Pharmacists' Attitudes and Perceived Barriers to Human Papillomavirus (HPV) Vaccination Services

State and territory immunization program activities and their association with human papillomavirus vaccine initiation in the United States of America: A multilevel approach

This study evaluates the association between immunization program (IP) activities aimed at increasing HPV vaccination among adolescents and their impact on initiation rates. Our data sources are: (i) 2016 AIM Annual Survey and (ii) 2019 National Immunization Survey-Teen. We estimated the prevalence of HPV vaccine initiation using a multilevel Poisson model, combining state-level IP data and individual characteristics of adolescents. We calculated the prevalence ratio (PR) of HPV initiation among adolescents to compare the effects of IP activities, adjusting for state of residence, age, sex, maternal education, and ethnicity. A total of 17,390 teens aged 13 and 17 were evaluated. States with publicly available school-based adolescent coverage rates and/or exemptions (PRw, activity Dadjusted: 1.08, 95% CI: 1.02, 1.14), and those that expanded the number of pharmacies entering HPV vaccination data (PRw, activity Nadjusted; 1.06, 95% CI: 1.02, 1.10) in Immunization Information Systems (IIS), had higher HPV vaccine initiation rates compared to states that did not implement these strategies. When stratifying, these findings were present in the younger group (13-15 years, PRw, activity D adjusted: 1.10, 95% CI: 1.01, 1.18; PRw. activity N adjusted: 1.10, 95% CI: 1.05, 1.16), but not in the older group (16-17 years, PRw, activity D adjusted: 1.05, 95% CI: 0.95, 1.15; PRw. activity N adjusted: 1.00, 95% CI: 0.94, 1.06). States that expanded the number of school-located programs entering HPV vaccine records in IIS (PRw, activity Eadjusted: 1.08, 95% CI: 1.01, 1.15) had higher vaccine initiation prevalence in the younger group but not in the older group. Limitations include a lack of operational definitions for IP activities, potential biases in the NIS-Teen survey, and reliance on provider-reported HPV vaccination. Nonetheless, these results highlight immunization activities that support national efforts to increase HPV vaccine uptake and inform public health programs on effective HPV vaccine promotion.

Recombinant adenoviruses expressing HPV16/18 E7 upregulate the HDAC6 and DNMT3B genes in C33A cells

OBJECTIVE

High-risk human papillomavirus (HPV) is a carcinogenic virus associated with nearly all cases of cervical cancer, as well as an increasing number of anal and oral cancers. The two carcinogenic proteins of HPV, E6 and E7, can immortalize keratinocytes and are essential for HPV-related cellular transformation. Currently, the global regulatory effects of these oncogenic proteins on the host proteome are not fully understood, and further exploration of the functions and carcinogenic mechanisms of E6 and E7 proteins is needed.

METHODS

We used a previously established platform in our laboratory for constructing recombinant adenoviral plasmids expressing the HPV16 E7 gene to further construct recombinant virus particles expressing HPV16/18 E6, E7, and both E6 and E7 genes. These recombinant viruses were used to infect C33A cells to achieve sustained expression of the HPV16/18 E6/E7 genes. Subsequently, total RNA was extracted and RNA-Seq technology was employed for transcriptome sequencing to identify differentially expressed genes associated with HPV infection in cervical cancer.

RESULTS

RNA-Seq analysis revealed that overexpression of the HPV16/18 E6/E7 genes upregulated GP6, CD36, HDAC6, ESPL1, and DNMT3B among the differentially expressed genes (DEGs) associated with cervical cancer. Spearman correlation analysis revealed a statistically significant correlation between the HDAC6 and DNMT3B genes and key pathways, including DNA replication, tumor proliferation signature, G2M checkpoint, p53 pathways, and PI3K/AKT/mTOR signaling pathways. Further, qRT-PCR and Western blot analyses indicated that both HPV16/18 E7 can upregulate the expression of HDAC6 and DNMT3B, genes associated with HPV infection-related cervical cancer.

