Dental providers’ perceptions of the feasibility and acceptability of implementing vaccine administration programs in dental settings: a qualitative study

Abstract

Objectives:

Involving dental offices in routine vaccinations could have a positive impact on public health. In this study, we assessed dental providers’ attitudes and perceptions regarding implementing vaccination in dental settings.

Methods:

We performed semi-structured interviews with 31 dental providers (25 dentists and 6 dental hygienists) enrolled in the Western region of the National Dental Practice-Based Research Network as of June 28, 2021. Interviews were recorded and transcribed. We analyzed transcripts using deductive and inductive coding approaches.

Results:

We identified three main themes that captured the perceptions of dental practitioners regarding the feasibility of implementing vaccine administration in a dental setting: 1) dental practitioners perceive contributing to the public health mission of disease prevention as having high value, 2) dental practitioners face considerable complexity when deciding whether to implement vaccine administration and 3) dental practitioners do not understand current laws and associated reimbursement models related to vaccine administration.

Conclusions:

To make vaccination commonplace in dental practices, legal changes to allow dental practitioners to administer vaccines should be followed by concrete guidance and relevant trainings to help interested dental practitioners successfully implement vaccination programs in their clinical settings.

Introduction

The practice of dental providers delivering vaccines in the U.S. has a short history. Prior to 2020, only Oregon, Illinois and Minnesota had passed state legislation that allowed dental providers to deliver vaccines. In Illinois and Minnesota, dentists were limited to administering flu vaccines to adult populations (Illinois General Assembly, 2016; Minnesota Department of Human Services, 2021; Oregon Dental Association, 2019). Recently, there has been greater interest in dental providers administering vaccines (Alawi, 2021; Villa, Chmieliauskaite, & Patton, 2021). A number of barriers to the widespread implementation of vaccinations in the dental context have been documented, including a lack of knowledge and uncertainty among dental providers about issuing vaccine recommendations (Naleway et al., 2018), uncertainty about patient willingness to receive vaccinations in dental offices (Naleway et al., 2018), a lack of preparedness among dental providers to discuss sensitive topics (Cynthia. L.; Stull & S. Lunos, 2019; Walker, Jackson, Sommariva, Neelamegam, & Desch, 2019) and perceptions that vaccine administration falls outside the scope of practice of dental providers (Harris et al., 2020).

The onset of the coronavirus pandemic, and the need for innovative measures to ensure that vaccines could be delivered as fast as possible to eligible populations, marked a change in the legislative landscape for dental practitioners to become involved in the delivery of vaccines. In March 2021, a federal government declaration authorized dental practitioners in all 50 states to deliver COVID-19 vaccinations (Department of Health and Human Services, 2021). While not all states authorized dental providers to deliver COVID-19 vaccinations following this declaration, over 40 did so, at least in some circumstances (American Dental Association, 2021). Despite this, there was no widespread implementation of vaccinations in dental offices.

Involving dental offices in routine vaccinations could have a positive impact on public health. To date, most research about implementing routine vaccinations in the dental context has focused on involving dental practitioners in the prevention of diseases related to oral health (Denise Guadiana, Nolan M. Kavanagh, & Cristiane H. Squarize, 2021; Hosking, Cappelli, Donly, & Redding, 2017; Naleway et al., 2018; Cynthia. L.; Stull & S. Lunos, 2019; Walker et al., 2019). No research has been conducted in the U.S. on implementing vaccinations unrelated to oral disease in the dental context. In this study, we conducted qualitative interviews investigating attitudes and perceptions of dental practitioners toward implementing vaccine administration in the dental setting. We specifically asked about potential barriers related to workflows, readiness of support staff, and appropriateness of delivering various types of vaccines in the dental setting. Understanding perceptions among dental providers about acceptability and feasibility of implementing vaccinations is a crucial step in developing effective strategies for the widespread introduction of vaccinations in dental settings.

