- Email: [email protected]
Knowledge, attitudes, and practices regarding influenza vaccination among health professional students
Research NOTES ing all routine adult immunizations in their pharmacy-based immunization programs. References 1. Centers for Disease Control and Prevention. Ten great public health achievements: United States, 1900–1999. MMWR Morb Mortal Wkly Rep. 1999;48:241–3.
Knowledge, attitudes, and practices regarding influenza vaccination among health professional students
2. Centers for Disease Control and Prevention. Department of Human Health and Services. Dear pharmacist letter. July 10, 2001.
Joycelyn Mallari, Jeffery Goad, Joanne Wu, Kathleen Johnson, Todd Forman, and Lawrence Neinstein
3. American Pharmacists Association. Policy handbook. Washington, D.C.: American Pharmacists Association; 1997.
Influenza is a serious health problem worldwide and is associated with an average of 226,000 hospitalizations each year in the United States.1 The principal method for prevention of influenza-related deaths and complications is vaccination of persons at high risk. The Advisory Committee on Immunization Practices (ACIP) recommends vaccination of health care workers (HCWs) because they care for persons at high risk for influenza-related complications.1 Despite these recommendations, vaccination rates among HCWs are only approximately 40%.1 Fear of vaccine adverse effects and inconvenience are among the reasons HCWs choose not to be vaccinated.2,3 ACIP defines HCWs as physicians, nurses, and other personnel in hospital and outpatient care settings; employees of nursing homes and chronic care facilities who have direct contact with patients and persons who provide care to persons at high risk.1 Student HCWs are also frequently in direct contact with patients at high risk for complications associated with influenza because of their program curriculum. Previous studies, primarily focused on nursing and medical students, determined
4. Grabenstein JD, Hayton BD. Pharmacoepidemiologic program for identifying patients in need of vaccination. Am J Hosp Pharm. 1990;47:1774–81. 5. Grabenstein JD, Hartzema AG, Guess HA, et al. Community pharmacists as immunization advocates: a clinical pharmacoepidemiologic experiment. Int J Pharm Pract. 1993;2:5–10. 6. Spruill WJ, Cooper JW, Taylor WJR. Pharmacist-coordinated pneumonia and influenza vaccination program. Am J Hosp Pharm. 1982;39:1904–6. 7. Grabenstein JD, Smith LJ, Carter DW, et al. Comprehensive immunization delivery in conjunction with influenza vaccination. Arch Intern Med. 1986;146:1189–92. 8. Grabenstein JD, Smith LJ, Watson RR, et al. Immunization outreach using individual needs assessments of adults at an Army hospital. Public Health Rep. 1990;105:311–6. 9. Ernst ME, Chalstrom CV, Currie JD, Sorofman B. Implementation of a community pharmacy–based influenza vaccination program. J Am Pharm Assoc. 1997;37:570–80. 10. Grabenstein JD, Guess HA, Hartzema AG. Effect of vaccination by community pharmacists among adult prescription recipients. Med Care. 2001;39:340–8. 11. Van Amburgh JA, Waite NM, Hobson EH, Midgen H. Improved influenza vaccination rates in a rural population as a result of a pharmacist-managed immunization campaign. Pharmacotherapy. 2001;21:1115–22. 12. Grabenstein JD, Guess HA, Hartzema AG. People vaccinated by pharmacists: descriptive epidemiology. J Am Pharm Assoc. 2001;41:46–52. 13. Weitzel KW, Goode JR. Implementation of a pharmacy-based immunization program in a supermarket chain. J Am Pharm Assoc. 2000;40:252–6. 14. Blake EW, Blair MM, Couchenour RL. Perceptions of pharmacists as providers of immunizations for adult patients. Pharmacotherapy. 2003;23:248–54.
J Am Pharm Assoc. 2007;47:498–502. doi: 10.1331/JAPhA.2007.07018 Joycelyn Mallari, PharmD, was Resident, School of Pharmacy, University of Southern California, Los Angeles, at the time this study was conducted; she is currently Assistant Professor, School of Pharmacy, Loma Linda University, Loma Linda, Calif. Jeffery Goad, PharmD, MPH, is Associate Professor, Joanne Wu, MS, is Research Associate, and Kathleen Johnson, PharmD, MPH, PhD, is Associate Professor, School of Pharmacy, University of Southern California, Los Angeles. Todd Forman, MD, is former Director of Student Health Services, Eric Cohen Health Center, Keck School of Medicine, University of Southern California, Los Angeles. Lawrence Neinstein, MD, is Professor and Director of Student Health Services, University Park Campus Health Center, University of Southern California, Los Angeles. Correspondence: Joycelyn Mallari, PharmD, 11262 Campus St., West Hall, Loma Linda, CA 92350. Fax: 909-5587927. E-mail: [email protected] Disclosure: The authors declare no conflicts of interests or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Previous presentation: American Pharmacist Association Annual Meeting, Orlando, Fla., April 4, 2005. Keywords: Influenza vaccine, immunizations, vaccines, heath professionals, student pharmacists, health professional students, allied health professions, physicians.
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Research NOTES influenza vaccination rates of approximately 25%.4,5 Few studies, however, have been conducted to determine the vaccination rates of other student HCWs, such as student pharmacists.
Objectives The purpose of this study was to determine influenza vaccination rates among student HCWs and whether they varied by program or year in school, assess student knowledge of the influenza vaccine and vaccination of HCWs, identify any association between knowledge and attitudes toward the influenza vaccine and higher vaccination rates, and describe the attitudes of students toward influenza immunization of other HCWs.