CONCLUSION

The successful expression of HPV16/18 E6/E7 in cells indicates that the recombinant viruses retain the replication and infection capabilities of Ad4. Furthermore, the recombinant viruses expressing HPV16/18 E7 can upregulate the HDAC6 and DNMT3B genes involved in cervical cancer pathways, thereby influencing the cell cycle. Additionally, HDAC6 and DNMT3B are emerging as important therapeutic targets for cancer. This study lays the foundation for further exploration of the oncogenic mechanisms of HPV E6/E7 and may provide new directions for the treatment of HPV-related cancers.

Pharmacists' Perceptions of Mental Well-Being and Immunization Safety During COVID-19

Purpose: To assess pharmacists' mental well-being, perceptions of safety, and willingness to administer vaccines before and during the COVID-19 pandemic. Methods: An electronic survey was administered to a convenient sample of practicing pharmacists working in Alabama, Tennessee and Texas. The 33-item survey examined pharmacists' beliefs about the pandemic's impact on their mental well-being, their perceptions of safety in vaccine administration, and their willingness to vaccinate. Responses were assessed on a 5-point Likert scale, ranging from strongly disagree (1) to strongly agree (5). A recruitment email with the survey link was sent to pharmacists, with periodic reminders over a 4-week period. Descriptive statistics and bivariate analyses were utilized to evaluate survey responses. Results: A total of 387 responses were analyzed, with an estimated response rate of 3.93%. Most respondents were women (65%) and had at least 6 to 10 years of practice experience (28%). Overall, participants felt that the pandemic worsened their mental well-being, with women reporting a more negative mental well-being compared with men (P < .001). They reported having less time during workflow to apply personal protective equipment (PPE) (P = .0074) compared to before the pandemic. They also reported a decrease in willingness to vaccinate adult patients during the pandemic (P < .0001), and that concern about contracting COVID-19 prevented them from giving vaccinations (P < .0001). Conclusions: Pharmacists felt their mental well-being and willingness to vaccinate patients suffered as a result of the COVID-19 pandemic. Future research and initiatives that focus on improving vaccination rates should also consider pharmacists' concerns and well-being.

Attitudes, awareness, and perceptions of general public and pharmacists toward the extended community pharmacy services and drive-thru pharmacy services: a systematic review

BACKGROUND

Several extended and newly added pharmacy services were evaluated in different countries. This review aims to provide a summary of studies on attitudes, awareness, or perceptions toward various extended and drive-thru pharmacy services at community settings among pharmacists and the general public.

METHODS

To find qualitative and descriptive quantitative studies, that reported on the attitudes, awareness, or perceptions of the general public and pharmacists toward the practice of any extended community pharmacy service and drive-thru pharmacy services in a community setting and conducted from March 2012 to March 2022. Researchers used databases such as Embase, Medline PubMed, Scopus, Web of Science, and Science Direct. The reviewers extracted data independently using the PRISMA checklist.

RESULTS

There were 55 studies found according to the inclusion criteria. Various extended pharmacy services (EPS) and drive-thru pharmacy services were noted in the community setting. Pharmaceutical care services and healthcare promotion services were the noticeable performed extended services. There were positive perceptions and attitudes toward extended and drive-thru pharmacy services among pharmacists and the public. However, some factors, such as lack of time and shortage of staff, affect the practice of those services.

CONCLUSION

Understanding the major concerns toward the provision of extended and drive-thru community pharmacy services and improving pharmacists' skills through more training programs to provide such services efficiently. In the future, more reviews for EPS practice barriers are recommended to faceup all concerns and find standardized guidelines by stakeholders and organizations for efficient EPS practices.

Community pharmacists' participation in adult vaccination: A cross-sectional survey based on the theoretical domains framework

OBJECTIVES

This study aims to assess Qatar community pharmacists' practices in advocating and promoting adult vaccination and to characterize and quantify potential determinants of participation in adult vaccination as vaccine administrators, based on the theoretical domains framework (TDF).

METHODS

A cross-sectional survey of a randomly selected sample of community pharmacists in Qatar was conducted using a self-administered validated questionnaire. Items in the questionnaire on potential determinants of participation in adult vaccination were based on TDF. TDF items were subjected to principal components analysis.

