A Narrative Inquiry of Critical Events Supporting Professional Identity Formation in Introductory Pharmacy Practice Experiences.

OBJECTIVE: Professional identity formation (PIF) is the process of internalizing a profession's core values and beliefs so that one begins to think, act, and feel like a member of that profession. PIF occurs over an individual's professional socialization in stages, precipitated by critical moments or experiences. The purpose of this study was to answer the following: (1) What are the critical events for pharmacy student PIF in introductory pharmacy practice experiences?; and (2) How do these events support or challenge PIF? METHODS: This study used critical event narrative inquiry methodology. A critical event is an experience that creates a change in understanding and affects professional performance. Semistructured interviews were conducted with pharmacy students who completed introductory pharmacy practice experience rotations in community (first year) and hospital (second year) settings. Interviews were coded and analyzed using narrative analysis. RESULTS: Twelve first-year and 10 second-year students participated in this study. Narratives revealed that common experiential education experiences resulted in a deeper understanding of core role elements (ie, professional autonomy, responsibility, interprofessional collaboration, and patient-centered care), leading to changes in agency, knowledge, and anticipated future behaviors. While first-year participants' narratives mainly focused on understanding pharmacist roles ("what"), second-year participants focused on understanding the process to fulfill those roles ("how to"). Emotions, assuming responsibility, external validation, and preceptor guidance supported these events. CONCLUSION: Critical events in introductory pharmacy practice experiences affect and shape pharmacy students' PIF. These events are relevant to pharmacy education because these experiences can result in changes in knowledge, agency, or future behaviors for students.

Indicators, influences, and changes in professional identity formation in early experiential learning in community pharmacy.

BACKGROUND: Experiential education is a key area in the pharmacy curriculum that professional identity formation (PIF) occurs. However, little is known about PIF influences and supports for pharmacy students during early experiential placements. The study aimed to explore pharmacy student PIF in an early experiential rotation in community pharmacy using reflective writing. EDUCATIONAL ACTIVITY AND SETTING: First-year pharmacy students completed written reflections describing their professional identity and influencing experiences, before and after a four-week community introductory pharmacy practice experience. Qualitative content analysis of the written reflections was performed using three analytical approaches: (1) deductive coding based on professional identity indicators; (2) inductive coding to identify influences; and (3) inductive coding of field notes to identify changes between pre- and post-written reflections. FINDINGS: Twelve students participated. All participants described discrete professional attributes and behaviors and valuing a patient-centered approach as part of their professional identity. Participants reported observation of pharmacists, the curriculum, and previous work experience influenced PIF prior to the experiential rotation. A strong influencer of PIF during the rotation was observation of pharmacist preceptors, whereas participants' own experiences were described less often. Changes in professional identity among participants were subtle and categorized as affirmation, acquisition, and growth. SUMMARY: Pharmacy students' markers and influencers of PIF should be considered when developing curricular experiences and preceptor development that support PIF. The use of professional identity indicators and analysis of written reflections as a method to uncover PIF, shows promise and warrants further investigation.

Increased self-reported pharmacist prescribing during the COVID-19 pandemic: Using the Theoretical Domains Framework to identify barriers and facilitators to prescribing.

BACKGROUND: Community pharmacists are positioned to improve access to medications through their ever-expanding role as prescribers, with this role becoming more pronounced during the COVID-19 pandemic. OBJECTIVES: Our research aimed to determine the extent of self-reported pharmacist prescribing pre-COVID-19 and during the COVID-19 pandemic, to identify barriers and facilitators to pharmacist prescribing, and to explore the relationship between these factors and self-reported prescribing activity. METHODS: A questionnaire based on the Theoretical Domains Framework (TDFv2) assessing self-reported prescribing was electronically distributed to all direct patient care pharmacists in NS (N = 1338) in July 2020. Wilcoxon signed-rank tests were used to examine temporal differences in self-reported prescribing activity. TDFv2 responses were descriptively reported as positive (agree/strongly agree), neutral (uncertain), and negative (strongly disagree/disagree) based on the 5-point Likert scale assessing barriers and facilitators to prescribing from March 2020 onward (i.e., 'during' COVID-19). Simple logistic regression was used to measure the relationship between TDFv2 domain responses and self-reported prescribing activity. RESULTS: A total of 190 pharmacists (14.2%) completed the survey. Over 98% of respondents reported prescribing at least once per month in any of the approved prescribing categories, with renewals being the most common activity reported. Since the pandemic, activity in several categories of prescribing significantly increased, including diagnosis supported by protocol (29.0% vs. 58.9%, p < 0.01), minor and common ailments (25.3% vs 34.7%, p = 0.03), preventative medicine (22.1% vs. 33.2%, p < 0.01). Amongst the TDFv2 domains, Beliefs about Consequences domain had the largest influence on prescribing activity (OR = 3.13, 95% CI 1.41-6.97, p < 0.01), with Social Influences (OR = 2.85, 95% CI 1.42-5.70, p < 0.01) being the next most influential. CONCLUSION: Self-reported prescribing by direct patient care community pharmacists in Nova Scotia increased during the COVID-19 pandemic, particularly for government-funded services. Key barriers to address, and facilitators to support pharmacist prescribing were identified and can be used to inform future interventions.