Methods

Study Design and Setting

This study was conducted within the National Dental Practice-Based Research Network (www.nationaldentalpbrn.org, referred to hereafter as the Network), a consortium of over 7,500 U.S. dental practitioners and researchers who investigate research questions with practical impacts for the quality of dental care. Network research activities are coordinated by six geographically dispersed administrative centers. This study was conducted within the Western Region of the Network, which includes over 1000 dentists and dental hygienists located in 11 states and Pacific Island territories. This qualitative study was part of a mixed-methods study analyzing dental providers’ attitudes about providing vaccinations in dental settings. The study was reviewed and approved by the Network’s Central Institutional Review Board (IRB) at the University of Alabama at Birmingham, and the Kaiser Permanente Northwest IRB, which oversees Western Region research activities. All study procedures followed the ethical standards of the responsible committee on human experimentation and the Helsinki Declaration of the World Medical Association. Funding for the study was provided by the National Institute for Dental and Craniofacial Research (X01-DE-031106) through administrative supplements to the main Network grants (U01-DE-28727; U19-DE-28717).

Data collection

Interview guide development

We developed an interview guide following a review of the existing literature to determine relevant concepts for exploration (Kornides, McRee, & Gilkey, 2018; Lazalde, Gilkey, Kornides, & McRee, 2018; Naleway et al., 2018; Reno et al., 2018; Cynthia. L.; Stull & S. Lunos, 2019). Drafts of the interview guide were reviewed by three practicing dentists from the Western Region Practitioner Advisory Committee (PAC) during a one-hour virtual meeting, with a focus on ensuring the relevance and clarity of questions and identifying missing concepts. Next, the draft interview guide was reviewed and revised by the Network’s Practitioner Executive Committee (PEC), which includes dentist representatives from each Network region, Principal Investigators from the Network Administrative and Coordinating Centers, and program officials from the National Institute for Dental and Craniofacial Research, during a 90-minute moderated discussion. We then revised and pilot tested the guide with two dentists through one-on-one mock interviews. After completing both mock interviews, we developed subsections with questions for (1) participants without experience administering vaccines and (2) participants who had completed the mandatory training to administer vaccines and had experience with vaccine administration. Concepts covered during the interviews included knowledge, awareness, and preparedness for implementing vaccines in dental settings; opinions on the appropriateness of delivering vaccines and perceptions of patient readiness to receive vaccines in these settings; and potential barriers and facilitators to implementing vaccine administration in the dental setting (e.g., staffing, workflows, legal barriers, reimbursement models). Some topics included in the interview guide did not emerge as salient themes impacting the decision to implement vaccination in dental settings; accordingly, these topics are not discussed in the results section.

Participant recruitment

We used the Network’s practitioner enrollment database to identify active U.S. practitioners located in the Western Region who were enrolled in the Network as of June 28, 2021, had indicated interest in participating in survey or clinical studies, and were categorized as general dentists, dental hygienists, or specialists with training in pediatric dentistry or Dental Public Health. We sought to recruit a demographically diverse group of 30 practitioners representing a variety of practice settings, practice types, and rural, urban, and suburban locations. We sent a recruitment email to 702 practitioners and received responses from 57 who expressed interest in the study. The study team reached out to interested participants via email and phone in the order in which they had responded, and scheduled telephone interviews with 31 practitioners.

Interview conduct

The researchers conducting the data collection and analysis (DPT and IG) are formally trained qualitative researchers; one is a PhD-level anthropologist with more than a decade of qualitative research experience and the other is a Masters-level public health researcher with several years of qualitative research experience in health care. One-on-one interviews lasting up to 45 minutes were conducted via teleconference in August 2021; interviewers were assigned based on availability. Participants provided verbal consent to participate and have their interview recorded at the beginning of the interview. All recordings were transcribed by a professional transcriptionist, and any identifying information was removed during the transcription process. The interviewers did not take any notes during the interview to ensure responsiveness to interview participants and focus on the interview guide. Participants received a $100 remuneration for their time, except for two participants working in the Kaiser Permanente Dental Program who could not receive this incentive due to a financial conflict of interest.

Data analysis

The interview transcripts were the sole data source for the data analysis process. We combined inductive and deductive approaches to coding interview responses (Pope, Ziebland, & Mays, 2000). Study researchers (DPT and IG) developed a code book based on predefined topics of interest and the interview guide (e.g., current vaccine administration status, experience with vaccine administration), and topics that surfaced during an initial review of the transcripts (e.g., volunteer role, mass events). First, each researcher coded the same two transcripts using qualitative software (NVivo 1.3) to assess the appropriateness of the code book and evaluate their level of coding agreement. The coded transcripts were compared, coding disagreements resolved through discussion and the code book was further revised. The final code book contained 18 codes (see appendix 1). The remaining transcripts were coded by one researcher.