RESULTS

In total, 271 respondents completed the questionnaire (67.7%). Most respondents (83.5%) did not have any previous training in vaccination administration and were not involved in any vaccine-related advocacy activities (78.9%). Principal components analysis of TDF items gave eight components: pharmacists' perceived knowledge and skills (median score of 22, interquartile range [IQR] 17-26, possible range: 7-35); perceived confidence (16; IQR 12-20, possible range: 5-25); perceived external support (9; IQR 7-11, possible range: 3-15); professional role identity (38; IQR 33-42, possible range: 11-55); emotions (10; IQR 9-12, possible range: 3-15); perceived consequences (22; IQR 18-24, possible range: 6-30); perceived usefulness (16; IQR 14-18, possible range: 4-20); and behaviour control (6; IQR 4-8, possible range: 2-10).

CONCLUSION

Pharmacists' perceived knowledge, skills, confidence and behavioural control are potentially important factors to address to facilitate participation in vaccination administration in Qatar. Along with providing vaccination training to community pharmacists, there is a need to change the current pharmacy practice structure to improve managerial and government support for and to equip pharmacies with resources for this role.

The interface between U.S. primary care clinics and pharmacies for HPV vaccination delivery: A scoping literature review

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.

Community pharmacists workforce readiness to deliver vaccination services: A cross-sectional study from Jordan

This study assesses Jordanian community pharmacists’ readiness and willingness to deliver vaccination services in their practice sites. Between February and April 2021, a self‐administered online questionnaire was distributed via social media, WhatsApp messages, and personal communication. The questionnaire targeted practicing community pharmacies. Descriptive and inferential data analysis was carried out. A total of 403 community pharmacists participated in the study. Almost 146 (36%) community pharmacists reported vaccinating patients in their practice sites. However, readiness assessment revealed that only 54 (13.4%) pharmacists received the required training and qualifications. Moreover, 33 (8.2%) study participants worked in adequately equipped and designed community pharmacies. Overall, surveyed participants held positive attitudes toward their involvement in vaccination services: 260 (64.5%) pharmacists were willing to vaccinate patients, and 227 (65.0%) out of unready, unqualified, participants were willing to get needed training and qualifications. According to study participants, regulatory and professional bodies (Ministry of Health, Jordan Pharmacists Association) are influential in supporting pharmacist‐vaccinators. Among the investigated factors, organizational structure and employment status were significantly associated with pharmacists’ readiness to deliver vaccination. This study revealed that further work is needed to increase pharmacists’ and pharmacies’ readiness to deliver vaccination services and that regulators should follow a more active approach in highlighting the importance of training and the impact of training in patients’ safety and satisfaction.

Availability of the HPV Vaccine in Regional Pharmacies and Provider Perceptions Regarding HPV Vaccination in the Pharmacy Setting

There is increasing support for HPV vaccination in the pharmacy setting, but the availability of the HPV vaccine is not well known. Additionally, little is known about perceptions of medical providers regarding referring patients to community pharmacies for HPV vaccination. The purpose of this study was to determine HPV vaccine availability in community pharmacies and to understand, among family medicine and obstetrics–gynecology providers, the willingness of and perceived barriers to referring patients for HPV vaccination in a pharmacy setting. HPV vaccine availability data were collected from pharmacies in a southern region of the United States. Family medicine and obstetrics–gynecology providers were surveyed regarding vaccine referral practices and perceived barriers to HPV vaccination in a community pharmacy. Results indicated the HPV vaccine was available in most pharmacies. Providers were willing to refer patients to a community pharmacy for HPV vaccination, despite this not being a common practice, likely due to numerous barriers reported. Pharmacist-administered HPV vaccination continues to be a commonly reported strategy for increasing HPV vaccination coverage. However, coordinated efforts to increase collaboration among vaccinators in different settings and to overcome systematic and legislative barriers to increasing HPV vaccination rates are still needed.

Perceptions of HPV vaccination and pharmacist-physician collaboration models to improve HPV vaccination rates

Background

Human Papillomavirus (HPV) is the most common sexually transmitted disease in the United States (US), with 12 cancer causing strains. Vaccination rates in the southern US fall below the national average. Pharmacists provide an opportunity to improve vaccination rates.

Objectives

The objectives of this study were to 1) identify barriers and facilitators to providing the HPV vaccine and Vaccines for Children (VFC) program participation in pharmacies and clinics, and 2) assess pharmacy staff, clinic staff, and parent perceptions of 3 collaboration models to improve HPV vaccination.

