The Role of the Ambulatory Care Pharmacist in Promoting Vaccine Confidence
A pharmacist’s role in the ambulatory care setting has traditionally included a review of medications for potential drug-drug interactions and adverse events, medication reconciliation, and the provision of counseling services.
Vaccines represent a cost-effective means of preventing illness, complications, and death from certain diseases.1 Nonetheless, across the health care system there remain challenges in promoting vaccine acceptance and addressing hesitancy and patient concerns. This article explores the role of ambulatory care pharmacists in addressing patient concerns to promote influenza vaccine acceptance.
The Ambulatory Care Clinic as a Vaccination Destination
Ambulatory care, according to the Board of Pharmacy Specialties, is a field that addresses the delivery of integrated, accessible health care services for ambulatory patients moving from the hospital to home or another health care facility.2 Ambulatory care can encompass a wide range of disciplines and populations,3 and some may describe it as the “internal medicine of the outpatient setting.” There may be ambulatory care pharmacists in family medicine clinics, pediatric or geriatric clinics, or in medical specialty clinics.
A pharmacist’s role in the ambulatory care setting has traditionally included a review of medications for potential drug-drug interactions and adverse events, medication reconciliation, and the provision of counseling services. Although the scope of the ambulatory care pharmacist’s role may vary according to local practice and different ambulatory clinic service models, ambulatory care pharmacists can initiate, adjust, or discontinue medications, monitor clinical laboratory studies, and assess patients’ vaccination history.3 Ambulatory care pharmacists can recommend appropriate immunizations based on a patient’s medical history, presence of medical comorbidities, and age. In the United States, pharmacists are permitted to vaccinate in all 50 states,4 although some states may have specific vaccine exemptions and limitations on the pharmacist scope of vaccine services. The accessibility of pharmacists increases opportunities for patients to receive vaccines, expands pharmacists’ scope of practice, and promotes continuity of care across the health care setting. In some ambulatory care clinics, identifying appropriate immunizations for patients may be an expectation, and in others it may serve as a metric of quality improvement and patient safety.
Impact and Consideration of Vaccine Quality Measures for the Health Care System
As health care delivery increasingly transitions to and incentivizes value-based care, ambulatory care pharmacists are poised to impact patient outcomes as members of the interprofessional care team. In the United States, the influenza vaccination rate remains low in adults 18 to 49 years of age (37.7%), with higher rates observed in older adults.5 For the 2020-2021 influenza season, influenza vaccination coverage among adults (≥ 18 years) was 50.2%. Offering influenza vaccination to eligible patients represents an important indicator of quality care and preventative medicine for both ambulatory and hospitalized inpatients according to the Centers for Medicare & Medicaid Services6 and The Joint Commission,7 respectively.
Addressing Vaccine Hesitancy and Supporting Vaccine Confidence
Vaccination uptake—or acceptance—is driven by several factors.8 The World Health Organization (WHO) defines vaccine hesitancy as a delay in acceptance or the refusal of vaccines despite availability of vaccine services. Vaccine hesitancy may depend on time, place, and particular vaccine.1 It is influenced by factors known as the “3 Cs” of complacency, convenience, and confidence. The WHO’s vaccine hesitancy model is depicted as 3 overlapping ovals, with each oval representing 1 of the 3Cs. Research has demonstrated that anecdotal evidence is often more influential than facts and science in informing patient vaccination decisions.9 This can make it difficult to discuss with patients the importance of immunizations when there are several factors influencing the decision to obtain a vaccine (eg, social media, news, etc). This model also emphasizes the multifaceted nature of vaccine hesitancy.8
In contrast to vaccine hesitancy, according to the CDC, vaccine confidence is the belief that vaccines work, are safe, and are a component of a trustworthy medical system.10 It is imperative that health care providers recognize the multiple factors that influence patient vaccine decision-making. The CDC offers resources for health care professionals to support vaccinating with confidence.11 Largely geared toward the acceptance and promotion of the COVID-19 vaccines, this framework provides a means to strengthen patient confidence in vaccines to prevent outbreaks of vaccine-preventable disease. To empower patients to have vaccine confidence, the CDC model references the following strategies: building trust, empowering health care personnel, and engaging communities and individuals (Figure).11
The foundation of vaccine confidence starts with building trust; this is accomplished by the health care professional sharing a clear, complete, and accurate message about vac- cines.11 The goal is to build trust not only with the vaccine but also in the vaccinator and the health care system in coordination with various partners. Empowering health care personnel to promote their decision to be vaccinated and recommending vaccination to their patients is an important step in building vaccine confidence. Engaging communi- ties and individuals in vaccine confidence can build trust, encourage communication, and increase collaboration.
