Knowledge, attitude and practice of emergency contraceptive pills among community pharmacy practitioners working in Kathmandu Valley: a cross-sectional study

Background Unintended pregnancy occurs due to incorrect or inconsistent use of a contraception method. Such pregnancies can create an economic burden on the family, society and nation as a whole. Unintended pregnancy is the underlying cause of abortion which can also result in infertility and maternal death. Adequate knowledge of emergency contraceptive pills (ECPs) and positive attitudes among the community pharmacy practitioners (CPPs) is a prerequisite for timely access of ECP, thus ultimately lessening the incidence of unintended pregnancies. This study intended to explore the knowledge, attitude and practice of CPPs toward ECPs in Kathmandu valley. Methods Cross-sectional study conducted in community pharmacies located in three districts of Kathmandu valley. A convenience sampling method was employed to interview CPPs in 227 community pharmacies using a validated questionnaire. Questionnaire assessed the demographic characteristics; knowledge, attitude and dispensing practice of the CPPs. Data were subjected to descriptive and inferential analysis using SPSS 18 (SPSS Inc., Chicago, IL, USA). Results Approximately 75% of respondents had a good practice on dispensing ECPs, and 70% of them counselled all the users. A significant association (p-value< 0.05) was obtained between the dispensing practice of respondents and their knowledge level. ECP related knowledge was higher among the age group 40–49 years, BPharm degree holders with experience above 10 years and community pharmacies located inside the city and in the Kathmandu district. After adjusting the possible confounder variables, age, degree and district of pharmacy were significantly associated with knowledge. Similarly, respondents’ practice towards ECP was higher among the age group 40–49 years with experience above 10 years and community pharmacies located inside the city and in the Kathmandu district. Adjusted for other variables, only community pharmacies located at Kathmandu district was significantly associated with the practice. Conclusion CPPs lacked specific important information on ECP and opined against its’ availability as an over-the-counter drug, despite good overall knowledge and positive attitude. Many thought that ECP without prescription would increase promiscuity towards sexual behaviour and result in unsafe sex along with its’ repeated use. Hence, training and proper counselling strategies should be afoot to refine the delivery of service by CPPs.