Methods This study was approved by the Human Subjects Committee (institutional review board) at the University of Southern California. The study design incorporated an Internet-based cross-sectional survey. Participants were students who had a valid e-mail address and were enrolled at the university during the 2004–2005 academic year in one of the following programs: Doctor of Dental Surgery (DDS), Dental Hygiene (DH), Doctor of Medicine (MD), Occupational Therapy (OT), Physical Therapy (PT), Physician Assistant (PA), or Doctor of Pharmacy (PharmD). Participants were e-mailed an invitation to complete an Internet-based questionnaire regarding influenza vaccination. The survey was distributed from March to May 2005. A total of 2,573 students were invited to participate via e-mail with an anonymous link to Zoomerang (MarketTools, Mill Valley, Calif.), a secure commercial Internet-based survey system. Students were excluded from the study if they did not complete the survey. Data were extracted from the online survey system in Excel format and analyzed using SAS version 9 (SAS Institute, Cary, N.C.). Data collected from the questionnaire included student demographics, whether vaccine was received, location and type of vaccination, and vaccination administration training. Six multiple-choice questions were used to determine student HCW knowledge of influenza vaccination. The attitudes of students regarding need for vaccination of various HCWs were assessed by asking students to rank the degree to which they agreed or disagreed with various statements. The statements were ranked on a scale of 1 to 5 (1, strongly disagree; 5, strongly agree).
Statistical analysis Descriptive statistics were performed for demographics of student HCW groups. A one-way analysis of variance test was used to determine differences in attitudes toward vaccination among the various programs of study. With respect to knowledge, differences among programs were assessed by chi-square tests. Multivariate logistic regression was used to determine variables associated with vaccination of student HCWs. A model was created to determine which factors were associated with vaccination of student HCWs. Age, program, medical conditions, Journal of the American Pharmacists Association
past influenza sickness, previous vaccination, high knowledge, and belief that one’s own profession is at risk were included in the multivariate logistic regression model. For analysis among groups, students in the DH program were grouped with those in the DDS program because of similarity of patient contact.
Results Of the 2,573 students invited to participate (DDS, 570; DH, 72; MD, 662; OT, 162; PT, 248; PA, 120; and PharmD, 739), 462 completed the study (overall response rate, 18%) (Table 1). Student pharmacists had the greatest response rate and comprised the highest proportion of respondents. The overall influenza vaccination rate among all student HCWs was 21%. Medical students had the highest vaccination rate (30%). The most common reason students gave for not getting vaccinated in the 2004–2005 influenza season was the vaccine shortage (61%). In addition, 24% of students were not vaccinated because they believed that they were not at risk and 16% perceived it to be an inconvenience. Most student HCWs were vaccinated in hospitals and physician offices (48%), followed by pharmacies (40%). Vaccination sites varied according to program: all dental students received vaccination in the student health center, most medical students were vaccinated in the hospital, and the majority of student pharmacists used the pharmacy. Overall, 63% of student HCW participants reported that they received formal training on vaccine administration. Large variations were observed among programs, with all student pharmacists trained compared with only 20% of medical students and fewer than 10% for OT, PT, and PA students. A majority of student pharmacists (71%) versus medical students (6%) also administered vaccines during the 2004–2005 influenza season. In general, knowledge among all students of the influenza vaccine and vaccination of HCWs was high. More than 60% of students answered five of six questions correctly. There were differences among the HCW programs in the proportions of students who answered five or more questions correctly (P < 0.001) (Figure 1). The allied student HCWs (OT, PT, and PA programs) displayed less knowledge of the vaccine and vaccination of HCWs than those in the other programs. Student pharmacists were significantly more knowledgeable than dentistry, OT, PT, and PA students. First-year students in all disciplines had the highest mean score of knowledge versus all other program years (P < 0.001; data not shown). The following true/false statement had the highest rate of incorrect responses: “You can get influenza from the injectable form of the vaccine.” In all, 24% of respondents thought one could get influenza from the inactivated vaccine. Overall, most students agreed that all HCWs should be vaccinated annually, as reflected by means of 3 or higher for the statements in Figure 1 (mean, 4.1; range, 3.24–4.69) (Table 2), but physicians were ranked highest. The attitudes of student pharmacists toward the necessity of vaccination for various HCWs differed from students in other programs. Student pharmacists w w w. p h a r m a c i s t . c o m
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Research NOTES Table 1. Demographics, vaccination rates, and influenza history of USC student HCWs participating in the study Program of study
DDS, DH
MD
OT, PT, PA
PharmD
Total
Participants, n (%) 39 (8) 96 (21) 61 (13) 266 (58) 462 (100) Time in program (years), n (%) 1 19 (49) 28 (29) 27 (44) 184 (69) 258 (56) 2 12 (31) 28 (29) 12 (25) 37 (14) 92 (20) 3 3 (8) 15 (16) 15 (25) 20 (8) 53 (11) 4+ 5 (13) 25 (26) 4 (7) 25 (9) 59 (13) Age, mean (range) 26 (21–38) 25 (22–36) 27 (22–51) 25 (21–41) 25 (21–51) Female gender, n (%) 20 (51) 54 (56) 54 (89) 209 (79) 337 (73) Ethnicity, n (%) African American 0 (0) 2 (2) 0 (0) 3 (1) 5 (1) Asian/Pacific Islander 13 (33) 15 (16) 21 (34) 187 (70) 236 (51) Caucasian 21 (54) 65 (68) 30 (49) 49 (18) 165 (36) Latino 2 (5) 7 (7) 30 (49) 4 (2) 18 (4) Other 3 (8) 7 (7) 5 (8) 23 (9) 38 (8) Vaccinated this season, n (%) 3 (8) 29 (30) 14 (23) 49 (18) 95 (21) Past influenza sickness, n (%) 26 (76) 64 (67) 44 (72) 189 (71) 323 (70) Past influenza immunization, n (%) 19 (49) 68 (71) 46 (75) 155 (58) 288 (62) Abbreviations used: DDS, Doctor of Dental Surgery; DH, Dental Hygiene; HCW, health care worker; MD, Doctor of Medicine; OT, Occupational Therapy; PT, Physical Therapy; PA, Physician Assistant; PharmD, Doctor of Pharmacy; USC, University of Southern California.
