Development of a community pharmacy human papillomavirus vaccine program for underinsured university students along the United States/Mexico border

A community-based, interdisciplinary approach to improving HPV vaccine uptake at a large urban public university

The purpose of this project was to pilot and determine the outcomes of a multi-faceted, interdisciplinary human papillomavirus awareness and vaccination campaign within a university community.

Students, faculty, and staff of a large urban Midwest-based public university.

METHODS

This consisted of five key interventions: promotion and outreach, volunteer training, patient education, access, and documentation. Perceived knowledge and attitudes toward HPV and the HPV vaccine, and HPV vaccine uptake were measured as outcome variables.

The project resulted in statistically significant increases in perceived knowledge regarding HPV and the HPV vaccine, willingness to receive HPV vaccination, and likeliness to recommend HPV vaccination (p < 0.001). The project also resulted in a 76.6% increase in the number of HPV vaccines administered at the university's Campus Health Center.

A novel HPV awareness and vaccination campaign led to increases in knowledge regarding HPV and HPV vaccines, and substantially increased HPV vaccinations administered at a large, urban public university.

Improving equity of services for sexually transmitted infections through community pharmacies: A scoping review

BACKGROUND

Pharmacists have the potential to improve care for marginalized populations. Stigmatized and racialized groups may not find traditional health services accessible in other settings. Research focused on health care access for these populations is fundamental in understanding how to improve health equity.

OBJECTIVES

This scoping review aimed to determine how health equity is addressed within services offered through community pharmacies for sexually transmitted infections (STIs).

METHODS

This scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews Checklist. A comprehensive search strategy was developed with an academic librarian to capture studies containing search terms related to each of the following 3 topics: STIs, pharmacy, and underserved groups. PubMed and Embase were both searched up to July 2023 and search results were uploaded to the screening software Covidence. Two researchers independently screened titles, abstracts, and full texts. Articles were included if they reported evaluation of a pharmacy-based sexual health service and addressed health equity in service design or implementation.

RESULTS

A total of 8 articles were identified that described services implemented for underserved groups. Four populations were identified: injection drug users, men who have sex with men, racial minorities, and those with low socioeconomic status. Equity was addressed through 2 mechanisms: location-based implementation of services in areas of high target population density or through specific targeting of marginalized populations in recruitment and promotion. All studies involved interventions for the prevention or testing services rather than assessment and treatment.

CONCLUSIONS

Equity is not being readily addressed in pharmacy-based services for STIs yet evidence exists that considering equity in the design and implementation of services may improve reach to underserved populations.

Vaccine promotion strategies in community pharmacy addressing vulnerable populations: a scoping review

CONTEXT

Social determinants of health are drivers of vaccine inequity and lead to higher risks of complications from infectious diseases in under vaccinated communities. In many countries, pharmacists have gained the rights to prescribe and administer vaccines, which contributes to improving vaccination rates. However, little is known on how they define and target vulnerable communities.

OBJECTIVE

The purpose of this study is to describe how vulnerable communities are targeted in community pharmacies.

METHODS

We performed a systematic search of the Embase and MEDLINE database in August 2021 inspired by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocols (PRISMA ScR). Articles in English, French or Spanish addressing any vaccine in a community pharmacy context and that target a population defined as vulnerable were screened for inclusion.

RESULTS

A total of 1039 articles were identified through the initial search, and 63 articles met the inclusion criteria. Most of the literature originated from North America (n = 54, 86%) and addressed influenza (n = 29, 46%), pneumococcal (n = 14, 22%), herpes zoster (n = 14, 22%) or human papilloma virus vaccination (n = 14, 22%). Lifecycle vulnerabilities (n = 48, 76%) such as age and pregnancy were most often used to target vulnerable patients followed by clinical factors (n = 18, 29%), socio-economical determinants (n = 16, 25%) and geographical vulnerabilities (n = 7, 11%). The most frequently listed strategy was providing a strong recommendation for vaccination, promotional posters in pharmacy, distributing leaflet/bag stuffers and providing staff training. A total of 24 barriers and 25 facilitators were identified. The main barriers associated to each vulnerable category were associated to effective promotional strategies to overcome them.

CONCLUSION

Pharmacists prioritize lifecycle and clinical vulnerability at the expense of narrowing down the definition of vulnerability. Some vulnerable groups are also under targeted in pharmacies. A wide variety of promotional strategies are available to pharmacies to overcome the specific barriers experienced by various groups.