Methods

A developmental formative evaluation was conducted with pharmacy staff, primary care clinic staff, and parents of adolescent children. Interview guides were informed by the Consolidated Framework for Implementation Research (CFIR). Barriers and facilitators to HPV vaccination and VFC participation were explored. Additionally, acceptability of 3 collaboration models were explored: 1) a shared-responsibility model in which a physician provides the first dose of HPV vaccine with the second provided in the pharmacy, 2) a pharmacy-based model in which a clinic refers patients to the pharmacy to receive both doses, and 3) an insourced model in which pharmacists schedule days to provide the vaccine in the collaborating clinic.

Results

Twenty-nine interviews were conducted between August 2019 and June 2020. Both pharmacy and clinic staff had positive views toward the HPV vaccine and vaccinations in general. Pharmacists and physicians reported parental awareness and education as a barrier to HPV vaccination. Counseling about HPV vaccine was reported as being more time-consuming because of the stigma associated with the vaccine. Parents were willing to have their children vaccinated for HPV in the pharmacy but desired their child's physician be involved in the immunization process. The shared-responsibility model was the most favored of the 3 collaboration models.

Conclusion

Perceptions of the HPV vaccine and vaccination in pharmacies were positive. Collaboration between clinics and pharmacies to improve HPV vaccination rates is viewed positively by pharmacy staff, clinic staff, and parents. This study will guide implementation of pharmacist-physician collaborative models to improve vaccination through pharmacy participation in the VFC program and HPV vaccination.

Factors associated with Turkish pharmacists' intention to receive COVID-19 vaccine: an observational study

Background Pharmacists have been taking part in vaccination services during the COVID-19 pandemic. However, research identifying pharmacists' intention to get COVID-19 vaccine is limited. Aim The objective of this study was to determine the intention to receive COVID-19 vaccine and to identify the factors related to it based on the Health Belief Model framework among Turkish pharmacists. Method This is an observational study conducted between December 2020 and January 2021. The online survey was sent to all hospital and community pharmacists working in Turkey. Transtheoretical Model of Behaviour Change and Health Belief Model were used for the development of the questionnaire. Univariate and multivariate logistic regression analyses were conducted to identify factors associated with the intention to receive COVID-19 vaccine. Results Among all participants (n = 961), 74.7% had an intention to receive the COVID-19 vaccine. In model 1, perceived susceptibility, perceived severity, perceived benefits, and perceived barriers were associated with their intention to receive the COVID-19 vaccine (p < 0.05). In model 2, the intention to receive COVID-19 vaccine was associated with being male, years of experience in the professional field, not having contracted COVID-19, having a pharmacy staff who had contracted COVID-19, and having had received seasonal flu shot within the previous year (p < 0.05). Conclusion This study highlights the factors related to the intention of the pharmacists to receive COVID-19 vaccines. Health Belief Model is the strongest predictor for vaccination intention and could be used to develop behavioural change techniques to promote vaccination.

Examining community pharmacists' intention to provide pharmacist-driven vaccination services: A structural equation modelling

BACKGROUND

The evidence of pharmacists' current involvement in vaccination services in low- and middle-income countries (LMICs) is uncertain. This study would be a first step to develop vaccination services by investigating community pharmacists' intention to be involved in PDV services not just during COVID-19 pandemic but also during standard service provision in Turkey which can be taken as an example across LMICs.

OBJECTIVE

Considering the efforts to empower community pharmacists in service provision, the goal of the present study was to develop a structural equation model to explain the "Pharmacist-Driven Vaccination Service Intention Model (PDV-SIM)" by using the theory of planned behavior (TPB).

METHODS

Based on the constructs of TPB, a measurement tool was developed. Sub-factors of PDV service intention was determined by conducting exploratory factor analysis (EFA). In the second step, confirmatory factor analysis (CFA) was conducted to prove the theoretical structure of the tool. Finally, a model explaining the relationship between observed variables, latent constructs from TPB was developed by SEM analysis.

RESULTS

In the proposed PDV-SIM, patient related attitude toward PDV services, attitude toward negative consequences of PDV services, and subjective norm about PDV services had an impact on the behavioral intention of community pharmacists. Nevertheless, professional development attitude toward PDV services and perceived behavioral control were not evaluated as determinants of the behavioral intention.