Using the behavior change wheel to link published deprescribing strategies to identified local primary healthcare needs.

BACKGROUND: Polypharmacy is a major global problem. Evidence in primary care shows deprescribing can be beneficial. Behaviour change theories such as the Theoretical Domains Framework (TDF) and the Behaviour Change Wheel (BCW) can help develop successful implementation of deprescribing initiatives. OBJECTIVES: To link locally identified deprescribing influencers with components of successfully trialed deprescribing strategies, with the aim of informing the development of local deprescribing initiatives. METHODS: Two background studies were completed. A qualitative study of interviews and focus groups identified influencers of deprescribing from local primary care physicians, nurse practitioners, and pharmacists. Transcripts were coded using the TDF and mapped to the Intervention Functions of the BCW. A scoping review identified studies that investigated primary care deprescribing strategies, which were mapped to the BCW Intervention Functions and the Behaviour Change Techniques (BCTs). For this analysis, six main TDF domains from the qualitative study were linked to the BCTs identified in the scoping review through the Intervention Functions of the BCW. RESULTS: Within the BCW component Capability, one TDF domain identified in the qualitative study, Memory, Attention and Decision Process, was linked to strategies like academic detailing from the scoping review. For the Opportunity component, two TDF domains, Social Influences and Environmental Context and Resources, were linked to strategies such as pharmacist medication reviews, providing patient information leaflets, and evidence-based deprescribing tools. For the Motivation component, three TDF domains, Social/Professional Role and Identity, Intentions, and Beliefs about Consequences, were linked to strategies such as sending deprescribing information to prescribers, using tools to identify eligible patients, and having patients report adverse events of medications. CONCLUSIONS: This analysis identified deprescribing strategies that can be used to address influencers related to behaviour change from the perspective of primary care providers, and to assist with future deprescribing initiative development and implementation in the local context.

Deprescribing interventions in primary health care mapped to the Behaviour Change Wheel: A scoping review.

BACKGROUND: Polypharmacy and inappropriate medication use are an increasing concern. Deprescribing may improve medication use through planned and supervised dose reduction or stopping of medications. As most medication management occurs in primary health care, which is generally described as the first point of access for day-to-day care, deprescribing in primary health care is the focus on this review. OBJECTIVE: This scoping review aimed to identify and characterize strategies for deprescribing in primary health care and map the strategies to the Behaviour Change Wheel (BCW). METHODS: A scoping review was conducted that involved searches of six databases (2002-2018) and reference lists of relevant systematic reviews and included studies. Studies that described and evaluated deprescribing strategies in primary health care were eligible. Two independent reviewers screened articles and completed data charting with charting verified by a third. Deprescribing strategies were mapped to the intervention functions of the BCW and linked to specific Behaviour Change Techniques (BCT). RESULTS: Searches yielded 6871 citations of which 43 were included. Nineteen studies were randomized, 24 were non-randomized. Studies evaluated deprescribing in terms of medication changes, feasibility, and prescriber/patient perspectives. Deprescribing strategies involved various professionals (physicians, pharmacists, nurses), as well as patients and were generally multifaceted. A wide range of intervention functions were identified, with 41 BCTs mapped to Environmental restructuring, 38 BCTs mapped to Enablement, and 34 BCTs mapped to Persuasion. CONCLUSIONS: Deprescribing strategies in primary health care have used a variety of BCTs to address individual professionals (e.g. education) as well as strategies that addressed the practice setting, including support from additional team members (e.g. pharmacists, nurses and patients). Further research is warranted to determine comparative effectiveness of different BCTs, which can help facilitate implementation of deprescribing strategies, thereby reducing polypharmacy, in primary health care.

A comparative analysis of recommendations provided by clinical practice guideline for use of natural health products in the treatment of menopause-related vasomotor symptoms.

OBJECTIVES: To systematically review Clinical Practice Guidelines (CPGs) for the management of menopause-related vasomotor symptoms (VMS) to 1) identify those that include Natural Health Products (NHPs); 2) identify which NHPs were included and the evidence supporting the recommendation for the place in therapy; and 3) compare methodological quality of the CPGs. METHODS: PubMed, EMBASE, Web of Science, BMJ Best Practice, DynaMed Plus and websites of gynecological and menopausal societies were searched (Jan 2000-Nov 2018). Records were screened to identify CPGs that were published in English, since 2000 and were for use in North America. CPGs were reviewed for inclusion of NHPs. Data regarding NHPs (evidence, recommendation) were extracted and analyzed. CPGs were critically appraised using the AGREE II tool. RESULTS: Five of six CPGs that met general inclusion criteria included NHPs. Black cohosh, isoflavones, soy food/extracts and phytoestrogens were included in all five CPGs. Comparative analysis of recommendations and level of supporting evidence revealed differences. All CPGs included recommendations regarding the use of NHPs in general, although recommendations differed. Four of five CPGs made recommendations for unique NHPs, however, recommendations differed. Using the AGREE II tool, CPGs scored well on domains for purpose and clarity. Lack of detailed description of methodology and author expertise affected scores in other domains. CONCLUSION: Five CPGs included general recommendations for the role of NHPs in treating VMS, with recommendations ranging from use with caution to not recommended. There were inconsistencies among CPGs regarding NHPs included and what evidence was used in making recommendations.