Evaluation methods for vaccination campaigns on college campuses: A scoping review

Background

Vaccinations are successful, cost-effective tools to prevent the spread of certain infectious diseases. Many colleges conduct vaccination campaigns on their campuses for various vaccine-preventable diseases, including measles, mumps, influenza, HPV, and most recently, for SARS-CoV-2, the virus responsible for COVID-19. Implementing these campaigns requires substantial effort and understanding their effectiveness is an important factor in justifying these programs.

Aim

This scoping review aims to identify, review, and summarize existing evaluation methods for vaccination campaigns on college campuses in order to provide evaluation guidance for institutions planning future vaccination campaigns.

Methods

Publications that focused on vaccination campaigns on college campuses for students and/or faculty and staff and described their evaluation methods were included in our analysis. A systematic search of the literature identified 2,101 articles. After duplicates were removed, titles and abstracts were screened, and references searched, 43 articles were identified for full-text review. Sixteen articles provided evaluation information and were systematically reviewed.

Results

Interventions targeted a variety of vaccine-preventable diseases, with the majority either aiming to increase HPV vaccine uptake or vaccinate against meningococcal serogroups. Most studies reported on campaigns that included both educational activities and provided vaccinations. Evaluation methods varied widely. Some studies measured vaccine-related knowledge and attitudes. Vaccine uptake was most commonly measured as a simple count of doses administered.

Conclusions

College campus vaccination campaigns are evaluated in multiple ways, with little consistency in how the effectiveness of campaigns are measured. There is a need to develop clear evaluation methods for college vaccination programs, especially how to calculate vaccination rates associated with these efforts.

The Interface Between U.S. Primary Care Clinics and Pharmacies for HPV Vaccination Delivery: A Scoping Literature Review

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For HPV vaccine delivery to improve, shared knowledge about and comfort with HPV vaccine administration are needed for all stakeholders (clinicians, pharmacists, parents, and patients).

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Intervention studies were small with weak study designs, many of which revealed that pharmacists were not successful in integrating services into broader primary care systems.

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Challenges include getting physicians to sign standing order protocols, service delivery being poor due to engagement barriers, and low parental demand for pharmacists to administer the vaccine.

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Larger more discerning studies are needed to fully understand the potential of primary care and pharmacy interactions for HPV vaccination.

Completion of the Human Papilloma Virus (HPV) vaccine series remains low. Partnerships between primary care (PC) clinics and local pharmacies could boost vaccination rates. We conducted a scoping literature review to address what is known and what gaps exist on the interface between U.S. primary care clinics and pharmacies for HPV vaccination. We searched Ovid MEDLINE ALL file and Cumulative Index to Allied Health Literature for articles published between 1/1/2010 and 12/31/2020. Search subjects included: 1) Pharmacy HPV Vaccination, 2) Pharmacy/PC Collaboration, and 3) Pharmacy/PC Collaboration vaccination. We developed an abstraction form to collect information on research methods, settings, strengths, weaknesses and findings. We screened 407 articles for inclusion; 17 met inclusion criteria: 13 (76.5%) reported on observational/descriptive studies; 4 articles (23.5%) reported on intervention studies, none of which were conducted in rural areas. Observational studies focused on willingness to be vaccinated for HPV and facilitators and barriers for vaccination, especially at pharmacies. Many studies concluded that knowledge about and comfort with HPV vaccine administration were needed for all vaccination stakeholders (clinicians, pharmacists, parents, and patients). Intervention studies were small with weak study designs, many of which revealed that pharmacists were not successful in integrating services into broader primary care systems. Challenges included getting physicians to sign standing order protocols, poor service delivery due to engagement barriers, and low parental demand for pharmacists to administer the vaccine. In conclusion, larger more discerning studies are needed to fully understand the potential of primary care and pharmacy interactions for HPV vaccination.

Sexual and reproductive health services provided by community pharmacists: a scoping review

OBJECTIVES

Pharmacists are increasingly providing patient-focused services in community pharmacies, including in the area of sexual and reproductive health (SRH). Specific SRH areas have been the focus of research, but a broader perspective is needed to position pharmacists as SRH providers. This review explored research that described and evaluated professional pharmacy services across a broad range of SRH areas.

DESIGN

Scoping review DATA SOURCES: Medline, EMBASE, CINAHL, Web of Science, Scopus and Cochrane Library (January 2007-July 2020).

STUDY SELECTION

Studies reporting on the description and evaluation of professional pharmacy SRH services provided by community pharmacists.

DATA EXTRACTION

Two investigators screened studies for eligibility, and one investigator extracted the data. Data were analysed to primarily describe professional pharmacy services and intervention outcomes.

