The Role of Intern Pharmacists in Implementing Innovative and Sustainable Practices to Enhance Rates of Non-influenza Immunizations

The objectives of this study were to:

• Assess perception of greater intern pharmacist involvement in implementing non-influenza immunizations.

• Identify important barriers to administering non-influenza immunizations that can be addressed by intern pharmacists.

• Determine innovative and effective intern pharmacist-led implementations to increase non-influenza immunization rates.

Immunizations are a key public safety measure supported by the Centers for Disease Control and Prevention (CDC) to decrease the prevalence, morbidity, and mortality of vaccine-preventable diseases.⁽¹⁾ Without recommended immunizations, individuals risk their health and the health of those vulnerable to illness. The CDC Advisory Committee for Immunization Practices recommends immunizations for people at targeted ages with guidelines for vaccine-preventable illnesses.⁽¹⁾ However, the American population remains below desired levels of immunization rates.^(2,3)

With immunization authority in all states, pharmacists improve immunization access as frontline healthcare providers in a large number of locations.⁽⁴⁾ Although pharmacists are capable of improving immunization rates, several barriers restrict immunization access including low prioritization, immunization opposition, cost, insurance, accessibility/supply, lack of awareness, cultural/geographical background, and personal beliefs.⁽⁵⁾ Despite these barriers, immunization rates increase after pharmacist interventions and collaboration between health systems and community pharmacists.⁽⁶⁾

Intern pharmacists are trained to screen for, administer vaccines, and counsel patients on immunization importance. Few studies have explored intern pharmacists’ involvement or role in increasing immunization rates. One study found that university staff and students were satisfied with services provided by intern pharmacists during an influenza campaign.⁽⁷⁾ A review of 18 studies demonstrated that intern pharmacists increased pneumococcal immunization rates in both inpatient and community settings.⁽⁸⁾ Despite this, intern pharmacists likely remain an underutilized immunization resource, particularly outside of the influenza season.⁽⁹⁾

Further research on their roles in non-influenza immunizations is crucial to improve health outcomes. Thus, the objectives of this study were to examine pharmacist and intern pharmacist perceptions of intern pharmacists’ roles in increasing non-influenza immunization rates, identify barriers that intern pharmacists may address, and determine innovative and effective intern pharmacist-led implementations to increase non-influenza immunization rates.

An anonymous cross-sectional survey was distributed through SurveyMonkey (San Mateo, CA) to evaluate California pharmacist and intern pharmacist perceptions of the intern pharmacist’s role in immunizing the community. State-wide pharmacy organizations including California Pharmacists’ Association (CPhA) and California Society of Health-System Pharmacists (CSHP) utilized membership listservs to distribute the survey invitation to pharmacists and intern pharmacists. CPhA included the survey link in weekly emails sent to approximately 4,300 members and posted the link on its website for five weeks. CSHP sent one email invitation to approximately 4,000 members. Additionally, the survey invitation was once sent to intern pharmacists on California Pharmacy Student Leadership teams (96 members) and twice to all students, faculty, alumni, and preceptor listservs at the University of California (UC) San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences.

Data were collected for five weeks in 2017. Respondents indicated their title (“Pharmacist” or “Intern Pharmacist”) and pharmacy practice setting. Immunization barriers that may be addressed by intern pharmacists were assessed using a 9-point scale ranging from least to most feasible. Perceptions of intern pharmacists’ roles in improving immunization rates (ranging from “Strongly Disagree to “Strongly Agree”) and opinions regarding potential interventions (“Not feasible in any setting”, “May be feasible in any setting”, “Feasible in any setting”, and “Currently implemented in my practice”) were also evaluated.

Data were summarized and responses were analyzed using STATA 15 (College Station, TX). Chi-square or Fisher’s exact tests were used to identify differences between pharmacist and intern pharmacist perceptions of potential interventions with alpha priori <0.05. Institutional Review Board approval was received from the UC San Diego Human Research Protections Program.

A total of 133 responses were collected from 62 (46.6%) pharmacists, 70 (52.6%) intern pharmacists, and one undisclosed title (0.7%). The majority worked in community pharmacy (n=77, 36%) or health-system/hospital (n=45, 34%) settings, with the remainder in ambulatory/outpatient clinics (n=19, 15%) or other pharmacy settings (n=20, 15%). Perceived barriers were identified and the most prominent barrier listed by both groups as feasible for intern pharmacists to overcome was lack of awareness regarding necessary vaccines (Figure 1).

With respect to perceptions of intern pharmacists to improve non-influenza immunization rates, 95% strongly agreed or agreed they could implement immunization programs (Table 1). There was also a consensus (78%) that they receive sufficient training. Furthermore, 54% stated that greater emphasis on intern pharmacist-administered immunizations would not hinder practice site workflow.