Background
Unintended pregnancy is a pregnancy that usually includes either unwanted or mistimed pregnancy which occurs due to failure to choose an effective contraception method or its' incorrect and inconsistent use [1,2]. Such pregnancies can place an economic burden on the nation as a whole and can put the women at reproductive health risk. Abortion can be a possible sequel which further can lead to infertility and maternal death [3,4]. Globally, it is estimated that 22% of such unintended pregnancies are terminated with unsafe techniques, and 18% end up in unplanned births thus imposing an economic burden on the health system [2,5]. According to the Nepal Demographic and Health Survey (NDHS) 2011, more than one in five births (21%) is unwanted and one in seven (14%) is mistimed [6] and 58% of women succumb to complications of clandestine abortion [7]. Early age at the time of menarche and late marriage are the underlying factors contributing to premarital sex and unintended pregnancies [8]. Ten to 20 % of adolescents in Nepal participate in pre-marital sex. Out of them, only 9% utilize a technique for contraception [9].
Emergency contraception (EC) is any method of contraception that women can use after unprotected sexual intercourse and before the potential time of implantation [10]. Emergency contraceptive pills (ECPs) are safe and effective drugs used to prevent the risk of pregnancy after unprotected or inadequately protected sexual intercourse [11]. ECP was first introduced in Nepal through the social marketing program held in 2004 [12]. Nevertheless, various barriers exist that keep young women from having easy access to ECPs. These barriers incorporate healthcare provider's knowledge and perception, distribution system for ECPs, legal and social barriers and cost [13].
Community pharmacies stand as an essential access point for obtaining ECPs as well as serve as a salient venue offering counselling services to the public and the first place to approach for drugs owing to its' flexible time of operation [14][15][16]. In a woman's access to ECPs, community pharmacies play a pivotal role, which is further influenced by the community pharmacy practitioners (CPPs) knowledge and attitude [14,15]. Appropriate knowledge and a positive attitude are crucial elements that enable the CPPs to provide comprehensive counselling and create awareness regarding ECP and maximize its rational use, thus preventing unwanted risk [17,18]. CPPs denote not only pharmacists who have a degree of Bachelor of Pharmacy, Diploma of Pharmacy, or Masters of Pharmacy but also other groups of individuals who have obtained a license from a short orientation training course before the development of pharmacy education in Nepal. Apart from them, Community Medicine Assistant (CMA) and health assistant also dispense medication; however, they are not considered as CPPs. In Nepal, three levels of pharmacy workers dispense medication which includes: Pharmacists who have acquired a bachelor's degree in pharmacy (BPharm) after twelve years of schooling; Assistant Pharmacists who have completed Diploma in Pharmacy (DPharm) course after ten years of school; and "professionals" who only completed a short orientation training program. However, only pharmacists and assistant pharmacists can register with the Nepal Pharmacy Council [16,19] and become eligible to run community pharmacy. In 1980, the 48-h orientation training course was introduced and at that point offered to people involved in the pharmaceutical business [20]. Over time, the span of the orientation course was stretched out to 72 h. Regardless of development in this period, the training course was still found to be deficient. It was recommended to discontinue the short orientation course and support the individuals linked with the diploma course in pharmacy [21]. This training has not been led throughout the previous twelve years. All three categories have equal rights to provide pharmaceutical services and to run community pharmacies. In context of Nepal, most of the registered pharmacies in Nepal are run by "professionals" [20][21][22]. Certain paramedical personnel, typically health assistants (HAs), and community medicine assistants (CMAs) also manage community pharmacies in Nepal. HAs and CMA have completed basic medical training for 36 months and 18 months, respectively, who have completed 10 years of schooling [21]. However, HAs and CMA are not allowed to register a community pharmacy in Department of Drug Adminstartion (DDA).
To the best of our knowledge and search, no previous published researches are investigating the knowledge, attitude and practice (KAP) of CPPs of Nepal on ECP However, the level of knowledge, attitude and practices of emergency contraceptives among college students and other female users have been studied [23,24]. With this background, this study was thus initiated considering the lack of information regarding KAP of CPPs towards ECPs in Kathmandu Valley.

Study design and study site
A cross-sectional study carried out at community pharmacies located in Kathmandu valley from May 2019 to October 2019. Kathmandu valley consists of 3 districts; Kathmandu, Lalitpur, and Bhaktapur, of Province Bagmati of which the total population is 2,472,071 and the total area are 902.61 km 2 (348.50 sq. mi). Kathmandu is the capital city, and the three districts are located in the central part of Nepal. The current study was restricted to these areas because urban agglomeration of these 3 districts covers a large population due to the facilities such as employment opportunities, health and transportation facilities and so on. Besides that, these three districts lie in the Central Development Region and Province Bagmati of Nepal. In 2014, the unintended pregnancy rate for Nepal was 68 per 1000 women of reproductive age [25] and ranged from 47 per 1000 women in the Far-Western region to 85 per 1000 in the Central development region [25].
Moreover, abortion rates in Nepal in 2014 ranged from 21 per 1000 reproductive-age women in the Far-Western development region to 59 per 1000 in the more urban Central development region, which includes the capital city of Kathmandu, Lalitpur and Bhaktapur [25]. Several factors may describe the reason for the higher unintended pregnancy rate and abortion rate in the Central region of Nepal [25]. In comparison to other developing regions, the couples those in or near the capital are intended to have smaller families due to various reasons such as higher expenses, busy life, and so forth. Due to the easy accessibility of abortion procedures in urban areas, there is the likelihood of pre-marital sex which results in unintended pregnancy and abortion [25]. Hence, to limit such incidences, there should be knowledge and awareness about ECPs.

Study population
The study population included the community pharmacies listed in the Department of Drug Administration (DDA) directory. According to the DDA directory, the total registered allopathic community pharmacy of whole Nepal was 12,865 and the total registered allopathic community pharmacy in the three districts of Kathmandu Valley was 2871 till November 2018.