Results

Participant characteristics

In total, 31 dental practitioners participated in the interviews: 22 general dentists, 3 pediatric dentists, and 6 dental hygienists. Women made up 55% of participants (N = 17), and 55% of participants were White, non-Hispanic (N = 17) (Table 1). Most dentists and dental hygienists worked in private practice (N = 22), in urban and suburban settings (N = 27). Nine dental practitioners had completed training to administer vaccines. 3 had experience administering vaccines either at mass vaccination events or in community health settings. No respondents had experience administering vaccines in private practice settings.

Table 1.

Participant characteristics

	N (%)
Sex at birth
Female	17 (55)
Male	14 (45)
Race
White	17 (55)
Black	2 (6)
Asian	6 (20)
Native Hawaiian or Other Pacific Islander	2 (6)
Other	4 (13)
Ethnicity
Hispanic or Latino	3 (10)
Practice type
General dentist	22 (71)
Specialist	3 (9)
Hygienist	6 (20)
Practice setting
Private practice	22 (71)
MCO/PPO/Corp	2 (6)
Public health/Federal	7 (23)
Practice location
California	8 (26)
Colorado	5 (16)
Hawaii	3 (10)
Idaho	2 (6)
Nevada	1 (3)
Oregon	5 (16)
Washington	6 (20)
Utah	1 (3)
Training and vaccination experience
Completed training to administer vaccines	9 (28)
Have administered vaccines	3 (9)

Qualitative interview themes

Through analysis of the interview transcripts we identified three main themes that captured the perceptions of dental practitioners regarding the feasibility of implementing vaccine administration in a dental setting: 1) dental practitioners perceive contributing to the public health mission of disease prevention as having high value, 2) dental practitioners face considerable complexity when deciding whether to implement vaccine administration and 3) dental practitioners do not understand current laws and associated reimbursement models related to vaccine administration.

• 1Dental practitioners perceive contributing to the public health mission of disease prevention as having high value

In general, most participants perceived the potential involvement of dental staff in administering vaccinations as valuable. They perceived the momentum created by the pandemic to implement vaccinations in a dental setting to align well with their overall practice and mission.

Many interview participants pointed out that a lot of their patients see their dental providers more regularly than their primary care providers, so offering vaccinations in dental offices could increase accessibility and convenience:

“I think if patients are... compliant with going in at least twice a year for their dental hygiene visits, assuming they see the dentist twice a year for an exam during those visits, why not take advantage of them being there? Instead of them having to make an appointment with their healthcare provider. Especially during these times where clinics might be overrun with sick people. I mean it would just make more sense to do it in a dental setting.” (Dental hygienist A)

Additionally, many practitioners noted that delivering vaccinations in their setting aligns well with an important underlying tenet of dentistry, the connectedness of oral and general health. Offering vaccine administration during a routine dental visit provides an important opportunity to implement this principle:

“Actually, it seems a little ironic when dentists don’t support that because you know we keep talking about this to the entire health of the body. So, if that is the intention that we are acknowledging, that there is this connection, then we should be on the side of helping to address general health needs, which would include vaccination.” (Dentist A)

Most participants recognized that dental practitioners’ personal beliefs and values may impact their decision to administer vaccines. At the same time, many thought that the value proposition of contributing to the larger public health mission may outweigh personal hesitations. However, some noted that it could be challenging to administer vaccines successfully unless all staff members are willing to participate in the process:

“And dental office staff, they all have their own personal beliefs which may very well conflict with the available scientific evidence. It’s been my experience from years […] of managing dental staff that if there’s no staff buy-in, then patients won’t buy in either. There’s a huge encumbrance there, having tried to implement evidence-based practice into the day-to-day private practice environment it can be very challenging to initiate a behavioral change that isn’t supported philosophically by the staff.” (Dentist B)

• 2Dental practitioners face considerable complexity when deciding whether to implement vaccine administration

When interview participants were prompted to reflect on the specifics of implementing vaccine administration in their dental settings, they highlighted multiple considerations that would play into their decision of whether to provide vaccines, and if so, which vaccines to administer.

