Implementation of mifepristone medical abortion in Canada: pilot and feasibility testing of a survey to assess facilitators and barriers

Abstract

Background: Direct primary care provision of first-trimester medical abortion could potentially address inequitable abortion access in Canada. However, when Health Canada approved the combination medication Mifegymiso® (mifepristone 200 mg/misoprostol 800 mcg) for medical abortion in July 2015, we hypothesized that the restrictions to distribution, prescribing, and dispensing would impede the uptake of this evidence-based innovation in primary care. We developed and pilot-tested a survey related to policy and practice facilitators and barriers to assess successful initiation and ongoing clinical provision of medical abortion service by physicians undertaking mifepristone training. Additionally, we explored expert, stakeholder, and physician perceptions of the impact of facilitators and barriers on abortion services throughout Canada. Methods: In phase 1, we developed a survey using 2 theoretical frameworks: Greenhalgh's conceptual model for the Diffusion of Innovations in health service organizations (which we operationalized) and Godin's framework to assess the impact of professional development on the uptake of new practices operationalized in Légaré's validated questionnaire. We finalized questions in phase 2 using the modified Delphi methodology. The survey was then tested by an expert panel of 25 nationally representative physician participants and 4 clinical content experts. Qualitative analysis of transcripts enriched and validated the content by identifying these potential barriers: physicians dispensing the medication, mandatory training to become a prescriber, burdens for patients, lack of remuneration for mifepristone provision, and services available in my community. To assess the usability and reliability of the online survey, in phase 3, we pilot-tested the survey for feasibility. Results: We developed and tested a 61-item Mifepristone Implementation Survey suitable to study the facilitators and barriers to implementation of mifepristone first-trimester medical abortion practice by physicians in Canada.

Could implementation of mifepristone address Canada’s urban–rural abortion access disparity: a mixed-methods implementation study protocol

“…The survey instruments used in this study were developed and tested following methods described elsewhere 51 52. Additionally, we conducted a rigorous process to develop and test the surveys used to measure implementation of mifepristone 40. The process for adapting and pilot testing the surveys for the present study is described in a forthcoming publication.…”

Pharmacist checklist and resource guide for mifepristone medical abortion: User-centred development and testing

“…As medical abortion counselling may require additional time and resources inadequately reflected in a pharmacist's dispensing fee, our data indicate this may act as an additional barrier to provision for some pharmacists. Ongoing research 3,[32][33][34][35] suggests that 3 years since mifepristone/misoprostol for medical abortion entered the Canadian market in January 2017, uptake continues to be variable across Canada. Several pharmacy managers in our study reported using the Pharmacist Checklist and Resource Guide to train staff pharmacists for medical abortion provision. Indeed, a strength of our study was our integrated knowledge translation strategy for engaging knowledge users throughout the research process.…”

“…As medical abortion counselling may require additional time and resources inadequately reflected in a pharmacist’s dispensing fee, our data indicate this may act as an additional barrier to provision for some pharmacists. Ongoing research 3 , 32 - 35 suggests that 3 years since mifepristone/misoprostol for medical abortion entered the Canadian market in January 2017, uptake continues to be variable across Canada.…”

Slow implementation of mifepristone medical termination of pregnancy in Quebec, Canada: a qualitative investigation

“…The development of the 14-question interview guide [17] was based on Rogers' theory [13] and its application in Table 1. Changes of baseline restrictions of Health Canada (2015) [7,9,42] and the College of physicians of Quebec (2017) [11,25,[43][44][45].…”