Inclusion criteria
Community pharmacies located at three districts of Kathmandu valley, i.e. Kathmandu, Lalitpur and Bhaktapur. Community pharmacies registered in the Department of Drug Administration (DDA). CPPs working at community pharmacies willing to participate in the study.

Exclusion criteria
CPPs not willing to participate in the study and community pharmacies not registered in DDA. Pharmacies located inside the hospital and the hospital pharmacies.

Sampling method and technique
The sample size was calculated using the list of registered community pharmacies obtained from the DDA directory. The community pharmacies located at Kathmandu, Lalitpur and Bhaktapur districts were used for the sampling frame. The Raosoft sample size calculator was used for calculating the required sample size (i.e. 227 calculated) with a 5% margin of error, 95% confidence interval, and 20% response distribution [26]. Questionnaire was distributed to a random sample of CPPs of community pharmacies by using a convenience sampling method. After that, the sample was stratified by three districts of Kathmandu valley. As per the stratification result, the samples taken from Kathmandu, Lalitpur and Bhaktapur districts were 170, 37 and 20 respectively.

Independent variables
The independent variables included characteristics related to socio-demography and work profile of CPPs. Sociodemographic variables included age, gender, religion and educational status. The work profile included the primary position of CPPs at working place, years of experience, location of the pharmacy, and district of pharmacy.

Outcome variables
The dependent variables included knowledge, attitude and practice (KAP) of CPPs working in the community pharmacy on ECPs. Community pharmacies play a pivotal role in a woman's access to ECPs and the CPPs need to have sufficient knowledge and a positive attitude towards the use of contraceptives to maximize its rational use. Access, use and availability of ECPs are, however, influenced by pharmacy personnel's knowledge and attitudes towards them. Studies have reported that a lack of knowledge and negative attitudes among the pharmacists hinder women's timely access to ECPs [14,15,17,18].
Hence, we chose KAP as the dependent variables, and the independent variables were chosen based on previous similar studies done in other countries to find out the association between the independent and the dependent variables. This study will generate the baseline data on KAP of community pharmacists on ECP, which will further help in developing future interventional studies that will ultimately aid in promoting rational use of ECP.

Data collection tool
A self-administered questionnaire (Additional file 1) was designed after reviewing the previous similar surveys with some modifications [27]. After development of the data collection questionnaire , it was subjected to a review and a validation process. Developed questionnaire was then verified for readability and ease of understanding among 23 CPPs (10% of 227), which were randomly selected CPPs working in different community pharmacies with similar settings to the study site. Face validation of the questionnaire was carried out by colleagues from the pharmacy department and content validation was finalized by discussing the questionnaire to content experts of community pharmacy, pharmacy practice, public health, consumers and statistician within the country. Internal consistency of the questionnaire was measured by calculating Cronbach's alpha value, which was found to be 0.70, which means there are acceptable reliability and consistency between the set of test items. An alpha of 0.70 indicates acceptable reliability and 0.80 or higher indicates good reliability [28]. Except for the adjustment of the questionnaire such as rephrasing sentence, grammar, wording and language, the outcomes of the pre-testing was excluded in the final data analysis.
The final version of the data collection questionnaire included four sections. Section 1 comprised of 8 items questionnaire that explored demographic and related information of CPPs: age, gender, religion, education(degree), primary position at workplace, years of working experience, location of pharmacy, and district in which pharmacy is situated. Section 2 of the questionnaire comprised of 14 items, which was designed to evaluate the practice of CPPs on ECPs. Section 3 comprised of 10 items designed to evaluate knowledge of CPPs on ECPs and section 4 included 13 items designed to evaluate attitude of CPPs on ECPs.
The questionnaire consisted of both closed-ended and open-ended questions. The questionnaire was handdelivered and was framed in the English language.

Process of data collection
First of all, CPPs were approached by the pharmacist from the study team, and the objectives of the study were explained. Written informed consent from the respondents was taken and was assured that their participation in this study was voluntary, and their confidentiality would be maintained. The final data collection tool (obtained after the pilot study) was distributed to CPPs working at different community pharmacies at Kathmandu valley. Thirty to forty-five minutes given to respondents for completing and returning the questionnaire required to CPPs.