Influencers on deprescribing practice of primary healthcare providers in Nova Scotia: An examination using behavior change frameworks.

Background: Deprescribing is a complex process requiring consideration of behavior change theory to improve implementation and uptake. Aim: The aim of this study was to describe the knowledge, attitudes, beliefs, and behaviors that influence deprescribing for primary healthcare providers (family physicians, nurse practitioners (NPs), and pharmacists) within Nova Scotia using the Theoretical Domains Framework version 2 (TDF(v2)) and the Behavior Change Wheel. Methods: Interviews and focus groups were completed with primary care providers (physicians, NPs, and pharmacists) in Nova Scotia, Canada. Coding was completed using the TDF(v2) to identify the key influencers. Subdomain themes were also identified for the main TDF(v2) domains and results were then linked to the Behavior Change Wheel-Capability, Opportunity, and Motivation components. Results: Participants identified key influencers for deprescribing including areas related to Opportunity, within TDF(v2) domain Social Influences, such as patients and other healthcare providers, as well as Physical barriers (TDF(v2) domain Environmental Context and Resources), such as lack of time and reimbursement. Conclusion: Our results suggest that a systematic approach to deprescribing in primary care should be supported by opportunities for patient and healthcare provider collaborations, as well as practice and system level enhancements to support sustainability of deprescribing practices.

A scoping review of community pharmacists and patients at risk of suicide.

BACKGROUND: Medications are commonly used in suicide attempts. Pharmacists are inextricably linked to medications and may have roles in helping those at risk of suicide. We conducted a scoping review to characterize the existing literature and make recommendations about future research. METHODS: We used a 6-step approach based on an existing scoping review methodological framework, including identifying the research question; identifying relevant studies and other literature; study and literature selection; data charting; collating, summarizing and reporting results; and dissemination of results. We searched electronic databases, various grey literature sources and mobile app stores. RESULTS: Thirty-five articles were included following screening of 1013 database citations. Of 1085 results from grey literature searches, we included 12. Most publications were opinion pieces (n = 22), followed by survey studies (n = 9), primarily assessing pharmacists' knowledge and attitudes. Themes included education and training to impact knowledge and attitudes, gatekeeping of medication supply, collaboration and integration, and role perception. Public perspectives on pharmacists' roles were limited. CONCLUSIONS: Research regarding pharmacists' roles in the care of people at risk for suicide is limited. The areas that have dominated the literature include legal liability, especially with respect to gatekeeping medications, ethical decision making and education and training. Research is needed to determine what methods, outcomes and measures are required to best serve in building the evidence base for policy and practice decisions in this area.

No. 329-Canadian Contraception Consensus Part 4 of 4 Chapter 9: Combined Hormonal Contraception.

OBJECTIVE: To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. OUTCOMES: Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the availability of cited contraceptive methods in Canada. EVIDENCE: Medline and the Cochrane Database were searched for articles in English on subjects related to contraception, sexuality, and sexual health from January 1994 to December 2015 in order to update the Canadian Contraception Consensus published February-April 2004. Relevant Canadian government publications and position papers from appropriate health and family planning organizations were also reviewed. VALUES: The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice are ranked according to the method described in this report. SUMMARY STATEMENTS: RECOMMENDATIONS.

No 329-Consensus canadien sur la contraception (4e partie de 4) : chapitre 9 ­ contraception hormonale combinée.

OBJECTIF: Mettre à la disposition des fournisseurs de soins des lignes directrices concernant le recours à des méthodes contraceptives pour prévenir la grossesse et la promotion d'une sexualité saine. ISSUES: Efficacité globale des méthodes contraceptives citées : évaluation de l'innocuité, des effets indésirables et de la baisse du taux de grossesse; effet des méthodes contraceptives citées sur la santé sexuelle et le bien-être général; disponibilité des méthodes contraceptives citées au Canada. RéSULTATS: Des recherches ont été effectuées dans MEDLINE et la base de données Cochrane afin d'en tirer les articles en anglais publiés entre janvier 1994 et décembre 2015 traitant de sujets liés à la contraception, à la sexualité et à la santé sexuelle, dans le but de mettre à jour le consensus canadien sur la contraception paru de février à avril 2004. Nous avons également passé en revue les publications pertinentes du gouvernement canadien, ainsi que les déclarations de principes issues d'organisations compétentes vouées à la santé et à la planification familiale. VALEURS: La qualité des résultats a été évaluée au moyen des critères décrits par le Groupe d'étude canadien sur les soins de santé préventifs. Les recommandations quant à la pratique sont classées en fonction de la méthode décrite dans le rapport du Groupe. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Canadian Contraception Consensus (Part 3 of 4): Chapter 7--Intrauterine Contraception.

