Summary of the main findings

A large number of requests for sexual health related care delivered via pharmacies were made over a 3-year period. As might be expected, there was a higher level of provision for certain services (emergency contraception, condoms, STI self-sampling kits), which were available in all Umbrella pharmacies (between 127 and 176 pharmacies between August 2015 and August 2018), compared with other services (oral contraception, contraceptive injection, chlamydia treatment) which were restricted to a limited number of pharmacies (between 18 and 47 pharmacies between August 2015 and August 2018).

Those self-identifying as female comprised the large majority of requests. Those between the ages of 16 and 24 accounted for more than 50% of requests. Most requests, for which ethnicity data were available, were made by those recorded as White/White British and Asian/Asian British. Monday was the most common day to present, whereas Saturday and Sunday were the days with lowest attendances. The majority of service requests occurring at the weekend and on Monday, were made by women presenting for emergency contraception.

Comparison with existing literature

Attendance patterns by gender varied and it was found that emergency contraception, condoms and STI self-sampling kits were most commonly requested on Mondays. It is likely that women requesting emergency contraception are also offered condoms and STI self-sampling kits by pharmacy staff when they attend. This would suggest that the concept of integrated services, where several services are provided in one visit, is working. Males appear to obtain condoms before the weekend, possibly because sexual intercourse is more likely to occur at the weekend.9

Our analysis found that pharmacy-based SRHS accessible to both sexes were used less frequently by those self identifying as male than female, which is consistent with previous studies that reported a lower proportion of males attending for STI testing in a community pharmacy setting.6 10 This could indicate a barrier for male pharmacy-based SRHS access, possibly linked to the high proportion of female support staff in pharmacies.11 Males report a preference for having a consultation with a male health provider12 and having to approach female staff for SRHS might act as a deterrent.13 However, males are generally less likely than females to attend for healthcare14 and several studies have shown that males are also less likely than females to access STI testing in other settings, including primary care,15 sexual health clinics16 and commercial venues.17 Males also have a lower uptake of self-sampling based STI testing,18 and less frequently order STI kits online16 19 or return STI kits sent to their homes.20–22 This suggests that the reduced use of sexual health services observed in males is not specific to pharmacies and indicates a need for further research to investigate the reasons for this and how best to address it.23

We only analysed STI self-sampling kits that were provided through Umbrella pharmacies whereas a recent study analysed the utilisation of Umbrella’s clinic-based STI testing and online STI self-sampling kits that were sent to people’s homes or collected at the clinic. We found that only one transgender person was provided with an STI kit through the pharmacy over 3 years; in contrast, the online testing based study found 14 transgender people pre-ordered an STI kit to their home or to a clinic, and 26 transgender people were provided with STI screening at the clinic within a 6-month period.16 A recent study found that community pharmacists felt that discrimination and lack of provider knowledge were identified as barriers to pharmacies for transgender people, and the low uptake of services by transgender people may support this finding.24 However, it is also possible that transgender people may have been incorrectly recorded as female or male and therefore not have been captured in our data set.

Based on the available ethnicity data, ethnic groups using SRHS in pharmacies were represented approximately in proportion to their prevalence in the local population25—White/White British (census 57.9% cf. study population 43.4%), Asian/Asian British (census 23.7% cf. study population 23.1%), Black/Black British (census 7.2% cf. study population 15.1%), Mixed/Mixed British (census 4.4% cf. study population 2.0%) and other ethnic groups (census 6.7% cf. study population 5.8%). Black/Black British appeared to be over-represented in comparison with the local population, suggesting that pharmacies may reach those associated with potentially poor sexual health outcomes.26 However, available data identified the number of service requests rather than the number of individual patients so this should be interpreted with caution.

Young people are particularly vulnerable to poor sexual health outcomes.27 Our data showed that people in the age group from 16 to 24 years old made up the majority of service requests and indicates that pharmacies have the potential to reach young people who are in high need for SRHS. Further, a higher proportion of those attending for STI screening were aged 16–24 in pharmacies compared with sexual health clinic attendees (3365/5530 (62.9%)) cf. 9654/19193 (50%)),16 suggesting that pharmacy-based STI testing is acceptable to this demographic.

In line with other studies, we found that the total number of emergency contraception requests was highest on Mondays and lowest on Sundays.28 29 This may reflect difficulties in accessing pharmacies on Sundays, as a result of variable pharmacy hours, closure or unavailability of trained staff. According to data provided by Umbrella, the majority of Umbrella pharmacies (76.7%, 122/159) are closed on Sunday, suggesting that limited Sunday access was the reason for the low uptake of services. However, retrospective data on opening times are not available and these opening times may have differed in the past. Limited availability is a concern because emergency contraception is more effective when taken earlier after unprotected sex28 29 suggesting that more research is required to explore the impact of limiting access.

Strengths and limitations

Although understanding healthcare utilisation is crucial to identify barriers to access, previous literature on the utilisation of pharmacy-based sexual health services is scarce and limited to the delivery of single sexual health services. This is the first study evaluating SRHS data collected over a prolonged period of time. A limitation of the study is that the uptake of services over time could not be analysed because the date of attendance was unavailable from the service provider. Another limitation of this study is that the findings are limited to a single health provider in Birmingham and relied on routinely collected data which limited the possible analyses. Missing data meant that the utilisation of STI self-sampling kits could not be described in terms of ethnicity and the lack of a reliable patient ID number prevented analysis at a patient level. Furthermore, transgender people might not have been identified as they may be recorded as female or male rather than transgender.

Our findings suggest that Umbrella’s novel pharmacy service, which encompasses more than 120 pharmacies serving a population over 1 million people and including attendees from a wide range of ethnic backgrounds, can provide useful background information to those planning and delivering pharmacy services elsewhere.

Implications for practice and future research

Research into the reasons for variation in service uptake according to different days of the week would be useful to better understand why this occurs. This might include analysis of pharmacies’ opening times and the time taken to access emergency contraception after intercourse.

Barriers to males accessing sexual health services and black people accessing pharmacy-based sexual health services also warrants further investigation. However, a main recommendation of this study is for sexual health providers to design systems which optimise efficient data collection to enable rigorous and comprehensive analysis. Data linkage to enable anonymised identification of sexual health service attendees across integrated sexual health services would allow an analysis of utilisation at the patient level and assist future evaluations. Further, accounting for both gender and sex in data collection would improve the quality analysis30 and should also be considered. Finally, research on whether the type of person using pharmacy-based SRHS reflects how and where those services were advertised is needed to understand the effectiveness of reaching certain demographics by advertisement.