CONCLUSION

Results of this study revealed that TPB is appropriate for modelling PDV service intention of community pharmacists. This model can be utilized as a guide to potential pharmacy regulatory bodies and policy makers in their efforts to enable community pharmacists as vaccinators across LMICs.

Pharmacists' Perceived Barriers to Human Papillomavirus (HPV) Vaccination: A Systematic Literature Review

About 45:000 cancers are linked to HPV each year in the United States alone. The HPV vaccine prevents cancer and is highly effective, yet vaccination coverage remains low. Pharmacies can play a meaningful role in increasing HPV vaccination access due to their availability and convenience. However, little is known about pharmacists’ perceived barriers to HPV vaccination. The objective of this systematic review was to summarize existing literature on perceived barriers to administering HPV vaccination reported by pharmacists. Barriers identified from selected studies were synthesized and further grouped into patient, parental, (pharmacist’s) personal, and system/organization barrier groups. Six studies were included in this review. The cost of the HPV vaccine, insurance coverage and reimbursement were commonly reported perceived barriers. Adolescent HPV vaccination barriers related to parental concerns, beliefs, and inadequate knowledge about the HPV vaccine. Perceived (pharmacist’s) personal barriers were related to lack of information and knowledge about HPV vaccine and recommendations. At the system/organization level, barriers reported included lack of time/staff/space; difficulty in series completion; tracking and recall of patient; perceived competition with providers; and other responsibilities/vaccines taking precedence. Future strategies involving pharmacy settings in HPV-related cancer prevention efforts should consider research on multilevel pharmacy-driven interventions addressing barriers.

Human papillomavirus vaccine administration behaviors and influences among Arizona pharmacists and pharmacy interns

This study assessed 27 Arizona community pharmacists' and pharmacy interns' human papillomavirus (HPV) vaccine administration behaviors and influences. We recruited community pharmacists and pharmacy interns from a statewide pharmacy conference to complete a 40-item cross-sectional survey. Informed by the Theory of Planned Behavior, the survey assessed pharmacists' HPV vaccine-related behaviors, intentions, attitudes, subjective norms, and perceived behavioral control to vaccinate against HPV. We analyzed all data using descriptive statistics and correlations. Overall, most pharmacists held positive attitudes about the HPV vaccine. However, the majority rarely administered the HPV vaccine. Intentions to vaccinate and subjective norms positively correlated with vaccine administration behavior. Pharmacists' positive attitudes about the vaccine, subjective norm to vaccinate, and behavioral control or self-efficacy to recommend the vaccine impacted their intentions to vaccinate against HPV. Most surveyed pharmacists believed that the most substantial HPV vaccine administration barriers include parental consent and parental stigma against the vaccine. The most common pharmacy-related barrier was the lack of a tracking and reminder system to encourage patients to return for additional HPV vaccine doses. This work highlights the need to increase public awareness that pharmacists can administer vaccines to adolescents. Study authors recommend offering communication training to increase pharmacists' perceived behavioral control to recommend the HPV vaccine.

Expanding access to HPV vaccination in South Carolina through community pharmacies: A geospatial analysis

OBJECTIVE

Human papillomavirus (HPV)-associated cancer rates are higher in rural areas. Despite the preventive benefits of HPV vaccination, uptake is lower among rural populations. Community-based pharmacies with a strong presence in rural communities may be ideal for improving HPV vaccination access. Our objective was to determine whether spatial access to pharmacies among adolescents and young adults in South Carolina varied by rurality and geographic access to primary care providers.

METHODS

Geographic information systems methods were used to evaluate spatial access to community-based pharmacies among persons aged 10-24 years in South Carolina census tracts (CTs). CTs were categorized as metropolitan, micropolitan, or small-town and isolated rural CTs using rural-urban commuting area codes and as health provider shortage areas (HPSAs) or not. Descriptive and spatial statistics were calculated to compare access across CT groupings and to evaluate geospatial clustering.