ranked their profession as being least in need for vaccination, while student HCWs from all other programs believed physical therapists were least in need (Figure 1). The mean attitude score was lowest for medical students’ belief in yearly vaccination for physical therapists. The two most significant factors associated with students receiving the vaccination were previous vaccination (P < 0.001) and a predisposition of one’s own professional risk (P = 0.03). Those vaccinated in the past were approximately 11 times more likely to be vaccinated again (odds ratio [OR], 11.4; 95% confidence interval [CI], 4.8–27.1). Those with a high belief that their own profession should be vaccinated yearly were about twice as likely to be vaccinated themselves (OR, 1.91; 95% CI, 1.061–3.431).
Discussion Student HCWs in this study had a lower influenza vaccination rate (21%) than that observed in a postgraduate HCW population (40%).1 The recent report of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and ACIP’s 2006 report expanded the definition of HCWs to include students and trainees by reinforcing immunization recommendations and called for further research in this population.6 Busy schedules, inconvenience, and concern over vaccination adverse effects have been previously reported to reduce vaccination rates.2,3 In this study, inconvenience was a prominent factor for student HCWs not getting vaccinated. A slight, but not statistically significant, increase in vaccination rate was observed from first- to third-year students, consistent with increasing patient contact. Most students chose to be vaccinated in pharmacies and hospi500 • JAPhA • 47: 4 • J u l /A u g 2 0 07
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tals, possibly because they are the most convenient locations for the population surveyed. Influenza vaccination is not required in the health care professional programs at our institution, and cost may vary depending on the location of vaccination. In this survey, the cost of obtaining the vaccine was only the fifth most cited reason for not getting vaccinated. Student HCWs had high knowledge of the influenza vaccine and the need for vaccination of HCWs overall. Still, high knowledge has not been associated with higher vaccination rates, as illustrated in other studies.7 In this study, students in the first year had the highest knowledge but the lowest vaccination rate. First-year students may have perceived their risk of contact with patients as not being considerable enough to warrant vaccination. All of the health care professional programs at our institution involve direct patient care from the first year. Variations in knowledge among professional programs also may relate to differences in curriculum. Although overall knowledge was high, it is concerning that 24% of respondents thought one could get influenza from the inactivated vaccine. Pharmacy, medicine, and physician assistant students were least likely to believe this myth. This may have represented another barrier to vaccination not elicited in the self-reported barriers section of the questionnaire. Student attitudes regarding vaccination of HCWs were similar. Most students regarded physicians as having the greatest need of yearly vaccination. Student pharmacists believed that pharmacists were least in need of vaccination, whereas students in all other programs ranked physical therapists as least in need. These results also may indicate a lack of awareness among stuJournal of the American Pharmacists Association
Research NOTES
5/6 correct
Fewer correct
300
250
No. Responses
69 200
150
100
196 40
50 21
57
18
0
DDS, DH
Table 2. USC students’ opinions about the need for vaccinating various types of HCWs for influenza HCWs to be vaccinated
Program of studya DDS, OT, PT, DH MD PA PharmD
Dentists Dental hygienists Physicians Physician assistants Pharmacists Physical therapists Occupational therapists
4.05 4.05 4.28 a 4.15 a 3.87 3.56 a 3.77a
4.01 4.01 4.52 4.41 3.91 3.24 a 3.92
4.05 4.02 4.26 a 4.20 4.03 3.52 a 4.00
4.41 4.38 4.69 4.55 4.23 4.53 4.29
Abbreviations used: DDS, Doctor of Dental Surgery; DH, Dental Hygiene; HCW, health care worker; MD, Doctor of Medicine; OT, Occupational Therapy; PT, Physical Therapy; PA, Physician Assistant; PharmD, Doctor of Pharmacy; USC, University of Southern California. a 1, strongly disagree; 5, strongly agree.
47 14
MD
OT, PT, PA
PharmD
Student HCW categories
Figure 1. Numbers of USC student HCWs correctly answering 5 of 6 questionnaire items. Student pharmacists scored significantly higher than other student HCWs (P <0.001; chi-square). Abbreviations used: USC, University of Southern California; HCWs, health care workers; DDS, Doctor of Dental Surgery; DH, Dental Hygiene; HCW, health care worker; MD, Doctor of Medicine; OT, Occupational Therapy; PT, Physical Therapy; PA, Physician Assistant; PharmD, Doctor of Pharmacy
dents of the type of patient care other student HCWs perform. Previous vaccination and perceived risk of acquiring influenza were the most important factors associated with being vaccinated among student HCWs. Medical students were the only group to rank MDs as having the greatest need for vaccination, and these students had the greatest rate of vaccination. A gap remains between knowledge and practice—99.4% of students knew that HCWs could spread influenza to their patients, but this was not reflected in their personal rate of vaccination.
Limitations Low response rates for all programs and the single-center nature of the study may limit generalizability, although there were notable exceptions in some subgroups (e.g., 69% response rate of first-year student pharmacists). Furthermore, professional patient experiences and curricula would not be expected to vary greatly for students in the same program of study. Another potential drawback is that the survey was based on recall and not validated by a record of vaccination. Still, recall bias should be minimal because students were asked only to remember vaccination practices and attitudes in the past year. Finally, the vaccine shortage during the 2004–2005 influenza season could have affected the vaccination rate of students; in fact, 61% of students reported that the shortage was their principal reason for not getJournal of the American Pharmacists Association
ting vaccinated. However, despite the shortage, the ACIP recommendation for vaccination of HCWs as a target population did not change at any point during the study period. In addition, there was no shortage of the live, attenuated influenza vaccine, and most students would have likely fit the criteria for immunization with this vaccine.
