitative survey

100 medical doctors

To determine knowledge, attitude, and practice of emergency contraception among medical doctors

Knowledge about its use was poor. 98% of them were aware of emergency contraception, 58% could not identify correctly any type. Oral mifepristone (RU486) was the most recognized form of EC identified by 38% of the doctors. Rape would be the commonest indication for emergency contraception as reported by 76% of the doctors, ahead of missed pills by 36% and incestuous sexual intercourse by 46% of the doctors. Postinor (levonorgestrel) given within 72 hours and IUCD inserted within 5 days of intercourse were the commonest forms of EC administered by 26% each of the doctors interviewed. Conclusion: Although the awareness of EC is high among the doctors in Port Harcourt, the knowledge and use of EC is low.

(Shaki 2013)

Tanzania: Dar es Salaam

Descriptive quantitative survey with open questions thematically coded

268 health care providers and 300 medical students

To examine knowledge, attitude and practices of EC among health care providers and medical students

A lack of knowledge about EC was found as only 30.4% of the health care providers and 32.9% of the medical students were found to have adequate knowledge of EC. EC provision was reported by 31% of the providers and EC utilization was found to be 14.9% among medical students. Majority of health care providers (94.9%) and 90.7% of medical students had positive attitudes towards EC provision and utilization respectively. Awareness of emergency contraception among health care providers and medical students was found to be moderate (59% vs 53.7%). Despite this, adequate knowledge on emergency contraception on both groups was low (30.4% vs 32.9%). Provision of EC by the health care providers as well as utilization of EC among medical students was found to be low. The majority of the providers and students had positive attitudes towards EC practices i.e. provision among the health care providers as well as EC utilization among the medical students.

(Syahlul & Amir 2005)

Indonesia: Jakarta

Descriptive quantitative survey

205 general practitioners 142 obstetricians and gynaecologists in 36 Community Health Centres and 25 private clinics

To examine attitude of medical practitioners towards the availability of EC

Most participants were familiar with EC, only 22% received a very good knowledge score (4 or 5/5 answers correct), while 52% received a poor score (0-2/5 correct). Most participants did not support the OTC availability of EC (70%). Logistic regression identified that participants who prescribed EC had an Odds of 3.8 (95% CI 1.90, 7.73) of approving OTC EC, after adjustment for age and speciality

(Sychareun et al. 2010)

Laos

Qualitative methods in-depth interviews, content analysis

10 policy makers, 22 public providers, and 10 providers at private clinics

To examine policy maker knowledge and attitudes towards provision of ECP

Most policy makers and health providers knew about ECP and supported their introduction in the public sector. Knowledge was poor, inconsistent attitudes, and they felt their ability to meet the demand of potential users is limited.

(Thapa 2013)

Nepal: Kathmandu and Lalitpur district

Descriptive quantitative survey

60 Nurses: ANM 29,

To examine knowledge, attitude and practices of EC among nurses

96.33% of nursing personnel had knowledge on general information of Emergency Contraception (EC), 88.78% had knowledge about intrauterine contraceptive device as EC, 66.1% had knowledge on general information of emergency contraceptive pills, 65.5% had knowledge on its dosage and administration and only 59.05% had knowledge on its side effects and their management. On an average, 72.83% of them had knowledge on EC as a whole. More than three- fourth (78.18%) of them had positive attitude towards EC. When comparing nurses’ knowledge between educational qualifications, training on EC, duration of experience and between in-service training on family planning counselling, there was statistically no significant difference on knowledge between these variables. When studying the correlation between nurses’ knowledge and attitude regarding EC, it was found to be moderately correlated (r = 0.537)

Staff Nurse 17, Senior Staff Nurse 11, charge nurse 3

(Tripathi, Rathore & Sachdeva 2003)

India:

Descriptive quantitative survey

Two groups of clients (abortion seekers at Family Welfare centre, and non-medical college students (prospective clients)); and 4 groups of health care providers (gynaecologists, general practitioners, paramedical workers, and medical students)

To describe knowledge, attitude, and practices among health care providers

Few of the clients were familiar with the concept of emergency contraception and so the rest of the information could not be obtained from them and hence this was excluded from further analysis. Many providers (84.8% gynaecologists, 41.0% general practitioners, 2.7% paramedical workers, and 64.4% medical students) were vaguely familiar with the concept of emergency contraception, very few knew accurately about timing and doses. The majority of these thought it to be an essential component of contraceptive services but preferred distribution through health care providers only. The practice of emergency contraception as reported in the present survey was inconsistent. Yuzpe regimen was the most commonly used method and nausea/vomiting were the commonest side-effects. The question of efficacy of emergency contraception was not answered reliably by the health care providers.

(Worku & Teklu 2011)

Ethiopia: Addis Ababa

Descriptive quantitative survey

Drug dispensers (n = 303) working in pharmacies and drug stores of Addis Ababa

To describe EC Knowledge, attitudes and practices

84% of respondents (n = 256) were aware of EC, but the remainder had never heard of it. Although nearly 80% of aware respondents had a knowledge and attitude score of more than 50%, only 25% had knowledge and 35% had an attitude score of more than 75%. Amongst aware respondents, 32% had prescribed ECP.