Scoring system
To assess the dispensing practice and knowledge of the respondents on ECP, selected variables were used and, then the correct answer was coded as 'yes' which means '1' and an incorrect answer was coded as 'No' which means '0'. The cumulative and mean scores were calculated. Respondents who scored above the mean score were defined as having "good practice" and good knowledge, and those who scored below the mean score were defined as having "poor practice" and "poor knowledge". The attitude of respondents was calculated with the help of a five-point Likert scale ranging from; 'Strongly agree,' i.e. '1' to 'Strongly disagree' i.e. '5'. Based on the cumulative score, the respondents who scored below the mean score were defined as having a "positive attitude", and those who scored above the mean score were defined as having a "negative attitude".

Data management and analysis
Data processing and analysis were done by using statistical package for social sciences (SPSS) version 18 (SPSS Inc., Chicago, IL, USA). Data were analyzed for descriptive and inferential statistics. Descriptive analysis was performed using frequencies and percentages and was presented in the form of text, figures, and tables. The Pearson Chi-square test (X 2 ) was used to determine associations among categorical variables. A p-value < 0.05 was considered as statistically significant. Crude, as well as Adjusted odds ratios and 95% confidence intervals, was derived from bivariate and multivariate logistic regression models respectively to identify determinant variables associated with dispensing practices, knowledge, and attitudes; crude and adjusted odds ratios were considered significant at p ≤ 0.05. Table 1 shows the socio-demographic information of the CPPs working at the community pharmacies. A total of 227 CPPs participated in the study. Majority of the respondents were of the age group 20-29 (47.1%). Among the total respondents, 57.7% were male, and most of them had a Diploma in Pharmacy (DPharm) degree. The highest number of respondents had a work experience of fewer than 5 years and a median length of work experience in the current study was found to be 5-10 years. Table 2 outlines the dispensing practice of CPPs. The overall dispensing practice of ECP in community pharmacies was found to be good. Out of 227 CPPs, 99.1% reported that they had dispensed ECP. Majority (67%) of CPPs stated that on average they dispensed 1-10 range of ECPs daily.

Association of demographic characteristics and dispensing practice
Chi-square test was used to determine the association between socio-demographic characteristics and dispensing practice, as presented in Table 3. There was a significant association of age, primary position, years of experience, location of community pharmacy and district in which the community pharmacy is situated with dispensing practice (p < 0.05) whereas gender, religion, and level of education were not significantly associated with dispensing practice (p > 0.05). Table 4 depicts the knowledge of respondents towards ECP. Approximately 149 (65.6%) had good knowledge, while 78 (34.4%) had poor knowledge of ECPs. The fact that ECPs work by preventing or delaying ovulation was agreed upon by the majority of the respondents (63.4%). When asked about how many times in the past years they had received information about ECP, only a lower percentage of the CPPs (21.1%) responded: "yes, more than once". Majority (81.5%) believed that ECPs should be taken after unprotected sexual intercourse to be clinically effective. Quite interestingly, a majority of the respondents presumed that "Levonorgestrel" is the main chemical constituents of ECP (76.7%). When asked about the dose of ECP, the majority (68.3%) of the respondents reported the dose as "Single dose of 1.5 mg or 2 doses of 0.75mg". Furthermore, 63.4% incorrectly stated that ECP could harm a developing fetus. A majority of the respondents (75.3%) correctly believed that ECP does not offer protection against sexually transmitted infections (STI). Majority of the CPPs (67.4%) responded that they know about the side effects of ECP.