OBJECTIVE: To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. OUTCOMES: Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada. EVIDENCE: Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 7: INTRAUTERINE CONTRACEPTION: SUMMARY STATEMENTS: 1. Intrauterine contraceptives are as effective as permanent contraception methods. (II-2) 2. The use of levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg by patients taking tamoxifen is not associated with recurrence of breast cancer. (I) 3. Intrauterine contraceptives have a number of noncontraceptive benefits. The levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg significantly decreases menstrual blood loss (I) and dysmenorrhea. (II-2) Both the copper intrauterine device and the LNG-IUS significantly decrease the risk of endometrial cancer. (II-2) 4. The risk of uterine perforation decreases with inserter experience but is higher in postpartum and breastfeeding women. (II-2) 5. The risk of pelvic inflammatory disease (PID) is increased slightly in the first month after intrauterine contraceptive (IUC) insertion, but the absolute risk is low. Exposure to sexually transmitted infections and not the IUC itself is responsible for PID occurring after the first month of use. (II-2) 6. Nulliparity is not associated with an increased risk of intrauterine contraceptive expulsion. (II-2) 7. Ectopic pregnancy with an intrauterine contraceptive (IUC) is rare, but when a pregnancy occurs with an IUC in situ, it is an ectopic pregnancy in 15% to 50% of the cases. (II-2) 8. In women who conceive with an intrauterine contraceptive (IUC) in place, early IUC removal improves outcomes but does not entirely eliminate risks. (II-2) 9. Intrauterine contraceptives do not increase the risk of infertility. (II-2) 10. Immediate insertion of an intrauterine contraceptive (10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher continuation rate compared with insertion at 6 weeks postpartum. (I) 11. Immediate insertion of an intrauterine contraceptive (IUC; 10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher risk of expulsion. (I) The benefit of inserting an IUC immediately postpartum or post-Caesarean section outweighs the disadvantages of increased risk of perforation and expulsion. (II-C) 12. Insertion of an intrauterine contraceptive in breastfeeding women is associated with a higher risk of uterine perforation in the first postpartum year. (II-2) 13. Immediate insertion of an intrauterine contraceptive (IUC) post-abortion significantly reduces the risk of repeat abortion (II-2) and increases IUC continuation rates at 6 months. (I) 14. Antibiotic prophylaxis for intrauterine contraceptive insertion does not significantly reduce postinsertion pelvic infection. (I) RECOMMENDATIONS: 1. Health care professionals should be careful not to restrict access to intrauterine contraceptives (IUC) owing to theoretical or unproven risks. (III-A) Health care professionals should offer IUCs as a first-line method of contraception to both nulliparous and multiparous women. (II-2A) 2. In women seeking intrauterine contraception (IUC) and presenting with heavy menstrual bleeding and/or dysmenorrhea, health care professionals should consider the use of the levonorgestrel intrauterine system 52 mg over other IUCs. (I-A) 3. Patients with breast cancer taking tamoxifen may consider a levonorgestrel-releasing intrauterine system 52 mg after consultation with their oncologist. (I-A) 4. Women requesting a levonorgestrel-releasing intrauterine system or a copper-intrauterine device should be counseled regarding changes in bleeding patterns, sexually transmitted infection risk, and duration of use. (III-A) 5. A health care professional should be reasonably certain that the woman is not pregnant prior to inserting an intrauterine contraceptive at any time during the menstrual cycle. (III-A) 6. Health care providers should consider inserting an intrauterine contraceptive immediately after an induced abortion rather than waiting for an interval insertion. (I-B) 7. In women who conceive with an intrauterine contraceptive (IUC) in place, the diagnosis of ectopic pregnancy should be excluded as arly as possible. (II-2A) Once an ectopic pregnancy has been excluded, the IUC should be removed without an invasive procedure. The IUC may be removed at the time of a surgical termination. (II-2B) 8. In the case of pelvic inflammatory disease, it is not necessary to remove the intrauterine contraceptive unless there is no clinical improvement after 48 to 72 hours of appropriate antibiotic treatment. (II-2B) 9. Routine antibiotic prophylaxis for intrauterine contraceptive (IUC) insertion is not indicated. (I-B) Health care providers should perform sexually transmitted infection (STI) testing in women at high risk of STI at the time of IUC insertion. If the test is positive for chlamydia and/or gonorrhea, the woman should be appropriately treated postinsertion and the IUC can remain in situ. (II-2B) 10. Unscheduled bleeding in intrauterine contraception users, when persistent or associated with pelvic pain, should be investigated to rule out infection, pregnancy, gynecological pathology, expulsion or malposition. (III-A)

Canadian Contraception Consensus (Part 3 of 4): Chapter 8 - Progestin-Only Contraception.

OBJECTIVE: To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. OUTCOMES: Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada. EVIDENCE: Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 8: PROGESTIN-ONLY CONTRACEPTION: Summary Statements Recommendations.

Consensus canadien sur la contraception (3(e) partie de 4) : chapitre 8 - contraception à progestatif seul.

OBJECTIF: Fournir des lignes directrices aux fournisseurs de soins quant à l'utilisation de modes de contraception pour la prévention de la grossesse et quant à la promotion d'une sexualité saine. ISSUES: Orientation des praticiens canadiens en ce qui concerne l'efficacité globale, le mécanisme d'action, les indications, les contre-indications, les avantages n'étant pas liés à la contraception, les effets indésirables, les risques et le protocole de mise en œuvre des modes de contraception abordés; planification familiale dans le contexte de la santé sexuelle et du bien-être général; méthodes de counseling en matière de contraception; et accessibilité et disponibilité des modes de contraception abordés au Canada. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans MEDLINE et The Cochrane Library entre janvier 1994 et janvier 2015 au moyen d'un vocabulaire contrôlé (p. ex. contraception, sexuality, sexual health) et de mots clés (p. ex. contraception, family planning, hormonal contraception, emergency contraception) appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs publiés en anglais entre janvier 1994 et janvier 2015. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en juin 2015. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. VALEURS: La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). CHAPITRE 8 : CONTRACEPTION à PROGESTATIF SEUL: Déclarations sommaires Recommandations.