Conclusion Recommendations call for HCWs, including students, with direct patient contact to receive annual influenza immunizations, yet vaccination rates remain low. Although knowledge was high overall, more effective educational interventions are needed to bridge the gap between knowledge and practice. To advance to the new HICPAC and ACIP recommendations of vaccination of students and trainees, student health departments should explore new ways, such as programs that involve pharmacies and/or student pharmacists, to increase vaccination rates among student HCWs. Additionally, professional health care programs at universities should consider recommendations for influenza vaccination similar to other required vaccinations, such as that for hepatitis B. References
1. Harper SA, Fukuda K, Uyeki TM, et al.. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005;54:1– 40. 2. Goldstein AO, Kincade JE, Gamble G, Bearman RS. Policies and practices for improving influenza immunization rates among healthcare workers. Infect Control Hosp Epidemiol. 2004;25:908–11. 3. Lester RT, McGeer A, Tomlinson G, Detsky AS. Use of, effectiveness of, and attitudes regarding influenza vaccine among house staff. Infect Control Hosp Epidemiol. 2003;24:839–44. 4. Nichol Kl. Medical student’s exposure and immunity to vaccine-preventable diseases. Arch Intern Med. 1993;153:1913–6.
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Research NOTES 5. Madar R, Repkova L, Baska T, Straka S. Influenza vaccination— knowledge, attitudes, coverage—can they be improved? Bratisl Lek Listy. 2003;104:232–5. 6. Pearson ML, Bridges CB, Harper SA, et al. Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55;1–16. 7. Martinello RA, Jones L, Topal JE. Correlation between healthcare workers’ knowledge of influenza vaccine and vaccine receipt. Infect Control Hosp Epidemiol. 2003;24:845–7.
Implementation of pharmacist training and counseling program on vitamins and minerals Katie Tibbs, Kelly Swensgard, Wayne Conrad, and Pamela C. Heaton
Use of OTC medications, including vitamins and minerals or dietary supplements, may enhance patient care and increase revenue as a result of their large profit margin.1 On average, 20% of patients taking prescription medications take at least one dietary supplement2; however, the vast majority of people who take dietary supplements (72%) do so without the advice of their physician.3 Pharmacists are in a unique position to educate patients on vitamins and minerals and are one of the most accessible health professionals, with approximately 250 million people walking through their doors every week.4,5 However, pharmacists currently do not consistently educate patients on the use of OTC products; specifically, counseling J Am Pharm Assoc. 2007;47:502–504. doi: 10.1331/JAPhA.2007.06045 Received May 5, 2006, and in revised form August 29, 2006. Accepted for publication October 7, 2006. Katie Tibbs, PharmD, was Community Pharmacy Practice Resident, University of Cincinnati/Community Care Pharmacy, at the time this study was conducted; she is currently Customer Service Pharmacist, Anthem, Cincinnati. Kelly Swensgard, PharmD, is Adjunct Professor; Wayne Conrad, PharmD, FASHP, is Professor and Chair; and Pamela C. Heaton, PhD, BPharm, is Assistant Professor, Division of Pharmacy Practice, College of Pharmacy, University of Cincinnati, Cincinnati, Ohio. Correspondence: Pamela C. Heaton, College of Pharmacy, University of Cincinnati, 3225 Eden Ave., Cincinnati, OH 45267-0004. Fax 513-558-0731. E-mail: [email protected] Disclosure: The authors declare no conflicts of interests or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Funding: Provided by an incentive grant from the APhA Foundation. Previous Presentations: Presented at the Great Lakes Residency Conference, West Lafayette, Ind., April, 2005, and at the American Pharmacists Association Annual Meeting, Orlando, April 1–5, 2005.
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on dietary supplements is lacking.6 Most pharmacists fail to recommend dietary supplements because they do not have an extensive knowledge base about these products.7 Many believe that if pharmacists are provided with information and training in this area, then they can considerably enhance patient care and increase revenue.1 However, no published studies exist in the literature that show the impact of training community pharmacists on dietary supplement counseling. Additionally, lack of time and reimbursement are often reported by pharmacists as barriers to implementation of programs in the community pharmacy setting.8 For programs to be successfully initiated in community pharmacies, they must be economically feasible and easily incorporated into the normal daily work flow.
Objective We aimed to design, implement, and evaluate a vitamin and mineral supplement counseling program in the community setting that is economically feasible and incorporated into the daily work flow.
Methods Community Pharmacy Care (CPC) is an independent pharmacy consisting of three stores located in northern Kentucky. All four pharmacists at two of the three CPC pharmacies participated in this educational program. The pharmacists at the third location elected not to participate in the program. CPC is dedicated to enhancing the quality of patient care at their pharmacies and is currently involved in many programs, including asthma and diabetes disease management programs, smoking cessation programs, and a senior medication advocacy program. A community pharmacy resident at CPC developed an educational program to provide pharmacists with information on vitamin and mineral supplementation. We first selected the following medication classes for the program: selective estrogen receptor modulators (SERMs), bisphosphonates, anticonvulsants, and antidiabetic agents. These medication classes were selected because the benefits of supplement use in these diseases are established. The recommended dietary supplements were as follows: calcium, vitamin D, and folic acid for phenytoin, carbamazepine, primidone, phenobarbital, ethosuximide, and oxcarbazepine use9; calcium and folic acid for zonisamide use9; folic acid for valproic acid use9; calcium and vitamin D for SERM and bisphosphonate use10,11; and magnesium for antidiabetes agent use.12 Affordable products were selected so that the majority of the patient population could benefit from the service. Next, each pharmacist was provided with a one-on-one educational session facilitated by the community pharmacy resident. This session lasted approximately 1 hour and emphasized key concepts to provide during dietary supplement counseling. During this meeting, each pharmacist was given a study guidebook. This guidebook was developed by the pharmacy resident and included information from the Drug-Induced Nutrient DepleJournal of the American Pharmacists Association
Knowledge, attitudes, and practices regarding influenza vaccination among health professional students
2. Centers for Disease Control and Prevention. Department of Human Health and Services. Dear pharmacist letter. July 10, 2001.