Regarding the feasibility of intern pharmacists’ ability to conduct novel interventions to increase immunization rates, 63% felt that intern pharmacists should be involved in college/university campuses that provide free non-influenza immunizations (Table 2). Similarly, 62% agreed that raising immunization awareness via educational booths/outreaches would be feasible. The least feasible suggestion was intern pharmacists educating technicians to encourage patients to receive appropriate immunizations (13%).

Potential interventions were stratified by comparing responses between pharmacists and intern pharmacists. Pharmacists indicated a higher perceived feasibility for intern pharmacists routinely reviewing patient profiles and documenting appropriate vaccines and making targeted telephone calls regarding recommended immunizations (both p <0.01).

This study examined pharmacist and intern pharmacist perceptions of intern pharmacists’ potential roles in improving non-influenza immunizations, overcoming immunization barriers, and interventions to increase administration rates. Most respondents felt that intern pharmacists can overcome immunization barriers and should have greater involvement in efforts that increase immunization rates.

A CDC study examining pharmacist opinions identified a lack of awareness of necessary immunizations and incomplete immunization records as top immunization barriers, which are consistent with what our findings highlight as opportunities for intern pharmacist involvement.⁽¹⁰⁾ Our study is also congruent with previous results demonstrating that barriers can be addressed by intern pharmacists to increase non-influenza immunization rates.⁽⁵⁾ Initiatives from four pharmacy schools and a hospital concluded that intern pharmacists increased pneumococcal immunizations by screening patients admitted to their service.^(3,11) These initiatives are models that pharmacy schools and departments can build upon.

Based on survey responses, intern pharmacists are widely considered to be adequately prepared to improve immunization awareness. They are encouraged to counsel patients and may be the first and/or only contact that patients have when visiting the pharmacy. Cheung et al determined that 92% of patients would seek future immunizations from a community pharmacy based on their experience with intern pharmacist vaccinators.⁽⁷⁾ Intern pharmacists are ideally-placed healthcare practitioners who can educate patients and address barriers regarding this public health issue. Preceptors and pharmacist supervisors should encourage this, particularly in a population that is increasingly suspicious about vaccinations’ adverse effects and lacks understanding of immunization importance. Additionally, intern pharmacists are well-suited for involvement in community booths/outreaches to promote patient awareness and education and may further increase patient trust. At such events, intern pharmacists could review immunization records, recommend immunizations, and provide educational resources. Furthermore, they may have involvement in campus clinics that provide free non-influenza immunizations.

Participants felt that recommending appropriate immunizations while providing medication consultations was a more feasible approach for intern pharmacists than simply reviewing patient profiles to document appropriate immunizations, which highlights the possibility of adding immunization screening into the workflow. Participants may have felt that intern pharmacists educating technicians on how to encourage patients to receive recommended immunizations would be least feasible because technicians have more pertinent responsibilities or that intern pharmacists may not have the training necessary. Nevertheless, 600 vaccine screenings were successfully performed by technicians at an independent community pharmacy; thus, having intern pharmacists educate technicians on screening and encouraging immunizations may be beneficial.⁽¹²⁾

Overall, respondents indicated similar perceptions regarding potential intern pharmacist-led interventions. Notably, pharmacists had stronger opinions supporting the feasibility of intern pharmacists to routinely review patient profiles and document appropriate vaccines and participate in personalized telephone calls regarding recommended immunizations. This may indicate that pharmacists are more confident in intern pharmacists’ capabilities to execute these interventions. This discrepancy should be considered when assessing potential interventions since pharmacists may be overestimating intern pharmacist capabilities and/or intern pharmacists may not feel prepared at that point in their education.

This study had several strengths including pharmacist and intern pharmacist participants, which is important in determining the feasibility of interventions. Respondents practiced in various settings, allowing for a broader scope of opinions. The data were also stratified by pharmacist and intern pharmacist perceptions to identify diverging viewpoints.

Limitations included a low response rate at <1% despite a large survey distribution. However, it is possible that potential participants overlapped if they were members of both organizations and/or school-based listservs/emails. Given that the optional survey was distributed via organization listservs and/or associated with schools of pharmacy, there is a possible voluntary response bias; many recipients may have chosen not to complete it, thus responses may not accurately reflect the opinions of all pharmacists and intern pharmacists. We were also unable to obtain the number of website visits during the time our survey was posted on CPhA’s website, so we could not assess the extent of any voluntary response bias. Due to the insufficient number of responses to perform certain adjusted analyses, analyses were limited to descriptive statistics. Lastly, pharmacists were not asked about their experience working with intern pharmacists, which could have influenced their opinions.

There was an overwhelming consensus that intern pharmacists could positively improve non-influenza immunization rates through diverse interventions. The identification of barriers that could be addressed by intern pharmacists is an integral step in determining how intern pharmacists can resolve these issues and improve immunization rates. Data on innovative and effective interventions can lead future research to explore these intern pharmacist-led initiatives and evaluate their effectiveness.

The authors would like to thank Lucy Chen, BS, and the California Pharmacy Student Leadership (CAPSLEAD) program for their support of this research endeavor.