Experiences Among African American Community Members With Pharmacy-Based Immunization Services in Detroit, Michigan

Abstract

Background: Although vaccination rates improved modestly in the United States during the 2014-2015 season, racial and ethnic disparities in the use of vaccines persist. Pharmacy-based immunization programs expand access to immunization services; however, African Americans in one metropolitan community did not have the same level of access to this service as non-Hispanic whites. Objective: To examine the experiences of African Americans with pharmacy-based services and identify how pharmacies and pharmacy organizations can better service patients in urban communities with similar dynamics. Methods: This qualitative study utilized focus group discussions among African American residents in Detroit, Michigan, where there are reported disparities in access to pharmacists that immunize to learn more about their experiences with pharmacy-based immunization services. Results: Three major themes emerged: the pharmacy location is often more convenient and accessible than doctors’ offices, there is clear communication with the pharmacist, and perceived lower immunization fees at pharmacies. Participants found pharmacies easier to access in their community for immunization services. Consistent interaction with familiar pharmacists and pharmacy staff members facilitated strong relationships and dialogue between pharmacists and patients. Patients perceived costs for vaccines to be less at the pharmacy than at their physicians’ offices. Conclusions: Participants reported positive experiences with pharmacy-based immunization services and expansion of these services may influence more African Americans to receive recommended vaccines in this community.

Introduction

Although the United States has seen modest improvements in adult vaccination rates for several vaccines, racial and ethnic disparities in vaccine use persist.¹ In May 2017, the Centers for Disease Control and Prevention published an updated study on immunization rates based on data from the 2014–2015 immunization season. The report acknowledged that vaccination rates had improved among adults for influenza (1.6% increase), pneumonia (2.8% increase), Tdap (3.1% increase), herpes zoster (2.7% increase), and hepatitis B (4.1%).¹ Despite these increases, racial and ethnic disparities continued for all 5 of these vaccines, and the increase in use was attributed to whites compared with other populations.¹ Individuals with health insurance, at least one contact with a physician, and a usual place for health care were more likely to receive the recommended vaccines.

As the delivery of vaccines in pharmacy has solidified and become the standard of practice, pharmacist-led strategies have been created to increase vaccine use. In Rhode Island, academic pharmacists created a statewide education campaign to improve pneumococcal vaccination rates and reduce invasive disease among adults.² Educational efforts targeted immunization providers including pharmacists, nurses, and physicians, as well as patients. After the intervention, there was a 20 per 1 000 000 population per year reduction (−42.25 to 0.14, P = .05) in invasive pneumococcal disease and 5% increase (P = .01) in pneumococcal vaccination within the state.² At a grocery store chain, pharmacists incorporated vaccine assessment within medication synchronization appointments. Practice sites that utilized the new model delivered significantly more vaccine compared with usual practice (1810.71 ± 500.88 vs 1455.09 ± 754.09; P = .01).³ Additionally, Pizzi and colleagues⁴ created the Pharmacists’ Pneumonia Prevention Program, with an aim to improve vaccine knowledge and activation among individuals in an African American community. Of 276 participants, knowledge improved by 54.2% and 37.2% of participants unvaccinated at baseline reported receiving one after the intervention.⁴ These novel interventions created by pharmacists assisted with increasing vaccine use in their respective communities.

Although pharmacy-based immunizations provide a more convenient avenue for adults seeking vaccines, not all populations receive the same level of access.^5-7 Analysis of the Medical Expenditure Panel Survey revealed that a larger portion of non-Hispanic whites received pharmacy-based vaccinations compared with non-Hispanic blacks (60.9% vs 49.1%; P < .001) and Hispanics (60.9% vs 51.7%; P < .0001).⁸ A 2017 review of data from the Behavioral Risk Factor Surveillance System concluded that non-Hispanic blacks were less likely to use pharmacy-based immunization services compared with other locations independent of education level.⁹ In Detroit, Michigan, it was reported that pharmacy-based immunization services are located in areas with higher proportions of white residents and higher incomes rather than in black and economically disadvantaged communities.¹⁰ Other disparities based on race in Detroit included reduced access to discounted prescription drugs and reduced hours of operation for pharmacies.¹⁰ With these reported disparities facing black residents of Detroit, there was a need to examine their experiences with pharmacy-based immunization services in more detail. In this report, we will review focus group discussions with African Americans who reside in a public housing complex in Detroit. Our goal was to examine the experiences of African Americans with pharmacy-based immunization services and identify how pharmacies and pharmacy organizations can better serve patients in urban communities with similar dynamics.