Some participants suggested that vaccine administration in dental clinics may be more important or valuable in some locations or settings than others (for example in rural vs urban settings) and that this may play a role in the decision to implement vaccinations in their dental settings:

“Here, where I practice in, healthcare is very accessible. So, I guess the same situation applies, you’re in an area, not just rural necessarily but if there’s a lot of barriers to care for the population that you practice with then that would be a good idea.” (Dentist C)

There were diverse opinions about the specific types of vaccinations that would be appropriate for dental practitioners to administer in their clinical settings. Some were concerned about duplicating vaccination services that other medical practitioners already offer, and the relationship of the vaccine to oral health was also considered. A consensus emerged that vaccines related to oral health would be most important and fitting to deliver in a dental setting. There was less agreement about the appropriateness of administering other vaccines:

“I think it would make more sense if it was related to oral health. But you know in this situation we’re in right now, I guess that it’s sort of good that the dentists are looked upon as being capable of doing it. And so that there’s another venue for the patients to be able to get it done. I don’t know that... I mean a lot of things can be related to... like HPV vaccines can be related to oral health so that would be maybe another thing that dentists would be willing to do. But some of the flu and you know tetanus, you know, those types of health measures are probably not directly related to dentistry.” (Dentist D)

While the participant quoted above was hesitant about providing seasonal influenza vaccines, others considered these appropriate and fitting given the frequency in which they saw their patients for dental services. Accessibility to vaccines for the public was also a consideration that played into providers’ thought processes. When the COVID-19 vaccine became available, access to the vaccine was limited and dentists’ involvement in delivering vaccinations contributed to increasing access. In such a situation, participation of dentists in vaccine delivery was considered highly appropriate by most participants.

Dental practitioners also emphasized the need to invest in education to shore up their staff’s knowledge of general medicine so they could issue appropriate recommendations about general vaccines, as well as the need to access patients’ medical records to document vaccinations administered. These were generally perceived as important obstacles for dentists to overcome in private practice settings. Dental practitioners working in community and health system settings emphasized that it would be relatively easy for them to administer vaccinations since they had established infrastructure readily available to train practitioners, address logistical challenges such as accessing medical records, and educate patients on vaccinations.

Some dental practitioners were also concerned that adding more injections to their patient services would invoke additional fears among dental patients:

“I think we have a difficult enough time with doing... injections by themselves that I think the only time it will really work for dental to really be part of that is an emergency. So, if your clinic is short staffed and you can do that. Other than that, I have patients coming in every day, I don’t want to get a shot, I don’t want to get a shot. So, I am going to tell them you are going to get a shot in the arm. We already have trouble getting them in to get routine work, I don’t want them to stay away from us because they’re going to get every vaccine available because I have them in the chair.” (Dentist E)

• 3Dental practitioners do not understand current laws and associated reimbursement models related to vaccine administration

As described above, general interest and value perceptions of administering vaccinations in the dental setting were high. Most interviewees, however, lacked knowledge and awareness of the current regulations and requirements regarding the implementation of vaccinations in dental settings.

The great majority of participants had either initial knowledge or general familiarity with the legal changes that enabled dentists to administer vaccines in the context of the coronavirus pandemic. They received notifications or emails from dental boards and/or professional organizations, read about it in dental publications, or heard about it from colleagues. From these sources, they learned that dentists could administer vaccinations in relation to preventing the spread of COVID-19. However, awareness that these changes provided broader permission to administer other vaccines was low and was primarily limited to practitioners who knew of colleagues providing non-COVID-19 vaccinations in their region.

Most dentists had also limited knowledge about the process for becoming involved in vaccine administration:

“In fact, at one point I believe, I don’t know if it was the DEA [Drug Enforcement Administration] or if it was my CDA [California Dental Association] here in California that had sent information gosh, I as stated would say almost a year ago to give us information to administer vaccines. Kind of went through all the dos and don’ts, where to inject, how to store it. But it was funny, they gave us all these training videos but then they never told us how it was going to be deployed and then we never heard any more from that. So, it’s never really... got a lot of traction at least in my area.” (Dentist F)

This quotation illustrates a sentiment shared by several dentists: several signed up for administering vaccines when they first learned about their ability to provide vaccines but were not aware of the steps they would need to take to administer vaccinations.