RESULTS

Forty-one studies were included. The main SRH areas and professional pharmacy services reported were sexually transmitted and bloodborne infections (63%) and screening (39%), respectively. Findings showed that pharmacists' delivery of SRH services was feasible, able to reach vulnerable and high-risk groups, and interventions were highly accepted and valued by users. However, integration into daily workflow, pharmacist remuneration, cost and reimbursement for patients, and policy regulations were some of the barriers identified to implementing SRH services. Studies were primarily in specific areas such as chlamydia screening or hormonal contraception prescribing, while studies in other areas (ie, medical abortion provision, long-acting reversible contraception prescribing and vaccine delivery in pregnant women) were lacking.

CONCLUSION

This scoping review highlights the expansion of pharmacists' roles beyond traditional product-focused services in a number of SRH areas. Given the potential feasibility, users' acceptability and reach, pharmacists are ideally situated to enhance SRH care access. Future research describing implementation and evaluation of professional pharmacy services in all SRH areas is needed to promote access to these services through community pharmacies and position pharmacists as SRH providers worldwide.

Enrolling a rural community pharmacy as a Vaccines for Children provider to increase HPV vaccination: a feasibility study

Background

Human papillomavirus (HPV) is the most common sexually transmitted infection in the U.S. with over 80 million infected individuals. High-risk strains are associated with 6 different cancers. Although infection is preventable, U.S. vaccination rates remain suboptimal and there are noted disparities between urban and rural communities due to economic barriers, lack of access, and low awareness and education.

Methods

The current pilot study sought to overcome these barriers through an interprofessional collaborative enrolling a community pharmacy in a rural, medically underserved Alabama county as a Vaccines for Children (VFC) provider to provide free vaccines to eligible adolescents. Program evaluation was conducted to determine the intervention’s feasibility. Potential efficacy was assessed by analyzing county-level HPV vaccination uptake and completion rates using state immunization registry data.

Results

Over the 8-month study, 166 total vaccines were administered to 89 adolescents ages 10–18, including 55 doses of HPV vaccine, 53 doses of Tdap vaccine, 45 doses of meningococcal vaccine, and 13 doses of influenza vaccine. Among these adolescents, mean age was 12.6 years old, and 64 (71.9%) were VFC patients. The pharmacy recorded an increase in total vaccine administration of 158.8%, an increase in prescription revenue of 34.8%, and an increase in total revenue by 24.4% during the course of the study, compared to the previous year.

Conclusions

Findings from the current work demonstrate the potential of this strategy and can serve as a blueprint for statewide and national dissemination and implementation to ultimately increase access to vaccination services, increase vaccination rates, and reduce urban-rural vaccine disparities.

Influenza and Intentions to Vaccinate in an Underserved Hispanic Population: The Role of Theoretically Derived Constructs

Background:

Past research has focused on understanding influenza vaccine acceptance in non-Hispanic white populations; however, research on the social causes of influenza vaccine acceptance rates in Hispanic populations is slowly developing.

Objective:

The purpose of this study was to assess theoretically driven predictors (i.e. attitudes, perceptions, behaviors, etc.) on influenza and the intention to vaccinate.

Methods:

A survey was administered to assess predictors of intentions to receive the influenza vaccine. The survey included items adapted from the National Flu Survey.

Results:

Key constructs common in models of health behaviors emerged as predictors of behavioral intentions to receive the flu vaccine. Recent vaccination within the past year ( P < 0.001), perceived effectiveness of the flu vaccine ( P < 0.004), and perceived safety of the flu vaccine ( P = 0.009) were predictors of intentions to vaccinate. Exploratory analyses revealed that government distrust was a statistically significant predictor of intentions to vaccinate ( P = 0.044).

Conclusion:

The above results have important implications for health-care providers and public health educators. The better we understand the relationship between theoretically driven predictors and vaccine behaviors, the more educators and health-care providers can focus on meaningful, culturally sensitive, targeted-vaccine education.

A Qualitative Comparative Analysis of Combined State Health Policies Related to Human Papillomavirus Vaccine Uptake in the United States

OBJECTIVES

To examine how combinations of state policies, rather than single policies, are related to uptake of human papillomavirus (HPV) vaccine.

METHODS

Using publicly available records and the literature, we characterized policies for each US state and Washington, DC, in 2015 (n = 51), including (1) Medicaid expansion, (2) policies permitting HPV vaccination in pharmacies, (3) school-entry requirements, (4) classroom sex education mandates, and (5) parental education mandates. Using qualitative comparative analysis, we identified which existing combinations of these policies were necessary and sufficient for high HPV vaccine initiation among adolescents, with National Immunization Survey-Teen data.