Canadian Contraception Consensus (Part 2 of 4).

OBJECTIVE: To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. OUTCOMES: Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general well-being; contraceptive counselling methods; and access to, and availability of, cited contraceptive methods in Canada. EVIDENCE: Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Chapter 1: Contraception in Canada Summary Statements 1. Canadian women spend a significant portion of their lives at risk of an unintended pregnancy. (II-2) 2. Effective contraceptive methods are underutilized in Canada, particularly among vulnerable populations. (II-2) 3. Long-acting reversible contraceptive methods, including contraceptive implants and intrauterine contraception (copper-releasing and levonorgestrel-releasing devices/systems), are the most effective reversible contraceptive methods and have the highest continuation rates. (II-1) 4. Canada currently does not collect reliable data to determine the use of contraceptive methods, abortion rates, and the prevalence of unintended pregnancy among reproductive-age women. (II-2) 5. A universal subsidy for contraceptive methods as provided by many of Canada's peer nations and a few Canadian provinces may produce health system cost-savings. (II-2) 6. Health Canada approval processes for contraceptives have been less efficient than those of other drug approval agencies and Health Canada processes for other classes of pharmaceuticals. (II-2) 7. It is feasible and safe for contraceptives and family planning services to be provided by appropriately trained allied health professionals such as midwives, registered nurses, nurse practitioners, and pharmacists. (II-2) Recommendations 1. Contraceptive counselling should include a discussion of typical use failure rates and the importance of using the contraceptive method consistently and correctly in order to avoid pregnancy. (II-2A) 2. Women seeking contraception should be counselled on the wide range of effective methods of contraception available, including long-acting reversible contraceptive methods (LARCs). LARCs are the most effective methods of reversible contraception, have high continuation rates, and should be considered when presenting contraceptive options to any woman of reproductive age. (II-2A) 3. Family planning counselling should include counselling on the decline of fertility associated with increasing female age. (III-A) 4. Health policy supporting a universal contraception subsidy and strategies to promote the uptake of highly effective methods as cost-saving measures that improve health and health equity should be considered by Canadian health decision makers. (III-B) 5. Canadian health jurisdictions should consider expanding the scope of practice of other trained professionals such as nurses, nurse practitioners, midwives, and pharmacists and promoting task-sharing in family planning. (II-2B) 6. The Canadian Community Health Survey should include adequate reproductive health indicators in order for health care providers and policy makers to make appropriate decisions regarding reproductive health policies and services in Canada. (III-B) 7. Health Canada processes and policies should be reviewed to ensure a wide range of modern contraceptive methods are available to Canadian women. (III-B) Chapter 2: Contraceptive Care and Access Summary Statements 8. Although there are many contraceptive options in Canada, only a narrow range of contraceptive methods are commonly used by those of reproductive age. (II-3) 9. Condom use decreases with longer relationship tenure and when the sexual partner is considered to be the main partner, likely due to a lower perceived risk of sexually transmitted infection in that relationship. Condom use may also decrease markedly as an unintended consequence when an effective non-barrier method, such as hormonal contraception or intrauterine contraception, is initiated. (II-3) 10. Family planning counselling provides a natural segue into screening for concerns about sexual function or intimate partner violence. (III) 11. Well-informed and well-motivated individuals who have developed skills to practise safer sex behaviours are more likely to use contraceptive and safer sex methods effectively and consistently. (II-2) Recommendations 8. Comprehensive family planning services, including abortion services, should be accessible to all Canadians regardless of geographic location. These services should be confidential, non-judgemental, and respectful of individuals' privacy and cultural contexts. (III-A) 9. A contraceptive visit should include history taking, screening for contraindications, dispensing or prescribing a method of contraception, and exploring contraceptive choice and adherence in the broader context of the individual's sexual behaviour, reproductive health risk, social circumstances, and relevant belief systems. (III-B) 10. Health care providers should provide practical information on the wide range of contraceptive options and their potential non-contraceptive benefits and assist women and their partners in determining the best user-method fit. (III-B) 11. Health care providers should assist women and men in developing the skills necessary to negotiate the use of contraception and the correct and consistent use of a chosen method. (III-B) 12. Contraceptive care should include discussion and management of the risk of sexually transmitted infection, including appropriate recommendations for condom use and dual protection, STI screening, post-exposure prophylaxis, and Hepatitis B and human papillomavirus vaccination. (III-B) 13. Health care providers should emphasize the use of condoms not only for protection against sexually transmitted infection, but also as a back-up method when adherence to a hormonal contraceptive may be suboptimal. (I-A) 14. Health care providers should be aware of current media controversies in reproductive health and acquire relevant evidence-based information that can be briefly and directly communicated to their patients. (III-B) 15. Referral resources for intimate partner violence, sexually transmitted infections, sexual dysfunction, induced abortion services, and child protection services should be available to help clinicians provide contraceptive care in the broader context of women's health. (III-B) Chapter 3: Emergency Contraception Summary Statements 12. The copper intrauterine device is the most effective method of emergency contraception. (II-2) 13. A copper intrauterine device can be used for emergency contraception up to 7 days after unprotected intercourse provided that pregnancy has been ruled out and there are no other contraindications to its insertion. (II-2) 14. Levonorgestrel emergency contraception is effective up to 5 days (120 hours) after intercourse; its effectiveness decreases as the time between unprotected intercourse and ingestion increases. (II-2) 15. Ulipristal acetate for emergency contraception is more effective than levonorgestrel emergency contraception up to 5 days after unprotected intercourse. This difference in effectiveness is more pronounced as the time from unprotected intercourse increases, especially after 72 hours. (I) 16. Hormonal emergency contraception (levonorgestrel emergency contraception and ulipristal acetate for emergency contraception) is not effective if taken on the day of ovulation or after ovulation. (II-2) 17. Levonorgestrel emergency contraception may be less effective in women with a body mass index > 25 kg/m2 and ulipristal acetate for emergency contraception may be less effective in women with a body mass index > 35 kg/m2. However, hormonal emergency contraception may still retain some effectiveness regardless of a woman's body weight or body mass index. (II-2) 18. Hormonal emergency contraception is associated with higher failure rates when women continue to have subsequent unprotected intercourse. (II-2) 19. Hormonal contraception can be initiated the day of or the day following the use of levonorgestrel emergency contraception, with back-up contraception used for the first 7 days. (III) 20. Hormonal contraception can be initiated 5 days following the use of ulipristal acetate for emergency contraception, with back-up contraception used for the first 14 days. (III) Recommendations 16. All emergency contraception should be initiated as soon as possible after unprotected intercourse. (II-2A) 17. Women should be informed that the copper intrauterine device (IUD) is the most effective method of emergency contraception and can be used by any woman with no contraindications to IUD use. (II-3A) 18.