Dental practitioners also had many unanswered questions about the logistics of providing vaccines, including questions about reimbursement, general liability, and integration of medical and dental information. Most interview participants were uncertain about whether malpractice insurance would extend to cover vaccination administration:

“I would have to talk to my malpractice insurance and see whether they cover me or not. Say you give a kid the flu vaccine and something God forbid goes wrong - am I going to be covered by my malpractice insurance?” (Dentist G)

Interview participants also highlighted the practical challenges associated with space requirements for vaccine administration, such as the need to have additional space to monitor patients after administering a COVID-19 vaccine. Many participants perceived the challenges as daunting:

“The ultimate question is, with the obstacles that currently exist and the reimbursement rates being what they are for ... doing this, it translates into a very limited revenue opportunity in private practice. So, there’s a difficult value proposition I think to overcome when it comes right down to all of the staff training issues, all of the supply chain issues. Because of the questions around scope of practice and professional liability coverage. With the obstacles in place, I doubt when it comes down to the rubber hitting the road, the reimbursement rates will be sufficient to incentivize providers to actually do this.” (Dentist B)

Many suggested that mass vaccination events may provide a more fitting venue for dentists to contribute to the public health mission of vaccine delivery. Several interview participants noted that they had volunteered at such events to administer COVID-19 vaccines when vaccinations first became available. They pointed out that partaking in such events resolved existing hurdles of medical and dental integration, liability, and logistical considerations, as well as the need to become familiar with the requirements and regulations of administering vaccines in their own practice settings.

Discussion

This study was the first to assess the perspectives of dentists and dental hygienists on the topic of implementing vaccine administration in dental settings. Through semi-structured interviews with practitioners, we found that dental practitioners generally felt it would be valuable to contribute to disease prevention through vaccine administration, but that the decision-making process about implementing vaccine administration is complex and context dependent. Additionally, dental practitioners typically had a low level of awareness and understanding of the current laws and requirements for implementing vaccine administration in the dental context.

Our study findings highlighted the broad interest of dental practitioners in contributing to disease prevention through vaccine administration, but also the large gap that continues to exist between this interest and implementation of vaccination in practice settings. While previous research in the dental context has exclusively focused on administering vaccinations related to oral health (Denise Guadiana et al., 2021; Harris et al., 2020; Deanna Kepka et al., 2019; Naleway et al., 2018; Cynthia. L.; Stull & S. Lunos, 2019; Walker et al., 2019), this study focused on vaccinations not related to oral health and took place in the midst of evolving laws regarding dental administration of vaccines in the context of COVID-19. We found that merely removing legal barriers to enable dentists to deliver COVID-19 vaccines was not sufficient for dentists to implement such vaccinations in their practice settings due to a variety of logistical challenges and lack of knowledge or support about how to implement such programs. However, the removal of legal barriers did make it possible for some dentists to become involved in delivering COVID-19 vaccinations in the context of mass vaccination events, allowing them to contribute to public health during a crisis.

Our findings also demonstrate that dental practitioners grapple with the questions of purpose and incentive when considering possible vaccine administration in dental settings, particularly those that fall outside the direct purview of oral health – such as the COVID-19 vaccine. When considering implementing vaccine administration in their dental clinics, providers considered availability (or lack thereof) of vaccinations in a geographical region, as well as a desire to avoid duplicating services that pediatricians and general medical practitioners are already successfully providing. Creating financial incentives through different reimbursement structures or developing a strong rationale for implementing vaccinations unrelated to oral health in the dental setting is a necessary foundation for any widespread implementation of vaccination.

Previous research has argued for the importance of providing targeted training to dental providers regarding the importance of (HPV) vaccination (Harris et al., 2020; Naleway et al., 2018). Our research suggests that merely training dental providers to educate patients about the importance of preventive care and vaccine administration will be insufficient to achieve implementation of vaccinations in the dental context. Participants in this study generally did not know the logistical steps they would need to take to implement vaccination services. Questions that surfaced repeatedly during interviews included how dental providers would access vaccination records and document current vaccination status; whether vaccine administration would be covered by existing liability insurance; and who dental providers would need to approach to initiate the process of administering vaccines. Thus, dental providers need logistical resources as well as educational training in order to be able to successfully implement vaccination in their clinics.

