Effect of neighborhood-level income on access to emergency contraception

Objective: We aim to investigate whether the availability of over-the-counter EC varies by neighborhood income level, independent vs chain pharmacies, or urban vs rural pharmacies. Study Design: We conducted a cross-sectional "mystery shopper" telephone survey in July 2019 to ascertain whether sampled pharmacies stocked EC. Pharmacies located in 12 Pennsylvania counties were randomly sampled after stratification by neighborhood income level. Results: Of 200 pharmacies sampled, 195 responded. Only 76% had EC available for same day purchase, which did not differ by neighborhood-level income. The odds that chain pharmacies stocked EC were nearly 10 times the odds that independent pharmacies stocked EC, with 96/105 chain pharmacies versus 52/90 independent pharmacies having EC available for same day purchase (91% vs 58%; OR 9.50, 95% CI 4.03 -22.42). The mean number of barriers (stocking over-the-counter EC behind-the-counter, cost > $40, and requiring identification for purchase) was lower among chain vs. independent pharmacies. Pharmacies in low/moderate-income areas (64% vs 44%, p = 0.02) and independent pharmacies (94% vs 32%, p < 0.01) were more likely to keep over-the-counter EC behind-the-counter. Independent pharmacies were more likely to require identification for purchase (29% vs 59%, p < 0.01). Conclusion: More than a decade after over-the-counter approval, EC is still not uniformly available at pharmacies in Pennsylvania. Barriers including behind-the-counter stocking and identification requirements disproportionally limit access in low-income neighborhoods and independent pharmacies, threatening equitable access to this contraceptive method. Implication: Pharmacies in lower-income neighborhoods and independent pharmacies were more likely to impose undue barriers to EC access and purchasing, disproportionally affecting residents in lowerincome areas. A multidisciplinary approach in advocacy and policy reform is necessary to ensure equitable access to EC.