RESULTS

Areas of highest access clustered among the metropolitan CTs. Whereas spatial access was higher in metropolitan than micropolitan CTs, there was no difference in spatial access between metropolitan and small-town and rural CTs. In general, HPSA-designated areas had lower spatial access to pharmacies than non-HPSA-designated areas. However, in micropolitan areas, there was no difference in spatial access to pharmacies based on HPSA designation.

CONCLUSION

Spatial access to pharmacies among small town and rural areas was comparable to urban areas as was HPSA-designated micropolitan areas and non-HPSA micropolitan areas. This suggests that pharmacies are equally accessible to both urban and rural populations in South Carolina, but additional research is needed to identify effective strategies to promote the uptake of and the availability of HPV vaccination in pharmacies (e.g., insurance coverage) and to ensure patients are educated on the benefits of HPV vaccinations and its availability in nonprimary care settings.

Pharmacist and pharmacy intern perceptions of adolescent vaccination administration

OBJECTIVES

To characterize pharmacists' and pharmacy interns' perceptions of administering adolescent vaccinations. Secondary objectives were to model the association between 1) perceptions and respondent demographic information and 2) pre- and post-training survey responses.

DESIGN

A 12-item survey, on the basis of the Theory of Self-Perception, was used to collect respondents' perceptions of adolescent vaccination administration retrospectively before and after pharmacist and pharmacy intern completion of Online training. The training reviewed Center for Disease Control and Advisory Committee on Immunization Practice recommendations for vaccination schedules, vaccine administration, managing adverse reactions, finding vaccine-related information, the importance of vaccinating, and dispelling common misconceptions.

SETTING AND PARTICIPANTS

Pharmacists and pharmacy interns representing 114 Indiana community pharmacy locations within a national supermarket chain were eligible to complete an Online survey between March and April 2019.

OUTCOME MEASURES

Descriptive statistics were used to characterize pharmacists' and pharmacy interns' perceptions of adolescent vaccination administration. A multivariable regression analysis was used to determine the association between perceptions and respondent demographic information. Differences in perceptions before and after the training module were evaluated using paired t tests.

RESULTS

Of the 293 eligible pharmacists and pharmacy interns, 138 (47.1%) completed the survey and 124 (42.3%) responses were included for analysis. Pharmacists and pharmacy interns had positive perceptions of adolescent vaccination administration. There was a negative relationship between the number of years that a pharmacist had been in practice and their baseline perceptions of adolescent vaccination administration (P = 0.02). There was a statistically significant increase in perceptions following completion of the training module (P < 0.001).

CONCLUSION

Pharmacists and pharmacy interns, specifically those who have been in practice for few years, had positive perceptions about adolescent vaccination administration but their perceptions were strengthened with additional training. Further research is needed to determine the relationship between additional training and vaccination rates.

Exploring Opportunities to Leverage Pharmacists in Rural Areas to Promote Administration of Human Papillomavirus Vaccine

Rural pharmacists have been identified as potential partners, along with health care providers, schools, and public health agencies, in administering and promoting the human papillomavirus (HPV) vaccine. We sought to understand the role of pharmacists in this work. We interviewed 11 pharmacists working at independently owned pharmacies in Iowa to explore their perspectives on HPV vaccine administration and promotion. Most pharmacists agreed that HPV vaccination was within their professional scope. They identified factors that facilitate vaccine administration (eg, accessibility of pharmacies). They also reported personal barriers (eg, lack of information, concerns about safety) and organizational barriers (eg, time and staff capacity). Future work should focus on alleviating barriers and building on strengths to improve vaccination rates and ultimately prevent HPV-related cancers.

Implementing pharmacy-located HPV vaccination: findings from pilot projects in five U.S. states