Implementing any new workflow is complex and time-consuming for a dental practice. The rise of evidence-based dentistry has provided insights into the challenges of introducing new workflows and routines (Kao, 2006; Sellars & Wassif, 2019). As many interview participants noted, staff buy-in is crucial for successfully revising existing services. In the context of vaccine administration, vaccine hesitancy among dental staff could present an additional barrier to implementation that would impact the successful execution of vaccine administration in a dental setting (Kwok et al., 2021; MacDonald & Dubé, 2015).

A limitation of our study was that while we reached out to several hundred dental practitioners for participation in this study, those who responded and participated may have differed from the population who did not respond to our invitation. In particular, those who responded may have been more interested or familiar with the topic. Our findings therefore may not be representative of the general population of dental practitioners.

Our findings demonstrate the need for research studies that test the implementation of vaccine administration in dental contexts to provide best practice guidance and recommendations that are rooted in the dental setting. Implementation will look different in the private practice and public health dental settings. Legal changes that allow dental practitioners to administer vaccines is an important first step to implementing vaccination in dental settings, but to make vaccinations commonplace in dental practices, such changes must be followed by concrete guidance and logistical support; access to reporting and reimbursement systems; training regarding indemnification and personnel and patient management. This support could pave the way for successful implementation of vaccination programs among dental providers.

Conclusion

In conclusion, dental practitioners participating in this study perceived added value in administering vaccines to dental patients, as it would contribute to general disease prevention. However, providers lacked consensus around specific details of such a program, such as what types of vaccines to administer and how to implement vaccine administration in various dental settings. Critically, dental practitioners also lacked experience and knowledge about the concrete steps they would need to take to implement vaccine delivery in their dental practices, and voiced concerns about resource constraints. Guidance by public health authorities about the specific added value that dental practitioners’ involvement in vaccine delivery may offer, along with concrete logistical guidance and support, could support dental providers in implementing vaccination programs within their practice settings.

Appendix 1. Interview guide for participants who have no experience administering vaccines

How long have you worked as a dentist/dental hygienist (in your current setting)?

Knowledge, awareness, preparedness

Do you currently administer any kind of vaccines? Yes/no

What do you know about the (possible) role of dental staff delivering the COVID-19 and possibly other vaccines (in the dental setting)?

Prompts: When did you first hear about it, familiar with legislation in different states (refer to 7th Prep Act amendment that allows dentists to administer Covid vaccines Federal Register: Seventh Amendment to Declaration Under the Public Readiness and Emergency Preparedness Act for Medical Countermeasures Against COVID-19)

We would like to learn more about your thoughts about your possible involvement in administering vaccines and your opinion about the larger role of dentists in administering vaccines.

There are several types of vaccines dentists could deliver, e.g. seasonal vaccines like the flu, multiple dose vaccines like HPV or vaccines typically delivered to children vs. adults. Does your willingness to administer vaccines depend on the type of vaccine? Which one/s do you think would be the most appropriate in your setting?

Prompts: Willingness possibly affected by patients’ response, training

Currently, dentists are authorized to administer COVID-19 vaccines in all 50 states. At least one state (WA) allows dental hygienists to vaccinate patients for COVID-19 under direct supervision of a dentist. In some states, dentists are authorized to also administer other vaccines such as HPV or for the flu.

Do you think that these changes provide a new opportunity for dental offices to expand their role in contributing to larger public health prevention efforts?

Prompts: What role do you think dentists should play in the prevention of disease through vaccinations (including flu, HPV, COVID-19, or other diseases)?

Under which circumstances do you think is it appropriate for dentists to administer vaccines?

Prompt: related to prevention of oral health issues like HPV, general disease prevention, contributing to public health, i.e. Covid-19, dependent on vaccine type, e.g. flu, Covid-19

There also is the possibility for dentists to participate in mass vaccination events rather than administering vaccines in dental offices. In your opinion, what are the advantages and disadvantages of this approach?

What kinds of trainings or preparation would you like to receive before administering vaccines?

What would help you feel successful/competent for the vaccine delivery process?