Objectif : Fournir des lignes directrices aux fournisseurs de soins quant à l'utilisation de modes de contraception pour la prévention de la grossesse et quant à la promotion d'une sexualité saine. Issues : Orientation des praticiens canadiens en ce qui concerne l'efficacité globale, le mécanisme d'action, les indications, les contre-indications, les avantages n'étant pas liés à la contraception, les effets indésirables, les risques et le protocole de mise en œuvre des modes de contraception abordés; planification familiale dans le contexte de la santé sexuelle et du bien-être général; méthodes de counseling en matière de contraception; et accessibilité et disponibilité des modes de contraception abordés au Canada. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans MEDLINE et The Cochrane Library entre janvier 1994 et janvier 2015 au moyen d'un vocabulaire contrôlé (p. ex. contraception, sexuality, sexual health) et de mots clés (p. ex. contraception, family planning, hormonal contraception, emergency contraception) appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs publiés en anglais entre janvier 1994 et janvier 2015. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en juin 2015. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Chapitre 1 : Contraception au Canada Déclarations sommaires 1. Les Canadiennes sont exposées à des risques de grossesse non planifiée pendant une partie considérable de leur vie. (II-2) 2. Les modes efficaces de contraception sont sous-utilisés au Canada, particulièrement au sein des populations vulnérables. (II-2) 3. Les modes de contraception réversible à action prolongée, dont les implants contraceptifs et la contraception intra-utérine (dispositifs / systèmes à libération de cuivre ou de lévonorgestrel), sont les modes de contraception réversible les plus efficaces; de plus, ils comptent les taux les plus élevés de poursuite du traitement. (II-1) 4. Au Canada à l'heure actuelle, nous ne recueillons pas de données fiables qui permettraient d'établir le taux d'utilisation des modes de contraception, le taux d'avortement et la prévalence des grossesses non planifiées chez les femmes en âge de procréer. (II-2) 5. L'octroi d'une subvention universelle destinée aux modes de contraception, à l'instar de bon nombre d'autres pays et de quelques provinces canadiennes, pourrait générer des économies pour le système de santé. (II-2) 6. Dans le cas des contraceptifs, les processus d'homologation de Santé Canada ont été moins efficaces que ceux d'autres organismes d'homologation, en plus d'être moins efficaces que les processus qu'elle a elle-même mis en vigueur en ce qui concerne d'autres catégories de produits pharmaceutiques. (II-2) 7. L'offre de contraceptifs et de services de planification familiale par des professionnels paramédicaux (tels que les sages-femmes, les infirmières autorisées, les infirmières praticiennes et les pharmaciens) ayant bénéficié d'une formation adéquate est faisable et sûre. (II-2) Recommandations 1. Les services de counseling traitant de la contraception devraient comprendre une discussion au sujet des taux d'échec liés à l'utilisation typique et de l'importance d'utiliser régulièrement et correctement le mode de contraception choisi, de façon à éviter la grossesse. (II-2A) 2. Les services de counseling offerts aux femmes qui cherchent à se prévaloir d'un mode de contraception devraient porter sur la vaste gamme des modes efficaces disponibles, y compris sur les modes de contraception réversible à action prolongée. Ces derniers sont les modes les plus efficaces de contraception réversible, comptent des taux élevés de poursuite du traitement et devraient être pris en considération, pour toutes les femmes en âge de procréer, au moment d'aborder avec celles-ci les options de contraception qui s'offrent à elles. (II-2A) 3. Les services de counseling en matière de planification familiale devraient aborder la question du déclin de la fertilité qui est associé au vieillissement chez la femme. (III-A) 4. Les décideurs canadiens du domaine de la santé devraient envisager la mise en œuvre de politiques de santé soutenant l'offre universelle d'une subvention à la contraception et de stratégies visant à promouvoir l'adoption de modes de contraception grandement efficaces, et ce, à titre de mesures de réduction des coûts permettant l'amélioration de la santé et de l'équité en matière de santé. (III-B) 5. Les territoires de compétence canadiens en matière de santé devraient envisager d'élargir le champ de pratique d'autres professionnels formés (comme les infirmières, les infirmières praticiennes, les sages-femmes et les pharmaciens) et de promouvoir le partage des tâches en planification familiale. (II-2B) 6. L'Enquête sur la santé dans les collectivités canadiennes devrait englober des indicateurs adéquats en matière de santé génésique, de façon à pouvoir permettre aux fournisseurs de soins de santé et aux décideurs de prendre des décisions opportunes à