Methods

Study Design

Our qualitative study utilized focus group discussions to gather information from community members. The Wayne State University Institutional Review Board approved the study methods and materials. Data that describe racial and ethnic disparities with regard to accessing pharmacy-based immunization services in Detroit, in combination with the ecological health belief model, were used to create study aims and the data collection script (see the appendix). The ecological model describes the impact of the interaction between the individual (intrapersonal and interpersonal factors) and the larger community structure (physical environment and policy) on public health.¹¹ Our “structuralist” approach contends that health behaviors, such as not receiving vaccines, are affected not only by individual factors, such as level of education, confidence, and complacency, but also by environmental factors, such as limited access to pharmacies that offer pharmacy-based immunization services within the community.¹¹

Study Recruitment and Participants

Prior to study recruitment, the principal investigator utilized his pharmacy site, located in East Detroit, as a focal point to enlist community partners for the project. Investigators completed a Google search of community-based organizations (CBOs) within a 10-mile radius of the pharmacy. Investigators then called each organization to inform them about the study and ask for support in promoting the project and hosting focus group sessions. One individual from a not-for-profit CBO located in a public housing complex requested a meeting with the investigators to discuss the project. A meeting was scheduled, and details about the CBO were shared, including its mission to serve residents of the housing complex by working with residents, organizations, institutions, and businesses on Detroit’s east side. Additionally, the CBO provided residents of the housing complex with information and action forums to address issues that adversely affect their lives. After discussion about the shared goal of helping the community, the executive director and community members agreed to collaborate with study investigators on the project, and the institutional review board–approved recruitment flyers were hung in communal areas to notify residents about the focus groups.

All English-speaking adults aged 50 years and older who resided in metropolitan Detroit were eligible to participate in the study. This age group was selected because it was thought they would be more familiar with influenza and pneumococcal vaccine, and have greater experience dealing with vaccinations. Originally, the Advisory Committee on Immunization Practice recommended influenza vaccine for healthy adults aged 50 years and older and recommendations did not expand to all healthy adults until 2011.¹² Recruitment flyers instructed interested individuals to call the principal investigator for further details. Within 3 weeks, 22 people called to express interest in participating in the study, and investigators scheduled focus group sessions in the community center of the housing complex. The principal investigator called the prospective participants about the scheduled times for focus groups, and 15 individuals reported for the group meetings. Table 1 provides a demographic breakdown of the participants who consented to participate in the study.

Table 1.

Study Demographics.

Characteristics	N = 15
Gender, n (%)
Female	7 (46%)
Age (years), n (%)
50-54	1 (6.6%)
55-64	6 (40%)
65-70	7 (46.6)
>70	1 (6.6%)
Ethnicity, n (%)
African American	15 (100%)
Education, n (%)
Some high school	2 (13.4%)
Completed high school	7 (46.6%)
Some college	6 (40%)
Time lived in the community, n (%)
6-10 years	3 (20%)
10-20 years	1 (6.6%)
>20 years	11 (73.4%)

Instruments and Data Collection

Study investigators used an iterative process to develop a data collection script. When an initial draft of the data collection script was developed, it was sent to peers within the principal investigator’s department and research mentors at the University of Pittsburgh School of Pharmacy. After 2 rounds of revisions, the final draft included 3 main topics areas with 10 total questions (see the appendix). The topic areas were designed to (1) understand the participants’ knowledge base about influenza and pneumonia vaccines and describe their experiences receiving vaccines; (2) learn participants’ feelings about pharmacists administering vaccines to patients; and (3) identify potential pharmacy-based solutions to improve vaccination rates in the community.