Pharmacies are promising alternative settings for human papillomavirus (HPV) vaccination because of their population reach, convenience, and existing infrastructure for vaccine delivery. However, pharmacies in the US are rarely used for adolescent HPV vaccination. We sought to document challenges and opportunities of implementing pharmacy-located HPV vaccination services in five US states by mapping process evaluation results onto key implementation science constructs: service penetration, acceptability, appropriateness, feasibility, fidelity, adoption, and sustainability. Pilot projects were planned in North Carolina (k = 2 pharmacies), Michigan (k = 10), Iowa (k = 2), Kentucky (k = 1), and Oregon (no pharmacy recruited) with varying procedures and recruitment strategies. Sites had open enrollment for a combined 12 months. Despite substantial efforts in these states, only 13 HPV vaccine doses were administered to adolescents and three doses to age-eligible young adults. We identified two major reasons for these underperforming results. First, poor outcomes on service penetration and appropriateness pointed to engagement barriers: low parent demand and engagement among pharmacy staff. Second, poor outcomes on feasibility, adoption, and sustainability appeared to result from administrative hurdles: lacking third party reimbursement (i.e., billing commercial payers, participation in Vaccines for Children program) and limited integration into primary care systems. In summary, pilot projects in five states all struggled to administer HPV vaccines. Opportunities for making pharmacies a successful setting for adolescent HPV vaccination include expanding third party reimbursement to cover all vaccines administered by pharmacists, increasing public awareness of pharmacists' immunization training, and improving care coordination with primary care providers.

Pharmacist insights into adolescent human papillomavirus vaccination provision in the United States

HPV vaccination coverage in the United States (US) falls short of the Healthy People 2020 goal of 80% coverage among 13-15 year-old adolescents. Pharmacies are a promising alternative vaccine delivery site that may increase access to HPV vaccination. Our objective was to assess pharmacists' insights into HPV vaccination provision to adolescents. We recruited 40 licensed pharmacists in eight states with different pharmacy vaccination laws: Alabama, California, Indiana, Kentucky, Maine, Tennessee, Texas, and Washington. Eligible pharmacists either previously provided or were currently providing HPV, tetanus-diphtheria-pertussis, or meningococcal vaccines to adolescents aged 9-17 years. Pharmacists were administered a semi-structured survey to explore insights into HPV vaccination provision. Forty-five percent of surveyed pharmacies offered HPV vaccination to adolescents. Pharmacists' reported challenges to providing HPV vaccination were parental consent (28%), tracking and patient recall (17%), perceived stigma of vaccination (17%), and education about or promotion of vaccination (17%). Pharmacists offering HPV vaccination sent patient reminders for vaccines with multiple doses (89%) and utilized telephone reminders (72%). Pharmacists informed patients' primary care providers of HPV vaccination doses most commonly through fax (72%) and updating electronic medical records (22%). One-third of pharmacists reported vaccination provision using the state immunization information system (IIS). Seventy-five percent reported vaccination rates could be increased at their respective pharmacy. Pharmacies are underutilized, although highly accessible, for HPV vaccination in the US. National efforts should expand educational programs to improve public awareness of in-pharmacy HPV vaccination, and improve the utilization of state IIS for reporting immunization coverage of adolescents by pharmacists.

Persuasive messaging for human papillomavirus vaccination by adolescent providers in a five-country multi-site study

OBJECTIVE

Strong persuasive messaging by providers is a key predictor for patient acceptance of prophylactic human papillomavirus vaccination. We aimed to determine optimal messaging to promote human papillomavirus adolescent vaccination across different geographical sites.

METHODS

Adolescent providers (n = 151) from Argentina, Malaysia, South Africa, South Korea, and Spain were surveyed on messages, family decision makers, and sources of communication to best motivate parents to vaccinate their adolescent daughters overall, and against human papillomavirus. Multivariate logistic regression assessed the likelihood of recommending messages specifically targeted at cervical cancer with providers' characteristics: gender, medical specialization, and previous administration of human papillomavirus vaccination.

RESULTS

Mothers were considered the most important human papillomavirus vaccination decision makers for their daughters (range 93%-100%). Television was cited as the best source of information on human papillomavirus vaccination in surveyed countries (range 56.5%-87.1%), except Spain where one-on-one discussions were most common (73.3%). Prevention messages were considered the most likely to motivate parents to vaccinate their daughters overall, and against human papillomavirus, in all five countries (range 30.8%-55.9%). Optimal messages emphasized cervical cancer prevention, and included strong provider recommendation to vaccinate, vaccine safety and efficacy, timely vaccination, and national policy for human papillomavirus vaccination. Pediatricians and obstetricians/gynecologists were more likely to cite that the best prevention messages should focus on cervical cancer (OR: 4.2, 95% CI: 1.17 to 15.02 vs other medical specialists).