Joycelyn Mallari, Jeffery Goad, Joanne Wu, Kathleen Johnson, Todd Forman, and Lawrence Neinstein
3. American Pharmacists Association. Policy handbook. Washington, D.C.: American Pharmacists Association; 1997.
Influenza is a serious health problem worldwide and is associated with an average of 226,000 hospitalizations each year in the United States.1 The principal method for prevention of influenza-related deaths and complications is vaccination of persons at high risk. The Advisory Committee on Immunization Practices (ACIP) recommends vaccination of health care workers (HCWs) because they care for persons at high risk for influenza-related complications.1 Despite these recommendations, vaccination rates among HCWs are only approximately 40%.1 Fear of vaccine adverse effects and inconvenience are among the reasons HCWs choose not to be vaccinated.2,3 ACIP defines HCWs as physicians, nurses, and other personnel in hospital and outpatient care settings; employees of nursing homes and chronic care facilities who have direct contact with patients and persons who provide care to persons at high risk.1 Student HCWs are also frequently in direct contact with patients at high risk for complications associated with influenza because of their program curriculum. Previous studies, primarily focused on nursing and medical students, determined
4. Grabenstein JD, Hayton BD. Pharmacoepidemiologic program for identifying patients in need of vaccination. Am J Hosp Pharm. 1990;47:1774–81. 5. Grabenstein JD, Hartzema AG, Guess HA, et al. Community pharmacists as immunization advocates: a clinical pharmacoepidemiologic experiment. Int J Pharm Pract. 1993;2:5–10. 6. Spruill WJ, Cooper JW, Taylor WJR. Pharmacist-coordinated pneumonia and influenza vaccination program. Am J Hosp Pharm. 1982;39:1904–6. 7. Grabenstein JD, Smith LJ, Carter DW, et al. Comprehensive immunization delivery in conjunction with influenza vaccination. Arch Intern Med. 1986;146:1189–92. 8. Grabenstein JD, Smith LJ, Watson RR, et al. Immunization outreach using individual needs assessments of adults at an Army hospital. Public Health Rep. 1990;105:311–6. 9. Ernst ME, Chalstrom CV, Currie JD, Sorofman B. Implementation of a community pharmacy–based influenza vaccination program. J Am Pharm Assoc. 1997;37:570–80. 10. Grabenstein JD, Guess HA, Hartzema AG. Effect of vaccination by community pharmacists among adult prescription recipients. Med Care. 2001;39:340–8. 11. Van Amburgh JA, Waite NM, Hobson EH, Midgen H. Improved influenza vaccination rates in a rural population as a result of a pharmacist-managed immunization campaign. Pharmacotherapy. 2001;21:1115–22. 12. Grabenstein JD, Guess HA, Hartzema AG. People vaccinated by pharmacists: descriptive epidemiology. J Am Pharm Assoc. 2001;41:46–52. 13. Weitzel KW, Goode JR. Implementation of a pharmacy-based immunization program in a supermarket chain. J Am Pharm Assoc. 2000;40:252–6. 14. Blake EW, Blair MM, Couchenour RL. Perceptions of pharmacists as providers of immunizations for adult patients. Pharmacotherapy. 2003;23:248–54.
J Am Pharm Assoc. 2007;47:498–502. doi: 10.1331/JAPhA.2007.07018 Joycelyn Mallari, PharmD, was Resident, School of Pharmacy, University of Southern California, Los Angeles, at the time this study was conducted; she is currently Assistant Professor, School of Pharmacy, Loma Linda University, Loma Linda, Calif. Jeffery Goad, PharmD, MPH, is Associate Professor, Joanne Wu, MS, is Research Associate, and Kathleen Johnson, PharmD, MPH, PhD, is Associate Professor, School of Pharmacy, University of Southern California, Los Angeles. Todd Forman, MD, is former Director of Student Health Services, Eric Cohen Health Center, Keck School of Medicine, University of Southern California, Los Angeles. Lawrence Neinstein, MD, is Professor and Director of Student Health Services, University Park Campus Health Center, University of Southern California, Los Angeles. Correspondence: Joycelyn Mallari, PharmD, 11262 Campus St., West Hall, Loma Linda, CA 92350. Fax: 909-5587927. E-mail: [email protected] Disclosure: The authors declare no conflicts of interests or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Previous presentation: American Pharmacist Association Annual Meeting, Orlando, Fla., April 4, 2005. Keywords: Influenza vaccine, immunizations, vaccines, heath professionals, student pharmacists, health professional students, allied health professions, physicians.
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Research NOTES influenza vaccination rates of approximately 25%.4,5 Few studies, however, have been conducted to determine the vaccination rates of other student HCWs, such as student pharmacists.
Objectives The purpose of this study was to determine influenza vaccination rates among student HCWs and whether they varied by program or year in school, assess student knowledge of the influenza vaccine and vaccination of HCWs, identify any association between knowledge and attitudes toward the influenza vaccine and higher vaccination rates, and describe the attitudes of students toward influenza immunization of other HCWs.