Combining the accessibility and role of the ambulatory care pharmacist with the importance of combating vaccine hesitancy opens a world of possibilities for engaging patients to receive any vaccine, including the influenza vaccine. The first inactive influenza vaccines became available for use in the 1940s.12 Although community pharmacists have been offering and administering patient immunizations for more than 25 years,13 the pharmacist’s role in promoting vaccine confidence continues to evolve, particularly in recent years. In an editorial by Petrelli and colleagues, they discuss the pivotal role of pharmacists in providing health information, vaccinations, and fostering health promotion.14 Although the editorial was published in 2019, many examples of vaccine hesitancy that are discussed still hold true today. The authors describe pharmacists as influential health care providers who can focus their efforts on patients who are uncertain and supply them with objective, scientific, and legal tools which are valuable yet underused.
As mentioned previously, the role of the ambulatory care pharmacist is unique and provides an additional point of connection that might not translate in the traditional doctor-provider relationship. The ambulatory care pharmacist can be a liaison between the provider and the patient, with more accessibility, flexibility with time, and the sense of an added advocate for the patient and provider. The ambulatory care pharmacist is also poised to combat specific influenza vaccine myths and misperceptions (Table 1) and instill vaccine confidence to protect their patients from vaccine-preventable illness.15-19
Case Study Revisited
The presenting patient has vaccine hesitancy and lacks vaccine confidence. In her interaction with the pharmacist, she agrees to receive the hepatitis B vaccine but not the influenza vaccine and appears to be comfortable with her decision to choose one vaccine over another. She is complacent with not getting a vaccine during her visit, given the negative information that she has received about the influenza vaccine. Although it would be convenient for her to get 2 vaccines at this visit, she respectfully declines at this time. Her confidence in the hepatitis B vaccine outweighs her confidence in the influenza vaccine. Although there was no reason provided in this interaction, her tone and voice change when the influenza vaccine is brought up. In this patient’s case, the pharmacist could leverage this patient’s vaccine confidence in the following ways:
(1) Build trust with the patient: Refrain from being judgmental. Listen to the patient and their concerns. In building trust, it would be important to know the situation in which the patient would be most comfortable receiving both vaccines.
(2) Empower health care providers: Trust in vaccines is a key aspect for fostering patient confidence and acceptance of indicated vaccines. The ambulatory care pharmacist can provide the patient the opportunity to seek a second opinion, since this patient is hesitant with receiving one vaccine over the other. Pharmacists can educate other members of the health care community on communication strategies for supporting effective vaccine conversations and motivational interviewing techniques.
(3) Engaging communities: Though not as clear-cut, engaging the community in vaccinations can make a large difference in vaccination uptake. In tight-knit communities, everyone talks to each other. In this case, if there was a positive reaction to the vaccine, it may persuade the patient to get her influenza vaccine in the near to distant future.
Ambulatory care pharmacists represent a key link between patients and health services, including administering immunizations. Pharmacists working in this setting may see patients with greater frequency and offer a wealth of health information by addressing patients concerns and addressing questions that may enhance vaccine confidence and acceptance of indicated preventative health services, such as immunizations. Additionally, practice-based resources to help pharmacists address concerns related to influenza and influenza vaccines are included in Table 2. It is critical that all pharmacists, regardless of their practice setting or role within the health care system, continue to advocate for vaccinations to reduce illness and promote public health. Influenza vaccination represents an import- ant aspect of such conversations.
About the Authors
Christine Dimaculangan, PharmD, BCACP, is a clinical assistant professor at Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and an ambulatory care pharmacy specialist at The Center for Comprehensive Care (Jersey City Medical Center at Greenville) in Jersey City, New Jersey.
Mary Barna Bridgeman, PharmD, FCCP, BCPS, BCGP, is a clinical professor at Ernest Mario School of Pharmacy at Rutgers University and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.