A medical anthropologist was hired to facilitate 2 focus group discussions using the data collection script. The principal investigator co-facilitated and took notes during focus group sessions. Each participant signed an informed consent document, and 6 to 9 individuals participated in each session. Focus groups were audio-recorded and lasted from 45 to 80 minutes. After each session, participants were offered lunch and a $20 gift card to a local grocery store.

Data Analysis

Investigators hired Wordsworth Typing & Transcription, Inc, a professional transcription company, to transcribe audio recordings from each focus group session. Pharmacy companies and the names of study participants were not included in the written text. After receiving the transcripts from each focus group session, investigators coded the data according to procedures described by Halcomb et al.¹³ This involved 2 investigators independently reviewing written notes with transcribed text to create preliminary themes. These investigators then came together to compare notes and subsequently reconciled and refined the themes. At a later meeting, all study investigators convened to read transcripts line-by-line and identified major statements, phrases, and quotations related to the themes and study objectives. Investigators met a final time to discuss themes identified in the analysis process.

Results

The results from the focus group discussions yielded stimulating and rich information that was shared by the collective group of participants. The responses indicated that only a small proportion of the participants receive their flu and pneumonia vaccinations from a hospital, while the majority of the group preferred to receive vaccinations at a pharmacy. Some of the comments referring to preference centered on a lower immunization fee, convenience and access, and clearer communication with a pharmacist than with a doctor. Three major themes from the focus group participants are presented below, with accompanying quotes that speak to each theme.

Pharmacy Location More Convenient and Accessible Than Doctors’ Offices

Approximately 13 of the 15 focus group participants stated that they prefer to receive their vaccinations from a pharmacy, as opposed to their doctor’s office, because it was easier to access the pharmacy of their choice from their residence. Some of their comments about access include the following:

Well, pharmacist by far is more accessible. They’ve got banners outside the pharmacies. We have the flu shot, we have the shingles shot. Yes, very well advertised.

I have a ride from my house to the pharmacy because that’s where I get my medication from too, so everything’s right there.

Two other participants among those who commented on convenience and access also talked about needing transportation from their residence to get to their doctor’s office but not to their pharmacy.

When I have to go to certain doctors, I have to call or have transportation pick me up. When I go for my primary doctor, I catch a cab around here because it’s not that far. For my pharmacy, I just walk to one.

A lot of people don’t have transportation who stay out here, it’s much easier to walk 2 to 5 blocks and the pharmacy is just right there, and it’s much convenient to get your shots because we don’t have transportation that go to all these hospitals where our doctors are at.

While most of the participants preferred the pharmacy, only 2 responded that they visited their doctor’s office for vaccinations.

I take my yearly flu shot, so I get that from my physician, my primary. . . . I walk to mine, and I might catch the bus if it’s too cold.

I went to the St John Hospital because I was there and they were giving them, and it was convenient.

Among a majority of the focus group participants, it appeared that geographical convenience of a pharmacy was part of the reason they received vaccinations at those locations as opposed to their doctors’ offices.

Clear Communication With My Pharmacist

An informative conversation regarding the relationships and previous conversations with pharmacists also emerged during the focus groups. The participants indicated strong and consistent interactions previously with their pharmacists.

I’m talking to the pharmacist. Sometimes the pharmacists are more clear than the doctor.

The pharmacist is easier to get a hold of than my doctor’s office.

For one thing, you can get a telephone and call your pharmacist or drug store. For the hospital, you go through so many different changes and still might not get that information that you want. Because doctors, a lot of doctors don’t have that extra 2 to 3 minutes to talk to you.

One participant commented specifically about interactions with a pharmacist when asking questions about a particular medication.

If I had any questions about my meds I would ask the pharmacist because my expectation is that they are familiar with the PDR [Physician’s Desk Reference], that they’ve got continuing education that’s specifically directed to medication interactions. And doctors know what they’re supposed to prescribe for a given diagnosis, but they may not always know what the interactions are. I always think of that as the pharmacist’s role.

Last, one participant commented on how consistent the employees are at the pharmacy that he uses, which allowed him to have a better relationship and experience at the pharmacy that he frequents.