Association of demographic characteristics and knowledge level
A significant association was found between age, degree, primary position, years of experience, location of community pharmacy, district of community pharmacy and the respondents' knowledge level (p < 0.05)whereas no significant association was observed between gender, religion and the respondents' level of knowledge (p > 0.05) ( Table 5). Table 6 shows the attitude of respondents towards ECP. Majority of the respondents had a positive attitude towards ECP (93.4%). More than half of the study respondents believed that ECPs are safe to use (53.4%). Only 25.6% reported that adolescents (teenagers) should be given easy access to ECPs and 34% agreed on the recommendation of ECP use. Regarding the medicalization of ECP, 36.5% of the respondents presumed that the government of all countries should medicalize ECPs. The majority of the respondents approved that all of the sexually active women should be aware of ECP (91.6%). Similarly, a large percentage believed that routine information about ECP should be included in contraceptive counselling (87.7%). Regarding information and formal training of ECP, a maximal percentage favoured that information regarding ECP should also be included in sex education in school (94.3%). In comparison, 86.4% of respondents believed that formal training is needed to enable the CPPs to dispense ECP appropriately. Also, the majority of the respondents believed that ECP without prescription would promote unsafe sex (65.2%).

Association of demographic characteristics and attitude level of the respondents
No significant association was found between the demographic variables and their level of attitude (p < 0.05) ( Table 7).
Association of dispensing practice of respondents with their level of knowledge and attitude A significant association was obtained between the dispensing practice of respondents and their knowledge level (p = 0.000), whereas no significant association was found between the dispensing practice of respondents and their level of attitude (p = 0.578). The multivariate analysis illustrated that the respondents having good knowledge were 11.86 times more likely to have good practice compared to those having poor knowledge of ECP [AOR = 11.86, 95% CI (5.821-24.190)] ( Table 8).
Association of the level of attitude of respondents with their level of knowledge Table 9 shows an association of the level of attitude of respondents with their level of knowledge. No significant association was observed between the level of attitude of the respondents and their knowledge level (p = 0.109).  -0.629)]. Similarly, respondents whose community pharmacy is located at Lalitpur and Bhaktapur districts were less likely to know about ECP compared to those whose community pharmacy is situated at Kathmandu district [AOR =  (Table 10).

b) Determinant factors related to respondents Dispensing Practice of ECP
Age groups, years of experience, location of community pharmacy and district of community pharmacy were the variables that met the inclusion criteria in multivariate logistic regression analysis as per the results obtained from the bivariate analysis. After adjusting the possible confounder variables in multivariate analysis, respondents whose community pharmacy is situated at Lalitpur and Bhaktapur districts were less likely to have practised on ECP compared to those whose community pharmacy is situated at Kathmandu district. [AOR = 0.062 95% CI (0.024-0.164), 0.069 (0.021-0.230)] respectively as shown in Table 10.

Discussion
The current study was undertaken to assess the knowledge, attitude, and practice (KAP) of ECP and their associated factors among CPPs of Kathmandu valley. In this study more than half of the respondents were male (57.7%) which was similar to the study conducted in Gondar Town, Northwestern Ethiopia (60%) [29] and Nigeria (57.3%) [18].

Practice of CPPs on ECP
A vast majority of the respondents in the current study had ever dispensed ECP and the majority of the product was sold on patient requests without a prescription which was similar to the study carried out in Managua, Nicaragua and Ibadan and Lagos Metropolis, Nigeria [18]. Most of the CPPs in our study were willing to dispense ECP to men seeking ECPs for their partner (77.5%) which was similar to the study conducted in Nicaragua (83.9%) [18]. This might be reflective of the fact that men's participation and support in the use of contraceptive is valued by pharmacy personnel. Provision of counselling to women seeking emergency contraceptives was reported to be an essential facet of dispensing by 92.1% of respondents, yet only, 70% of the respondents did counsel all the users while dispensing ECP. This statistic was somewhat lower than the studies carried out in Turkey and Ethiopia in which counselling was offered as an essential service by almost all of the pharmacists [29,30]. This difference may be due to lack of private counselling areas in the community pharmacies of Kathmandu Valley, which was reportedly present in 75% of the pharmacies in Turkey. Furthermore, 53.7, 26.4 and 33.5% did not offer counselling on the mechanism of action of ECP, the timing of ECP intake and its' side effects respectively which are essential for a woman to get acquainted with, to make choices concerning their reproductive health [31].
Although 86.4% of the respondents agreed to the need of formal training, only 35.3% of the respondents in our study had received any kind of formal training/ education on dispensing of ECP which was consistent with the study conducted in Gondar Town, Northwestern Ethiopia (38.3%) but was lower than the findings by Ehrle et al., and Belachew et al., in which 50% of respondents had received information about the method in the past year [27,29]. This contrast may be due to the difference in the training facilities in two settings and the lack of awareness of the place and time where the training is conducted. The government and the different pharmacy organizations should take advantage of the enthusiasm of the CPPs and design and run educational campaigns that can aid in mainstreaming ECP use by improving their existing KAP. In the same vein, Kishore et al. pointed out a significant improvement in knowledge, attitude and dispensing practice of the providers after attending training programs on ECP (p < 0.05) [32].
In this study, 30.8% of respondents felt that ECPs should be categorized under OTC drugs. This result was slightly lower than the study conducted in Jamaica and Barbados, in which 50.3 and 40.3% of respondents voted for the provision of making it available without a prescription, respectively [33]. This difference may be due to the unsubstantiated belief of the CPPs that ECP without prescription would increase promiscuity towards sexual behaviour and result in unsafe sex along with repeated use of ECP. Therefore, positive aspects of ECPs should be highlighted during training with proper educational messages.