l'égard des politiques et des services de santé génésique au Canada. (III-B) 7. Les processus et les politiques de Santé Canada devraient être passés en revue pour que l'on puisse s'assurer qu'ils ne nuisent pas indûment à l'offre d'une vaste gamme de modes de contraception modernes aux Canadiennes. (III-B) Chapitre 2 : Soins en matière de contraception et accès à la contraception Déclarations sommaires 8. Bien que le Canada compte de nombreuses options en matière de contraception, les modes de contraception couramment utilisés par les femmes en âge de procréer sont issus d'une gamme restreinte. (II-3) 9. L'utilisation du condom diminue au fur et à mesure que se poursuit une relation et lorsque le partenaire sexuel est considéré comme étant le partenaire principal, probablement en raison d'une baisse du risque perçu d'infections transmissibles sexuellement au sein de la relation en question. L'utilisation du condom pourrait, de façon fortuite, également connaître une baisse marquée à la suite de la mise en œuvre d'un mode de contraception efficace ne faisant pas partie des méthodes de barrière (comme la contraception hormonale ou intra-utérine). (II-3) 10. Le counseling en matière de planification familiale peut naturellement mener au dépistage de la violence conjugale et des problèmes liés à la fonction sexuelle. (III) 11. Les personnes bien renseignées et bien motivées qui ont acquis les compétences nécessaires à la pratique de comportements sexuels à risques réduits sont plus susceptibles d'utiliser des modes de contraception et des pratiques sexuelles à risques réduits de façon efficace et systématique. (II-2) Recommandations 8. Des services exhaustifs de planification familiale (y compris des services d'avortement) devraient être offerts à tous les Canadiens, peu importe leur emplacement géographique. Ces services devraient être confidentiels et assurer le respect de la vie privée et des contextes culturels des personnes qui les utilisent. (III-A) 9. Les consultations en matière de contraception devraient comprendre une anamnèse, un dépistage des contre-indications, l'offre ou la prescription d'un mode de contraception, ainsi que l'exploration des choix en matière de contraception et des facteurs associés à l'observance dans le cadre élargi du comportement sexuel, des risques liés à la santé génésique, du contexte social et des croyances de la femme en question. (III-B) 10. Les fournisseurs de soins devraient offrir des renseignements pratiques sur la vaste gamme des options en matière de contraception et sur leurs avantages potentiels n'étant pas liés à la contraception, en plus d'aider les femmes et leurs partenaires à choisir le mode de contraception étant le mieux adapté à leurs besoins. (III-B) 11. Les fournisseurs de soins devraient aider les femmes et les hommes à acquérir les compétences nécessaires à la négociation du recours à la contraception, ainsi qu'à l'utilisation correcte et systématique du moyen de contraception choisi. (III-B) 12. Les soins en matière de contraception devraient aborder les risques de contracter des infections transmissibles sexuellement et en assurer la prise en charge; ils devraient, à ce chapitre, être fondés sur la formulation de recommandations appropriées en ce qui concerne l'utilisation de condoms et d'une protection double, le dépistage des infections transmissibles sexuellement, la prophylaxie post-exposition et la vaccination contre l'hépatite B et le virus du papillome humain. (III-B) 13. Les fournisseurs de soins devraient souligner que l'utilisation de condoms n'a pas seulement pour but de conférer une protection contre les infections transmissibles sexuellement, mais qu'elle agit également à titre de méthode d'appoint lorsque l'observance envers un contraceptif hormonal pourrait être sous-optimale. (I-A) 14. Les fournisseurs de soins devraient se tenir au fait des controverses médiatiques qui font rage dans le domaine de la santé génésique et obtenir les données factuelles pertinentes qui pourront être communiquées (de façon brève et directe) à leurs patientes. (III-B) 15. Des ressources spécialisées en ce qui concerne la violence conjugale, les infections transmissibles sexuellement, le dysfonctionnement sexuel, lesservices d'avortement provoqué et les services de protection de l'enfance devraient être disponibles pour aider les cliniciens à offrir des soins en matière de contraception dans le contexte élargi de la santé des femmes. (III-B) Chapitre 3 : Contraception d'urgence Déclarations sommaires 12. Le dispositif intra-utérin au cuivre constitue la méthode de contraception d'urgence la plus efficace. (II-2) 13. Un dispositif intra-utérin au cuivre peut être utilisé à des fins de contraception d'urgence jusqu'à sept jours à la suite d'une relation sexuelle non protégée, pour autant que la présence d'une grossesse ait été écartée et qu'il n'existe aucune autre contre-indication à son insertion. (II-2) 14. La contraception d'urgence au lévonorgestrel est