Methods This study was approved by the Human Subjects Committee (institutional review board) at the University of Southern California. The study design incorporated an Internet-based cross-sectional survey. Participants were students who had a valid e-mail address and were enrolled at the university during the 2004–2005 academic year in one of the following programs: Doctor of Dental Surgery (DDS), Dental Hygiene (DH), Doctor of Medicine (MD), Occupational Therapy (OT), Physical Therapy (PT), Physician Assistant (PA), or Doctor of Pharmacy (PharmD). Participants were e-mailed an invitation to complete an Internet-based questionnaire regarding influenza vaccination. The survey was distributed from March to May 2005. A total of 2,573 students were invited to participate via e-mail with an anonymous link to Zoomerang (MarketTools, Mill Valley, Calif.), a secure commercial Internet-based survey system. Students were excluded from the study if they did not complete the survey. Data were extracted from the online survey system in Excel format and analyzed using SAS version 9 (SAS Institute, Cary, N.C.). Data collected from the questionnaire included student demographics, whether vaccine was received, location and type of vaccination, and vaccination administration training. Six multiple-choice questions were used to determine student HCW knowledge of influenza vaccination. The attitudes of students regarding need for vaccination of various HCWs were assessed by asking students to rank the degree to which they agreed or disagreed with various statements. The statements were ranked on a scale of 1 to 5 (1, strongly disagree; 5, strongly agree).
Statistical analysis Descriptive statistics were performed for demographics of student HCW groups. A one-way analysis of variance test was used to determine differences in attitudes toward vaccination among the various programs of study. With respect to knowledge, differences among programs were assessed by chi-square tests. Multivariate logistic regression was used to determine variables associated with vaccination of student HCWs. A model was created to determine which factors were associated with vaccination of student HCWs. Age, program, medical conditions, Journal of the American Pharmacists Association
past influenza sickness, previous vaccination, high knowledge, and belief that one’s own profession is at risk were included in the multivariate logistic regression model. For analysis among groups, students in the DH program were grouped with those in the DDS program because of similarity of patient contact.
Results Of the 2,573 students invited to participate (DDS, 570; DH, 72; MD, 662; OT, 162; PT, 248; PA, 120; and PharmD, 739), 462 completed the study (overall response rate, 18%) (Table 1). Student pharmacists had the greatest response rate and comprised the highest proportion of respondents. The overall influenza vaccination rate among all student HCWs was 21%. Medical students had the highest vaccination rate (30%). The most common reason students gave for not getting vaccinated in the 2004–2005 influenza season was the vaccine shortage (61%). In addition, 24% of students were not vaccinated because they believed that they were not at risk and 16% perceived it to be an inconvenience. Most student HCWs were vaccinated in hospitals and physician offices (48%), followed by pharmacies (40%). Vaccination sites varied according to program: all dental students received vaccination in the student health center, most medical students were vaccinated in the hospital, and the majority of student pharmacists used the pharmacy. Overall, 63% of student HCW participants reported that they received formal training on vaccine administration. Large variations were observed among programs, with all student pharmacists trained compared with only 20% of medical students and fewer than 10% for OT, PT, and PA students. A majority of student pharmacists (71%) versus medical students (6%) also administered vaccines during the 2004–2005 influenza season. In general, knowledge among all students of the influenza vaccine and vaccination of HCWs was high. More than 60% of students answered five of six questions correctly. There were differences among the HCW programs in the proportions of students who answered five or more questions correctly (P < 0.001) (Figure 1). The allied student HCWs (OT, PT, and PA programs) displayed less knowledge of the vaccine and vaccination of HCWs than those in the other programs. Student pharmacists were significantly more knowledgeable than dentistry, OT, PT, and PA students. First-year students in all disciplines had the highest mean score of knowledge versus all other program years (P < 0.001; data not shown). The following true/false statement had the highest rate of incorrect responses: “You can get influenza from the injectable form of the vaccine.” In all, 24% of respondents thought one could get influenza from the inactivated vaccine. Overall, most students agreed that all HCWs should be vaccinated annually, as reflected by means of 3 or higher for the statements in Figure 1 (mean, 4.1; range, 3.24–4.69) (Table 2), but physicians were ranked highest. The attitudes of student pharmacists toward the necessity of vaccination for various HCWs differed from students in other programs. Student pharmacists w w w. p h a r m a c i s t . c o m
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Research NOTES Table 1. Demographics, vaccination rates, and influenza history of USC student HCWs participating in the study Program of study
DDS, DH
MD
OT, PT, PA
PharmD
Total
Participants, n (%) 39 (8) 96 (21) 61 (13) 266 (58) 462 (100) Time in program (years), n (%) 1 19 (49) 28 (29) 27 (44) 184 (69) 258 (56) 2 12 (31) 28 (29) 12 (25) 37 (14) 92 (20) 3 3 (8) 15 (16) 15 (25) 20 (8) 53 (11) 4+ 5 (13) 25 (26) 4 (7) 25 (9) 59 (13) Age, mean (range) 26 (21–38) 25 (22–36) 27 (22–51) 25 (21–41) 25 (21–51) Female gender, n (%) 20 (51) 54 (56) 54 (89) 209 (79) 337 (73) Ethnicity, n (%) African American 0 (0) 2 (2) 0 (0) 3 (1) 5 (1) Asian/Pacific Islander 13 (33) 15 (16) 21 (34) 187 (70) 236 (51) Caucasian 21 (54) 65 (68) 30 (49) 49 (18) 165 (36) Latino 2 (5) 7 (7) 30 (49) 4 (2) 18 (4) Other 3 (8) 7 (7) 5 (8) 23 (9) 38 (8) Vaccinated this season, n (%) 3 (8) 29 (30) 14 (23) 49 (18) 95 (21) Past influenza sickness, n (%) 26 (76) 64 (67) 44 (72) 189 (71) 323 (70) Past influenza immunization, n (%) 19 (49) 68 (71) 46 (75) 155 (58) 288 (62) Abbreviations used: DDS, Doctor of Dental Surgery; DH, Dental Hygiene; HCW, health care worker; MD, Doctor of Medicine; OT, Occupational Therapy; PT, Physical Therapy; PA, Physician Assistant; PharmD, Doctor of Pharmacy; USC, University of Southern California.
ranked their profession as being least in need for vaccination, while student HCWs from all other programs believed physical therapists were least in need (Figure 1). The mean attitude score was lowest for medical students’ belief in yearly vaccination for physical therapists. The two most significant factors associated with students receiving the vaccination were previous vaccination (P < 0.001) and a predisposition of one’s own professional risk (P = 0.03). Those vaccinated in the past were approximately 11 times more likely to be vaccinated again (odds ratio [OR], 11.4; 95% confidence interval [CI], 4.8–27.1). Those with a high belief that their own profession should be vaccinated yearly were about twice as likely to be vaccinated themselves (OR, 1.91; 95% CI, 1.061–3.431).