Knowledge of the respondents towards ECP
This study illustrated that about 149 (65.6%) of the respondents possessed a good knowledge of ECP. The result was slightly lower than the study conducted in New Mexico, in which the pharmacists had overall knowledge scores of 71.2 ± 11.3 [34]. Regarding the mechanism of action of ECP, 63.4% gave the correct answer which was consistent with the study done in Managua, Nicaragua in which more than half of the respondents (59%) knew how the ECPs worked [27]. However, 11.6% of participants believed that ECP could induce abortion. Quite surprisingly, despite this belief of ECP acting as an abortifacient, they were selling it without a prescription which might reflect the financial pressure on the CPPs to earn their livelihood [27]. Majority (81.5%) of the respondents reported that ECP should be taken after unprotected sexual intercourse to be clinically useful which is in agreement with the findings of research conducted * indicates statistically significant at p-value less than 0.05 on Nicaraguan pharmacists in which this awareness was observed in 79% of the respondents [27,34]. An unexpected response was obtained from 16.3% of the respondents who recommended the use of ECP before and during intercourse. Most of the respondents reported that ECP should be taken within 72 h after unprotected sexual intercourse, but very few knew that it was also useful if taken within 120 h of unprotected sexual intercourse. This corroborates the findings of studies conducted in Jamaica and Barbados and South Africa [33,35]. Inadequate knowledge in such important affairs might have significant undesirable effects. For instance, a woman approaching the community pharmacy after 72 h of unprotected intercourse might not receive the legal service and may have to opt for other measures of terminating the resulting pregnancy. A study conducted in South-Eastern Hungary which reported that nearly all (97%) pharmacists were aware of the active agent of the ECP reflects a higher statistic than our study where only 76.7% of the respondents voted for levonorgestrel as the active constituents of ECP. Despite WHO assertion, 57% of respondents in Managua, Nicaragua, and 68% in New Mexico incorrectly believed that ECP could cause harm to the developing fetus versus 63.4% in the current study. Side effects mentioned by the CPPs in this study were no different from those stated by another study [31], except for the mentioning of infertility and cancer as the probable side effects by a few respondents. Such responses might create fear among the women, thus hindering the timely consumption of the ECP and resulting in unwanted pregnancies and the consequent sequel.
In the current study, 67.4% of the respondents knew about the side effects of ECP and 68.3% reported the right dosing, which was lower than the study carried out in South Africa. The reason for this result may be due to the differences in educational levels. Only pharmacists were interviewed in the study conducted in South Africa, whereas all the CPPs irrespective of their degree or level of education were enrolled in the current study. This may be the reason that the present study may have lower knowledge regarding the side effects and dosing schedule of ECP compared to the study conducted in South Africa [35]. A right proportion of the respondents (75.3%) correctly believed that ECP does not offer protection against sexually transmitted infections (STI), underpinning the findings of Szucs et al. [31]. However, 5.3% still believed that ECP is protective against STI. Such a false notion can put the women at significant sexual health risk [31].
A well-informed patient and a well-informed pharmacist are the foundation of a reliable healthcare system. Pharmacists being the information conveyers to the patients thus bear a considerable responsibility to remain adequately prepared and knowledgeable regarding the various contraceptive methods including the ECP to ensure that a woman gets an excellent sexual and reproductive health service. Furthermore, researches conducted among higher secondary students and women of the reproductive age group in Nepal depict the existence of limited knowledge regarding the use of emergency contraceptives [23,24]. This is indicative of the dire need for educational intervention and training for the CPPs on ECP as they are the first point of contact for customers seeking ECP after unprotected intercourse and thus play an essential role in maintaining good sexual and reproductive health in women [31].