CONCLUSIONS

Provider communication messages that would motivate parents to vaccinate against human papillomavirus were based on strong recommendation emphasizing prevention of cervical cancer. To frame convincing messages to increase vaccination uptake, adolescent providers should receive updated training on human papillomavirus and associated cancers, while clearly addressing human papillomavirus vaccination safety and efficacy.

National survey of pharmacy-based immunization services

INTRODUCTION

Pharmacists in the United States (U.S.) are authorized to administer vaccines. This study described: how and to what extent immunization services are offered, promoted, and documented in community pharmacies; reasons for referral to other locations for vaccination; and perceived barriers to immunization services.

METHODS

A mixed-mode (mail/electronic) survey of a stratified random sample of 1999 nationally-representative community pharmacies in the U.S. was conducted in April-July 2017. Survey instrument development was informed by validated scales and 10 in-depth interviews with community pharmacists; content and face validity were ensured via pre- (n = 5) and pilot-tests (n = 26) among community pharmacists. Potential non-response bias was investigated and descriptive statistics were used to analyze survey responses.

RESULTS

Of the 1999 community pharmacies, 119 pharmacies were deemed ineligible. Of those eligible pharmacies, complete responses were provided by 292 respondents, each representing a unique pharmacy (15.5% response rate). Respondents were evenly split male/female (52.5/47.5%) and about half were pharmacy managers (51.3%). The majority (79.5%) reported offering at least one type of vaccine in 2016, with the most commonly administered vaccine types (average doses in 2016) being: Influenza (484), Pneumococcal 13-valent conjugate (55), Herpes Zoster (41), and Pneumococcal polysaccharide (39). Two-thirds (66.7%) of immunizing pharmacies provided adolescent vaccinations. Most frequently reported referral reasons were patients' insurance not covering vaccine administration at the pharmacy and patients' age not within approved protocol, policy or state law. The majority of respondents did not perceive organizational and environmental factors as barriers; however, they reported patient-related factors, especially cost and insurance coverage, as important barriers.

CONCLUSIONS

The majority of U.S. community pharmacies reported offering at least one type of vaccine. The scope of pharmacy engagement in immunization services varied in terms of how and to what extent they were offered and documented. Addressing patient-related barriers is needed to further enhance pharmacy-based immunization services.

Utah pharmacists' knowledge, attitudes, and barriers regarding human papillomavirus vaccine recommendation

OBJECTIVES

To evaluate Utah community pharmacists' knowledge and attitudes toward recommendation of human papillomavirus (HPV) vaccine, to determine whether the knowledge and attitude of pharmacists regarding the HPV vaccine influence their recommendation behaviors, and to capture any self-identified barriers to recommending the HPV vaccine.

DESIGN

A cross-sectional anonymous 73-item survey was developed and administered to community, outpatient, and ambulatory care pharmacists.

SETTING

Utah.

PARTICIPANTS

Utah community pharmacists.

MAIN OUTCOME MEASURES

Recommendation of the HPV vaccine by the pharmacist, knowledge and attitude of pharmacists regarding HPV vaccine, and barriers to vaccine receipt.

RESULTS

The mean HPV vaccine knowledge score was 7.45 ± 2.15 (out of 13), and scores were higher when pharmacists had 4 to 6 technicians per day in the pharmacy and when they were residency trained. The mean attitude score was 24.26 ± 3.16 (out of 30). Positive attitudes were found if they had more than 1 pharmacist and 4 to 6 pharmacy technicians working at any given time in the pharmacy. Those who identified with "other Christianity" had a more positive attitude than Latter Day Saints. Although positive attitude toward the HPV vaccine was a predictor for recommending the vaccine to both boys and girls, higher knowledge was a significant predictor only in recommending the HPV vaccine for boys. Female pharmacists were more likely to recommend the HPV vaccine. The top 3 reported barriers included lack of parental knowledge, parental concerns and opposition, and lack of educational materials to provide parents.

CONCLUSION

Although the majority of respondents perceived HPV vaccination as useful for preventing certain types of cancer, and more than one-half of respondents reported being comfortable in recommending the vaccine, only one-third actually recommended the vaccine for girls and for boys. The results indicate the need for improving knowledge about the HPV vaccine for pharmacists, patients, and parents.