efficace jusqu'à cinq jours (120 heures) à la suite d'une relation sexuelle non protégée; son efficacité diminue au fur et à mesure que s'allonge le délai entre la relation sexuelle non protégée et son administration. (II-2) 15. La contraception d'urgence à l'acétate d'ulipristal est plus efficace que celle qui fait appel au lévonorgestrel, et ce, jusqu'à cinq jours à la suite d'une relation sexuelle non protégée. Cette différence en matière d'efficacité devient plus prononcée au fur et à mesure que s'allonge le délai entre la relation sexuelle non protégée et l'administration, particulièrement après 72 heures. (I) 16. La contraception d'urgence hormonale (au lévonorgestrel ou à l'acétate d'ulipristal) n'est pas efficace lorsqu'elle est administrée le jour de l'ovulation ou par la suite. (II-2) 17. La contraception d'urgence au lévonorgestrel pourrait être moins efficace chez les femmes dont l'indice de masse corporelle est supérieur à 25 kg/m2, tandis que la contraception d'urgence à l'acétate d'ulipristal pourrait être moins efficace chez les femmes dont l'indice de masse corporelle est de 35 kg/m2 ou plus. Quoi qu'il en soit, la contraception d'urgence hormonale pourrait tout de même conserver une certaine efficacité, peu importe le poids ou l'indice de masse corporelle de la femme qui en fait la demande. (II-2) 18. La contraception d'urgence hormonale est associée à des taux d'échec plus élevés lorsque les femmes qui l'utilisent continuent par la suite à connaître des relations sexuelles non protégées. (II-2) 19. Une contraception hormonale peut être entamée le jour de l'utilisation d'une contraception d'urgence au lévonorgestrel, ou le jour suivant celle-ci, en s'assurant de mettre en œuvre une contraception d'appoint pendant les sept premiers jours. (III) 20. Une contraception hormonale peut être entamée cinq jours à la suite de l'utilisation d'une contraception d'urgence à l'acétate d'ulipristal, en s'assurant de mettre en œuvre une contraception d'appoint pendant les quatorze premiers jours. (III) Recommandations 16. La contraception d'urgence, toutes méthodes confondues, devrait être mise en œuvre dès que possible à la suite d'une relation sexuelle non protégée. (II-2A) 17. Les femmes devraient être avisées que le dispositif intra-utérin au cuivre constitue la méthode de contraception d'urgence la plus efficace et que ce dispositif peut être utilisé par toute femme qui ne présente pas de contre-indications à son utilisation. (II-3A) 18. Les fournisseurs de soins ne devraient pas déconseiller l'utilisation de la contraception d'urgence hormonale en fonction de l'indice de masse corporelle de la femme qui en fait la demande. L'utilisation d'un dispositif intra-utérin au cuivre à des fins de contraception d'urgence devrait être recommandée pour les femmes présentant un indice de masse corporelle supérieur à 30 kg/m2 qui sollicitent une contraception d'urgence. En présence de conditions favorables en matière d'accessibilité et de coût, la contraception d'urgence faisant appel à l'acétate d'ulipristal devrait constituer l'option de première intention à offrir aux femmes présentant un indice de masse corporelle de 25 kg/m2 ou plus qui préfèrent avoir recours à une contraception d'urgence hormonale. (II-2B) 19. Les fournisseurs de soins devraient discuter d'un plan visant la mise en œuvre d'une contraception continue avec les femmes qui en viennent à utiliser des pilules de contraception d'urgence; ils devraient également offrir des modes adéquats de contraception continue à ces femmes, lorsque celles-ci s'y montrent intéressées. La contraception hormonale devrait être entamée dans les 24 heures suivant l'administration d'une contraception d'urgence faisant appel au lévonorgestrel; de plus, une contraception d'appoint (ou l'abstinence) devrait être mise en œuvre pendant les sept premiers jours suivant le début de l'utilisation d'une contraception hormonale. (III-B) Dans le cas de la contraception d'urgence faisant appel à l'acétate d'ulipristal, la contraception hormonale devrait être entamée cinq jours après l'administration de la contraception d'urgence. Une contraception d'appoint (ou l'abstinence) doit être mise en œuvre pendant les cinq premiers jours suivant l'administration d'une contraception d'urgence faisant appel à l'acétate d'ulipristal, puis pendant les 14 premiers jours suivant le début de l'utilisation d'une contraception hormonale. (III-B) 20. L'acétate d'ulipristal et le lévonorgestrel ne devraient pas être utilisés de façon concomitante à des fins de contraception d'urgence. (III-B) 21. Un test de grossesse devrait être mené en l'absence de menstruations dans les 21 jours suivant l'utilisation de pilules ou l'insertion d'un dispositif intra-utérin au cuivre à des fins de contraception d'urgence. (III-A) 22. Des services de santé devraient être élaborés pour permettre aux Canadiennes d'obtenir un accès en temps opportun à toutes les méthodes efficaces de contraception d'urgence. (III-B).