Attitude of the respondents towards ECP
The current study found that a large majority of the respondents (93.4%) have a positive attitude. More than half of the study respondents agreed that ECPs are safe to use (53.4%), which is similar to the study conducted in Ethiopia [29]. Similarly, a large proportion of respondents agreed that routine information about ECP should be included in contraceptive counselling (87.7%) as well as all sexually active women should be aware of ECP (91.6%). These results were higher in comparison to the study conducted in Ethiopia with a percentage of (75%) and (58.3%) respectively [36] and similar to the study conducted in Turkey with a percentage of (85%) and (92%) respectively [28]. Despite this positive apprehension, a total of 53.4% of respondents disagreed that adolescents should be given easy access to ECPs which was in agreement with research conducted in South Africa in which a significant number of pharmacists doubt their appropriateness for women younger than 18 years of age [33]. Early age marriage between 15 to 19 years is common in Nepal due to illiteracy and poverty that has increased the incidence of adolescent pregnancies which is further escalated by the social pressure of giving birth to a son [37]. Adolescent engagement in pre-marital sex has been reported by several studies done in Nepal, which in many cases has resulted in unwanted pregnancies and subsequent medical or surgical terminations [24,25]. Amidst such condition, denial of ECP access to minors or imposing age-based restriction by CPPs who are the first point of approach for adolescent females for ECP might surge the occurrence of unintended pregnancies putting them into a reproductive health risk. Regarding the medicalization of ECP, 36.5% of the respondents agreed that the government of all countries should medicalize ECPs while more than two-thirds (68.3%) of the study respondents of Ethiopia and Sweden favoured de-medicalization of ECPs and proposed it to be OTC drug [29,35]. This difference in result may be due to the concern of CPPs of Kathmandu valley regarding unwise use of ECP by the adolescents and the risk of an increase in unsafe sex, which is evident from the proportion (65.2%) of CPPs consenting to the statement that ECP without prescription will promote unsafe sex. This finding was in line with the study conducted in South Africa in which the majority stated that the use of pills promoted promiscuity, repeat use and increased risk of contracting human immunodeficiency virus (HIV) and other STIs [35], but is contrary to the findings of Apikoglu-Rabus et al. where 52% of the pharmacists believed that teenagers are fully capable of taking responsibility for ECP use [30]. Medicalization of ECP might pose a huge challenge for women seeking emergency contraception due to the obligation of obtaining an appointment from the doctor within the time-frame of 72 h. Hence, the community pharmacy serves as an important facility that offers prompt access to most women seeking ECP within the crucial time-frame, thus safeguarding them from the risk of unintended pregnancies or abortions [30]. This ultimately depends on the CPPs' attitude and acceptance regarding the use of emergency contraceptives [29]. Majority of the respondents (94.3%) believed that ECP should be a part of comprehensive sexuality education in schools. This data was higher than the study carried out in Turkey, in which only 73.1% of the respondents agreed with the above statement [30]. A course focused on emergency contraceptives and its' public health benefits can be incorporated in the pharmacy education that could enable pharmacists to offer adequate counseling services to women seeking emergency contraception.