RESULTS

No single policy was necessary or sufficient for high HPV vaccine uptake; however, 1 set of policies had consistently high HPV vaccine uptake: adoption of all policies except parental education mandates (girls: consistency = 1.00, coverage = 0.07; boys: consistency = 0.99, coverage = 0.08).

CONCLUSIONS

We identified a set of polices related to high HPV vaccine uptake. Future studies should examine how these policies and others, individually and in combination, are associated with HPV vaccine uptake. Public Health Implications. This study provides insight into what sets of policies are consistently related to high HPV vaccine uptake.

Adolescent human papillomavirus vaccination in the United States: Opportunities for integrating pharmacies into the immunization neighborhood

Human Papillomavirus (HPV) vaccination faces several barriers, including a social stigma which carries religious and philosophical implications among parents of adolescents as well as young adults. Hundreds of immunization interventions and programs have been developed to address these factors and boost HPV vaccination rates in the United States. We sought to review the existing literature highlighting barriers to HPV immunization, as well as programs targeting increased HPV vaccine uptake in effort to develop novel vaccination initiatives. The most impactful barriers identified were parental stigma and low quality of provider recommendations for the vaccine. Despite the implementation of many HPV initiatives, outcomes of these programs are largely limited to modest improvements in vaccine uptake in small, homogeneous populations. We describe pharmacies as distinctly advantageous but underutilized resources within the immunization neighborhood and propose a novel concept to improve vaccination rates as well as reduce HPV-related disease burden in all demographics.

Application of the Consolidated Framework for Implementation Research to community pharmacy: A framework for implementation research on pharmacy services

BACKGROUND

Community pharmacies are an increasingly important health care setting with opportunities for improving quality and safety, yet little is understood about determinants of implementation in this setting.

OBJECTIVE

This paper presents an implementation framework for pharmacy based on the Consolidated Framework for Implementation Research (CFIR).

METHODS

This study employed a critical review of 45 articles on professional services provided in community pharmacies, including medication therapy management (MTM), immunizations, and rapid HIV testing.

RESULTS

The relevant domains and associated constructs for pharmacy services were as follows. Intervention Characteristics ultimately depend on the specific service; of particular note for pharmacy are relative advantage and complexity. The former because implementation of services can pose a cost-benefit challenge where dispensing is the primary role and the latter because of the greater challenge implementing multi-faceted services like MTM compared to a discrete service like immunizations. "In terms of Outer Setting, pharmacies are affected by patient needs and acceptance, and external policies and incentives such as reimbursement and regulations. For Inner Setting, structural characteristics like pharmacy type, size and staff were important as was pharmacists' perception of their role and available resources to provide the service. Key Characteristics of Individuals include training, preparedness, and self-efficacy of the pharmacist for providing a new service. Few studies revealed relevant Process constructs, but if they did it was primarily related to engaging (e.g., champions).

CONCLUSIONS

As pharmacists' roles in health care are continuing to expand, a framework to inform implementation research in community pharmacy (and other) settings is crucially needed.

Parental acceptance of human papillomavirus vaccinations and community pharmacies as vaccination settings: A qualitative study in Alabama

Purpose

To determine parents’ knowledge and attitudes regarding human papillomavirus (HPV) vaccinations in their adolescent children and to describe parents’ perceptions of adolescent vaccinations in community pharmacies.

Methods

In-depth interviews were completed with parents or guardians of children ages 11–17 years from Alabama's Lee and Macon counties. One-hour long, open-ended telephonic or in-person interviews were conducted until the saturation point was reached. Using ATLAS.ti software and thematic analysis, interview transcripts were coded to identify themes.

Results

Twenty-six parents were interviewed, most of whom were female (80.8%) and white (50%). A total of 12 themes were identified. First, two themes emerged regarding elements facilitating children's HPV vaccination, the most common being positive perception of the HPV vaccine. Second, elements hindering children's vaccination contained seven themes, the top one being lack of correct or complete information about the HPV vaccine. The last topic involved acceptance/rejection of community pharmacies as vaccination settings, and the most frequently cited theme was concern about pharmacists’ clinical training.

Conclusions

Physician-to-parent vaccine education is important, and assurances of adequate pharmacy immunization training will ease parents’ fears and allow pharmacists to better serve adolescents, especially those who do not see physicians regularly.

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Physicians play a crucial role in parents’ HPV vaccination decisions.

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Parents are reluctant to use pharmacists as HPV vaccine providers.

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Parents are concerned about pharmacists’ training and pharmacy infrastructure.

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Community pharmacists must work in conjunction with physicians.