Prompt: Trainings specific to vaccines, e.g. flu, HPV vs. COVID-19, standardized text (e.g. issued by the CDC) to broach the subject with patients, how to manage safety concerns

For private practice:

Delivering vaccinations requires interprofessional collaboration. Staff for example, need to check state records to see if a patient is due for a vaccine or need to enter information about delivering vaccines into an existing system. Would you be able and/or willing to prepare and assign staff to perform such roles?

What challenges do you foresee/have you experienced with information management (e.g. recording vaccinations into your Practice Management Software, communicating vaccinations to the patient’s physician, auditing and following up on claims status, reporting adverse events)?

Appropriateness, personal beliefs

Do you believe that the personal beliefs of dental staff can play a role in their willingness to administer vaccines?

Do you think that other dentists in your region/area would be interested in administering vaccines? Why or why not?

In general, do most people support vaccinations in the area where you practice? Please explain.

Research has demonstrated that most dental patients are open to receiving vaccines from dentists or dental hygienists. Does this affect your comfort level of discussing this topic with your patients?

What do you think would be your patients’ typical response to you (as their dentist/hygienist) suggesting vaccine administration in the dental setting?

Staffing, workflows & spatial arrangements

Among dental staff, who do you think should broach the topic of vaccinations with patients during a visit?

What workflows do you think would be most appropriate for administering a vaccine during a dental visit?

What barriers do you anticipate in incorporating this to your workflow?

Administering vaccines brings unique space requirements for a dental office, such as a refrigerator or freezer for storing vaccines and an area where you may need to monitor patients for possible reactions. Would your practice be able to make such accommodations?

Legal barriers/liability concerns

Do you have any concerns about the liability involved with vaccine administration?

Reimbursement and information management

What role do/would reimbursement models play in your decision to administer vaccines in your dental office?

Do you or your staff have experience filing medical claims?

If yes, please describe this experience.

If no, what challenges do you foresee integrating medical claims (including CPT & ICD-10 coding, means by which to file electronic claims, credentialing, registration etc.) into your current Revenue Cycle Management process?

Are current reimbursement rates for private and public insurance appropriate? Do you have any suggestions for revisions of these models?

Appendix 2. Interview guide for participants who have experience administering vaccines

How long have you worked as a dentist/dental hygienist (in your current setting)?

Knowledge, awareness, preparedness

Do you currently administer any kind of vaccines? Yes/no

How did you become involved in administering vaccines?

Which vaccines do you currently administer and in which setting do you administer vaccines? As part of a mass vaccination, in your private practice or as part of a group practice?

What kind of trainings have you received for administering vaccines?

Prompts: medical training about HPV, how to approach patients, how to monitor side effects, rationale for administering vaccines in dental setting, provide information to address vaccine hesitancy

How has participating in these trainings changed your attitude about delivering vaccines?

How would you describe the experience of administering vaccines? Can you tell me a little bit about your expectations and how they compare to your actual experiences?

What have been your patients’ responses to you suggesting vaccine administration in the dental setting?

Prompt: if there were challenges, how were they resolved?

Can you identify any specific areas where you continue to feel ill prepared to deliver vaccines?

Prompts: patient education, outreach, side effects, managerial support, personal comfort level, workflow considerations

What has been the most valuable lesson for you in administering vaccines that you would like to share with other dentists?

There are several types of vaccines dentists could deliver, e.g. seasonal vaccines like the flu, multiple dose vaccines like HPV or vaccines typically delivered to children vs. adults. Does your willingness to administer vaccines depend on the type of vaccine? Which one/s do you think would be the most appropriate in your setting?

Prompts: Willingness possibly affected by patients response, training

Given your experience with administering vaccines, what are your thoughts about involving other dental staff in contributing to larger public health disease prevention efforts. What role do you think dentists should play in the prevention of disease through vaccinations (including flu, HPV, COVID-19, or other diseases)?

There also is the possibility for dentists to participate in mass vaccination events rather than administering vaccines in dental offices. In your opinion, what are the advantages and disadvantages of this approach?

Appropriateness, personal beliefs

Do you believe that the personal beliefs of dental staff can play a role in their willingness to administer vaccines?

Do you think that other dentists in your region/area would be interested in administering vaccines? Why or why not?