Determinant factors associated with knowledge and practice of ECP
Age, primary position, years of experience, location of community pharmacy and district of community pharmacy were found to be the determinant factors statistically associated with dispensing practice. Age and years of experience shared a positive relationship with dispensing practice in bivariate analysis and the district in which community pharmacy was situated was found to be a statistically significant factor for dispensing practice in the multivariate analysis. There was no significant association of gender, religion, and level of education with dispensing practice. In the study conducted in Delhi, India, age, years of experience were found to have statistical significance with the dispensing practice of ECP, which was consistent with the current study [32]. Years of experience were found to have a positive relation with dispensing practice in the study conducted in Ethiopia, which was in agreement with the current study [29]. Age, primary position, degree, years of experience, location of community pharmacy and district of community pharmacy was found to be statistically significant factors for the level of knowledge. In bivariate analysis, age and years of experience were found to show positive relation with the level of knowledge. In multivariate analysis, age showed a positive relationship with the level of knowledge of CPPs about ECP whereas years of experience and location in which community pharmacy was situated were found to share negative relation with their level of knowledge. There was no significant association between gender and religion with their level of knowledge. The result is similar to the study conducted in South Dakota state of USA in which years of experience were found to be statistically significant with the level of knowledge [38]. The extent of knowledge of respondents towards ECP was a statistically significant factor for the good dispensing practice of respondents and had a positive relation [AOR = 11.86, 95% CI (5.821-24.190)]. This result was found to be consistent with the studies conducted in India [32] and Florida state of USA [39] in which the dispensing practice of providers were found to be positively correlated with their knowledge (p < 0.05).
Even though the majority of the respondents possessed a positive attitude, dispensing practice and knowledge level of the respondents towards ECP did not show any significant association with their level of attitude. However, this result was not consistent with the study done in India [32]. This contradiction may be accounted for the possibility that some of the respondents may have filled in responses they perceived to be desirable rather than their actual perceptions.
However, a positive attitude without adequate knowledge does not correspond with the level of dispensing practice. It is the knowledge that holds a more significant role in decision making in dispensing practice [32].

Limitations
This study, however, is not without limitations. The study participants were from three districts of Kathmandu valley, i.e. Kathmandu, Bhaktapur and Lalitpur and the findings of this study may not be generalizable to CPPs from other districts of Nepal. Another limitation was the use of convenience sampling method due to which the findings may not be representative of the target population of Nepal. Some of the respondents might have given the answers which the interviewer wants to hear rather than their actual performance and behaviour in day to day practice. Besides KAP, barriers such as cultural and religious beliefs towards contraception may exist, which has not been addressed by this study. This is a call for further study to observe other variables such as culture and religion using the KAP approach.

Recommendations
The outcomes of this study are presumed to aid in assessing the current level of KAP of the CPPs towards ECP that demands refinement. Educational campaigns focusing the pharmacists and other healthcare professionals are imperative to enhance the knowledge, improve the dispensing practice and exterminate the misbelief of the CPPs towards ECP, which will help to loosen the existing reservation notions. Furthermore, the curricula relating to reproductive medicines and contraceptives should be strong as finding from this study showed that the significant source of information of most of the respondents was textbooks.

Conclusion
Emergency contraceptive pills (ECPs) are a widely used contraceptive measure in Nepal where the incidence of unwanted pregnancies in on the rise. Community pharmacies are an essential access point for obtaining ECP because of its' flexible time of operation and its' closer proximity than the other healthcare facilities, and they play a significant role in providing ECP and promoting its' rational use. The findings conclude that knowledge is a crucial element to improve the dispensing practice of ECP. Majority of the respondents had good knowledge and good practice on dispensing ECP and possessed a positive attitude towards the use of ECP. However, some of the respondents felt that ECP should not be categorized under OTC drugs and agreed that ECP without prescription would promote unsafe sex and the CPPs lacked specific information about ECP such as side effects, dosing schedule, time frames. This could affect the information given during counselling by the CPPs to their users. A lack of knowledge can result in the delivery of misinformation to ECP users and can result in inappropriate use of the drug, thus leading to unwanted pregnancies. Hence, educational intervention and awareness programs should be designed to educate pharmacy personnel on emergency contraception methods that are essential for providing excellent sexual and reproductive health services to women.