1. Report of the SAGE Working Group on vaccine hesitancy. World Health Organization. November 12, 2014. Accessed May 17, 2022. https://cdn.who.int/ media/docs/default-source/immunization/sage/2014/october/sage-work- ing-group-revised-report-vaccine-hesitancy.pdf?sfvrsn=240a7c1c_4
2. Ambulatory care pharmacy fact sheet. Board of Pharmacy Specialties. April 12, 2022. Accessed May 16, 2022. https://www.bpsweb.org/wp-con- tent/uploads/factsheet_ambulatorycare.pdf
3. The ambulatory care career tool. American Society of Health-System Pharmacists. Updated March 11, 2019. Accessed May 16, 2022. https:// www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/ ambulatory-care/ambulatory-care-career-tool.ashx
4. Pharmacist immunization authority. National Alliance of State Pharmacy Associations. April 25, 2021. Accessed May 22, 2022. https://naspa.us/ resource/pharmacist-authority-to-immunize/
5. Influenza (flu) general population vaccination coverage. United States, 2020-2021 influenza season. Centers for Disease Control and Prevention. Updated October 7, 2021. Accessed April 18, 2022. https://www.cdc.gov/flu/ fluvaxview/coverage-2021estimates.htm
6. Preventive care and screening: influenza immunization. Electronic Clinical Quality Improvement (eCQI) Resource Center. Updated May 4, 2022. Accessed May 24, 2022. https://ecqi.healthit.gov/ecqm/ep/2021/cms147v10
7. Immunization. The Joint Commission. Accessed April 18, 2022. https:// www.jointcommission.org/measurement/measures/immunization/
8. Essential programme on immunization. World Health Organization. 2022. Accessed May 16, 2022. https://www.who.int/teams/immunization-vac- cines-and-biologicals/essential-programme-on-immunization/demand
9. Brewer NT, Chapman GB, Rothman AJ, Leask J, Kempe A. Increasing vaccination: putting psychological science into action. Psychol Sci Public Interest. 2017;18(3):149-207. doi:10.1177/1529100618760521
10. What is vaccine confidence? Centers for Disease Control and Prevention. Updated February 7, 2022. Accessed May 17, 2022. https://www.cdc.gov/ vaccines/covid-19/vaccinate-with-confidence/building-trust.html
11. Vaccinate with confidence. Centers for Disease Control and Prevention. September 8, 2021. Accessed May 17, 2022. https://www.cdc.gov/vaccines/ covid-19/downloads/vaccinate-with-confidence.pdf
12. History of flu pandemic 1930 - today. Centers for Disease Control and Prevention. Updated January 30, 2019. Accessed April 18, 2022. https:// www.cdc.gov/flu/pandemic-resources/pandemic-timeline-1930-and- beyond.htm
13. Hogue MD, Grabenstein JD, Foster SL, Rothholz MC. Pharmacist involvement with immunizations: a decade of professional advance- ment. J Am Pharm Assoc (2003). 2006;46(2):168-179; quiz 179-182. doi:10.1331/154434506776180621. Published correction appears in J Am Pharm Assoc (Wash DC). 2006;46(3):308.
14. Petrelli F, Tiffi F, Scuri S, Nguyen CTT, Grappasonni I. The pharmacist’s role in health information, vaccination and health promotion. Ann Ig. 2019;31(4):309-315. doi:10.7416/ai.2019.2264
15. How flu vaccines are made. Centers for Disease Control and Prevention. Updated August 31, 2021. Accessed May 17, 2022. https://www.cdc.gov/flu/ prevent/how-fluvaccine-made.htm#recombinant
16. Misconceptions about flu vaccines. Centers for Disease Control and Prevention. Updated November 18, 2021. Accessed April 18, 2022. https:// www.cdc.gov/flu/prevent/misconceptions.htm
17. Key facts about flu vaccines. Centers for Disease Control and Prevention. Updated November 18, 2021. Accessed May 17, 2022. https://www.cdc.gov/ flu/prevent/keyfacts.htm
18. Who is at higher risk of flu complications. Centers for Disease Control and Prevention. Updated November 18, 2021. Accessed May 17, 2022. https://www.cdc.gov/flu/highrisk/index.htm
19. How flu viruses can change: antigenic drift and antigenic shift. Centers for Disease Control and Prevention. Updated September 21, 2021. Accessed May 17, 2022. https://www.cdc.gov/flu/about/viruses/change.htm