Discussion Student HCWs in this study had a lower influenza vaccination rate (21%) than that observed in a postgraduate HCW population (40%).1 The recent report of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and ACIP’s 2006 report expanded the definition of HCWs to include students and trainees by reinforcing immunization recommendations and called for further research in this population.6 Busy schedules, inconvenience, and concern over vaccination adverse effects have been previously reported to reduce vaccination rates.2,3 In this study, inconvenience was a prominent factor for student HCWs not getting vaccinated. A slight, but not statistically significant, increase in vaccination rate was observed from first- to third-year students, consistent with increasing patient contact. Most students chose to be vaccinated in pharmacies and hospi500 • JAPhA • 47: 4 • J u l /A u g 2 0 07
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tals, possibly because they are the most convenient locations for the population surveyed. Influenza vaccination is not required in the health care professional programs at our institution, and cost may vary depending on the location of vaccination. In this survey, the cost of obtaining the vaccine was only the fifth most cited reason for not getting vaccinated. Student HCWs had high knowledge of the influenza vaccine and the need for vaccination of HCWs overall. Still, high knowledge has not been associated with higher vaccination rates, as illustrated in other studies.7 In this study, students in the first year had the highest knowledge but the lowest vaccination rate. First-year students may have perceived their risk of contact with patients as not being considerable enough to warrant vaccination. All of the health care professional programs at our institution involve direct patient care from the first year. Variations in knowledge among professional programs also may relate to differences in curriculum. Although overall knowledge was high, it is concerning that 24% of respondents thought one could get influenza from the inactivated vaccine. Pharmacy, medicine, and physician assistant students were least likely to believe this myth. This may have represented another barrier to vaccination not elicited in the self-reported barriers section of the questionnaire. Student attitudes regarding vaccination of HCWs were similar. Most students regarded physicians as having the greatest need of yearly vaccination. Student pharmacists believed that pharmacists were least in need of vaccination, whereas students in all other programs ranked physical therapists as least in need. These results also may indicate a lack of awareness among stuJournal of the American Pharmacists Association
Research NOTES
5/6 correct
Fewer correct
300
250
No. Responses
69 200
150
100
196 40
50 21
57
18
0
DDS, DH
Table 2. USC students’ opinions about the need for vaccinating various types of HCWs for influenza HCWs to be vaccinated
Program of studya DDS, OT, PT, DH MD PA PharmD
Dentists Dental hygienists Physicians Physician assistants Pharmacists Physical therapists Occupational therapists
4.05 4.05 4.28 a 4.15 a 3.87 3.56 a 3.77a
4.01 4.01 4.52 4.41 3.91 3.24 a 3.92
4.05 4.02 4.26 a 4.20 4.03 3.52 a 4.00
4.41 4.38 4.69 4.55 4.23 4.53 4.29
Abbreviations used: DDS, Doctor of Dental Surgery; DH, Dental Hygiene; HCW, health care worker; MD, Doctor of Medicine; OT, Occupational Therapy; PT, Physical Therapy; PA, Physician Assistant; PharmD, Doctor of Pharmacy; USC, University of Southern California. a 1, strongly disagree; 5, strongly agree.
47 14
MD
OT, PT, PA
PharmD
Student HCW categories
Figure 1. Numbers of USC student HCWs correctly answering 5 of 6 questionnaire items. Student pharmacists scored significantly higher than other student HCWs (P <0.001; chi-square). Abbreviations used: USC, University of Southern California; HCWs, health care workers; DDS, Doctor of Dental Surgery; DH, Dental Hygiene; HCW, health care worker; MD, Doctor of Medicine; OT, Occupational Therapy; PT, Physical Therapy; PA, Physician Assistant; PharmD, Doctor of Pharmacy
dents of the type of patient care other student HCWs perform. Previous vaccination and perceived risk of acquiring influenza were the most important factors associated with being vaccinated among student HCWs. Medical students were the only group to rank MDs as having the greatest need for vaccination, and these students had the greatest rate of vaccination. A gap remains between knowledge and practice—99.4% of students knew that HCWs could spread influenza to their patients, but this was not reflected in their personal rate of vaccination.
Limitations Low response rates for all programs and the single-center nature of the study may limit generalizability, although there were notable exceptions in some subgroups (e.g., 69% response rate of first-year student pharmacists). Furthermore, professional patient experiences and curricula would not be expected to vary greatly for students in the same program of study. Another potential drawback is that the survey was based on recall and not validated by a record of vaccination. Still, recall bias should be minimal because students were asked only to remember vaccination practices and attitudes in the past year. Finally, the vaccine shortage during the 2004–2005 influenza season could have affected the vaccination rate of students; in fact, 61% of students reported that the shortage was their principal reason for not getJournal of the American Pharmacists Association
ting vaccinated. However, despite the shortage, the ACIP recommendation for vaccination of HCWs as a target population did not change at any point during the study period. In addition, there was no shortage of the live, attenuated influenza vaccine, and most students would have likely fit the criteria for immunization with this vaccine.