In general, do most people support vaccinations in the area where you practice? Please explain.

Staffing, workflows & spatial arrangements

What does your workflow for administering a vaccine during a dental visit currently look like?

Prompt: who broaches the topic, who administers vaccines, where is patient monitored

What barriers did you experience incorporating the administration of vaccines into your workflow?

Do you think your currently workflow would be appropriate for any type of vaccine?

Legal barriers/liability concerns

Do you have any concerns about the liability involved with vaccine administration?

Reimbursement and information management

What role do/would reimbursement models played in your decision to administer vaccines in your dental office?

Do you or your staff have experience filing medical claims?

If yes, please describe this experience including any challenges

If no, what challenges do you foresee integrating medical claims (including CPT & ICD-10 coding, means by which to file electronic claims, credentialing, registration etc.) into your current Revenue Cycle Management process?

Are current reimbursement rates for private and public insurance appropriate? Do you have any suggestions for revisions of these models?

Appendix 3. CARAD Codebook

Length of experience in current setting – captures number of years they’ve been working in current setting

Current vaccine administration status – captures information about experience administering vaccines, could be ‘Yes’, ‘No’, or ‘Yes at mass events but not in clinical setting’

Volunteer role – captures if participant sought volunteer opportunities to train and administer vaccines, was volunteering pursued/preferred over clinical administration, experience volunteering

Experience with administration – captures lived experiences with vaccine administration and if these met expectations, changed over actual experience

Familiarity with dental staff administering vaccines – captures participants knowledge/familiarity with legislation/lived experiences, when they first heard about it, where etc

Willingness to administer vaccines – captures factors that are considered when assessing willingness in administering vaccines such as patient receptivity, bandwidth, return of investment, type of vaccine

Most appropriate vaccines– captures the specific vaccines participants would find most appropriate to administer to their patients, how it aligns with their practice or oral health, preference, comfort level

Patient receptivity to vaccine administration – captures provider perception of patient reactions and factors that influence this such, why patients would or would not be receptive, role of provider trust and rapport, importance of receiving vaccine in familiar setting, patients seeing their dentist more frequently than their PCP

Provider hesitation – captures reasons why providers may be hesitant to implement vaccinations in dental setting; e.g., discomfort with injections, liability concerns, unfamiliarity with reimbursement, workflow logistics, lack of FDA approval

Contribution of dental providers – captures perceptions of dental providers about positive contribution of vaccine administration, e.g., as an opportunity to contribute to larger public health efforts, how they’re viewed by public and patients, how they compare with other clinicians, disease prevention

Circumstances for dental vaccine administration – captures rationale for engaging in vaccine administration, e.g., general disease prevention, combat a global pandemic, preventative care for oral health

Mass events for vaccinations – captures advantages and disadvantages of participating in mass events for vaccinations as a dental provider

Training – captures types of training that would be helpful, what topics should be covered, what makes one feel successful and/or competent, format of training, role training has on competence, training received

Training status – captures training experience, e.g., ‘Yes’ or ‘No’, reason/motivation for training

Private practice considerations – captures considerations specific to private practice seeting such as interprofessional collaboration, ability to incorporate vaccine administration into clinic setting, information management considerations, assigning staff to specific tasks

Personal beliefs – captures personal beliefs/considerations about vaccine administration that may impact implementation, e.g., dentists in nearby area willing to administer vaccines, patient receptivity to receiving vaccine in dental setting, people in that area willing to be vaccinated

Patient-driven actions – captures impact of perceived patient response on provider actions, e.g., deciding to broach the topic of vaccines due to patient receptivity, willingness to incorporate vacc. administration in clinic due to patient response, how patients would respond to dental staff offering vaccines

Workflow considerations – captures possible integration of vaccine administration into clinic workflows, e.g., how is vaccine administration incorporated into workflow, who should bring up topic in clinic, potential barriers to workflow, time allotment, space requirements, experience filing medical claims

Liability considerations – captures role that liability considerations play in considering vaccine administration, also includes lack of knowledge regarding liability involved

Role of reimbursement – captures role that reimbursement plays in adopting vaccine administration, e.g., are current rates for dental services appropriate, suggestions for changing them, how much of a factor it plays to incorporate vaccine administration in clinic