Conclusion Recommendations call for HCWs, including students, with direct patient contact to receive annual influenza immunizations, yet vaccination rates remain low. Although knowledge was high overall, more effective educational interventions are needed to bridge the gap between knowledge and practice. To advance to the new HICPAC and ACIP recommendations of vaccination of students and trainees, student health departments should explore new ways, such as programs that involve pharmacies and/or student pharmacists, to increase vaccination rates among student HCWs. Additionally, professional health care programs at universities should consider recommendations for influenza vaccination similar to other required vaccinations, such as that for hepatitis B. References
1. Harper SA, Fukuda K, Uyeki TM, et al.. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005;54:1– 40. 2. Goldstein AO, Kincade JE, Gamble G, Bearman RS. Policies and practices for improving influenza immunization rates among healthcare workers. Infect Control Hosp Epidemiol. 2004;25:908–11. 3. Lester RT, McGeer A, Tomlinson G, Detsky AS. Use of, effectiveness of, and attitudes regarding influenza vaccine among house staff. Infect Control Hosp Epidemiol. 2003;24:839–44. 4. Nichol Kl. Medical student’s exposure and immunity to vaccine-preventable diseases. Arch Intern Med. 1993;153:1913–6.
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Research NOTES 5. Madar R, Repkova L, Baska T, Straka S. Influenza vaccination— knowledge, attitudes, coverage—can they be improved? Bratisl Lek Listy. 2003;104:232–5. 6. Pearson ML, Bridges CB, Harper SA, et al. Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55;1–16. 7. Martinello RA, Jones L, Topal JE. Correlation between healthcare workers’ knowledge of influenza vaccine and vaccine receipt. Infect Control Hosp Epidemiol. 2003;24:845–7.
Implementation of pharmacist training and counseling program on vitamins and minerals Katie Tibbs, Kelly Swensgard, Wayne Conrad, and Pamela C. Heaton
Use of OTC medications, including vitamins and minerals or dietary supplements, may enhance patient care and increase revenue as a result of their large profit margin.1 On average, 20% of patients taking prescription medications take at least one dietary supplement2; however, the vast majority of people who take dietary supplements (72%) do so without the advice of their physician.3 Pharmacists are in a unique position to educate patients on vitamins and minerals and are one of the most accessible health professionals, with approximately 250 million people walking through their doors every week.4,5 However, pharmacists currently do not consistently educate patients on the use of OTC products; specifically, counseling J Am Pharm Assoc. 2007;47:502–504. doi: 10.1331/JAPhA.2007.06045 Received May 5, 2006, and in revised form August 29, 2006. Accepted for publication October 7, 2006. Katie Tibbs, PharmD, was Community Pharmacy Practice Resident, University of Cincinnati/Community Care Pharmacy, at the time this study was conducted; she is currently Customer Service Pharmacist, Anthem, Cincinnati. Kelly Swensgard, PharmD, is Adjunct Professor; Wayne Conrad, PharmD, FASHP, is Professor and Chair; and Pamela C. Heaton, PhD, BPharm, is Assistant Professor, Division of Pharmacy Practice, College of Pharmacy, University of Cincinnati, Cincinnati, Ohio. Correspondence: Pamela C. Heaton, College of Pharmacy, University of Cincinnati, 3225 Eden Ave., Cincinnati, OH 45267-0004. Fax 513-558-0731. E-mail: [email protected] Disclosure: The authors declare no conflicts of interests or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Funding: Provided by an incentive grant from the APhA Foundation. Previous Presentations: Presented at the Great Lakes Residency Conference, West Lafayette, Ind., April, 2005, and at the American Pharmacists Association Annual Meeting, Orlando, April 1–5, 2005.
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on dietary supplements is lacking.6 Most pharmacists fail to recommend dietary supplements because they do not have an extensive knowledge base about these products.7 Many believe that if pharmacists are provided with information and training in this area, then they can considerably enhance patient care and increase revenue.1 However, no published studies exist in the literature that show the impact of training community pharmacists on dietary supplement counseling. Additionally, lack of time and reimbursement are often reported by pharmacists as barriers to implementation of programs in the community pharmacy setting.8 For programs to be successfully initiated in community pharmacies, they must be economically feasible and easily incorporated into the normal daily work flow.
Objective We aimed to design, implement, and evaluate a vitamin and mineral supplement counseling program in the community setting that is economically feasible and incorporated into the daily work flow.
Methods Community Pharmacy Care (CPC) is an independent pharmacy consisting of three stores located in northern Kentucky. All four pharmacists at two of the three CPC pharmacies participated in this educational program. The pharmacists at the third location elected not to participate in the program. CPC is dedicated to enhancing the quality of patient care at their pharmacies and is currently involved in many programs, including asthma and diabetes disease management programs, smoking cessation programs, and a senior medication advocacy program. A community pharmacy resident at CPC developed an educational program to provide pharmacists with information on vitamin and mineral supplementation. We first selected the following medication classes for the program: selective estrogen receptor modulators (SERMs), bisphosphonates, anticonvulsants, and antidiabetic agents. These medication classes were selected because the benefits of supplement use in these diseases are established. The recommended dietary supplements were as follows: calcium, vitamin D, and folic acid for phenytoin, carbamazepine, primidone, phenobarbital, ethosuximide, and oxcarbazepine use9; calcium and folic acid for zonisamide use9; folic acid for valproic acid use9; calcium and vitamin D for SERM and bisphosphonate use10,11; and magnesium for antidiabetes agent use.12 Affordable products were selected so that the majority of the patient population could benefit from the service. Next, each pharmacist was provided with a one-on-one educational session facilitated by the community pharmacy resident. This session lasted approximately 1 hour and emphasized key concepts to provide during dietary supplement counseling. During this meeting, each pharmacist was given a study guidebook. This guidebook was developed by the pharmacy resident and included information from the Drug-Induced Nutrient DepleJournal of the American Pharmacists Association