Yes, I always see mine. The same people are there every time since I been taking medication, and it’s been some years. I just go to one pharmacist and the same people; they haven’t switched. They might bring every now and then someone in there new, a new student, then they might leave, but in the process the main ones been in there for a while and, like you say, get some input on the medication that I be taking, you know.

Lower Immunization Fees at Pharmacies

Another theme that came from focus group discussions about preference was centered on cost to patients of receiving immunizations at the pharmacy compared with the doctor’s office. Participants discussed saving money by receiving immunizations at a pharmacy rather than at their doctor’s office. For some, cost, along with convenience and previous experiences, was a deciding factor in choosing a pharmacy over a doctor’s office. Not every participant commented about immunization price, but for a small number of participants, the cost of the immunization was the reason for their choice to visit a pharmacy for immunizations and medication as opposed to a hospital or doctor’s office. Participants simply shared:

I go to the pharmacy because it was cheaper.

When I went to the doctor’s office, there was a fee on the invoice, ten dollars to administer the flu shot, and when I went to one pharmacy, I just gave them my cards and that was it, and I thought, “This is above and beyond,” so it was a cost factor.

One year I had it [immunization] at my physician because I happened to be in seeing her and so I went ahead and had it there, and it was $85. Medicare didn’t cover all of it, and if I hadn’t had a Medigap policy it would have been out of my pocket. [One pharmacy] said it’s either $25, or if you have a Medicare card, it’s nothing. So it was nothing, and that’s why I do the pharmacy since then.

Discussion

Focus group discussions with African Americans of this particular housing complex in Detroit revealed 3 major themes based on their experiences with local pharmacy-based immunization services, which include the convenience of pharmacy locations, clear communication with the pharmacist, and perceived lower fees at the pharmacy than at doctor’s offices. Participants who preferred to receive vaccinations at a pharmacy reported greater ease of access in terms of traveling to the pharmacy compared with traveling to their doctors’ offices. Pharmacies established in grocery store chains may be perceived as more convenient because patrons visit these locations frequently for prescriptions, groceries, and other needs, in addition to patient care services in the pharmacy. Study participants mentioned that they have a clear understanding of information relayed to them by pharmacists. Pharmacists’ ability to communicate may enhance pharmacist-patient interactions where patients learn about medications and potential risks from drug interactions. Additionally, participants enjoyed familiarity with a particular pharmacist, which helps to strengthen relationships. In terms of out-of-pocket costs, it was perceived that vaccinations in the pharmacy were less expensive than at the doctor’s office.

Pharmacies offer an option for primary care for individuals who reside in communities with limited health care resources.¹⁴ Participants interviewed in our study reside in a community designated as a medically underserved area (MUA); however, participants reported greater ease in accessing pharmacies than other health care entities.¹⁵ Previous studies describe how the availability of pharmacists affect public health. Gai et al¹⁶ utilized the Behavioral Risk Factor Surveillance System data to evaluate the relationship between pharmacist density and adult influenza vaccination rates. After controlling for socioeconomic status and access to health care resources results showed that the increase of 1 pharmacist per 1000 population was associated with a 13% greater odds of influenza vaccination (adjusted odds ratio = 1.13, 95% confidence interval = 1.11-1.15).¹⁶ Although doctors’ offices are the number one place where Americans receive vaccinations, further expansion of pharmacy-based immunization can reach those who lack primary care in their communities. Access to a pharmacy can be described as proximity to geographic locations and expanded hours of operation when services are available (evenings and weekends) compared with doctors’ offices.¹⁷ It can also be discussed in terms of legislation that allow certain services to be offered in the pharmacy.¹⁸ For instance, all states allow pharmacists to administer vaccines; however, there are differences in the types of vaccines that may be administered by pharmacists.¹⁹

Although participants mentioned pharmacy locations are easily available in this community, examination of what services are being offered in these pharmacies is warranted. As mentioned previously, Erickson et al¹⁰ reported pharmacies located in Wayne County with a higher proportion of African Americans offered fewer immunization services and limited services to the dispensing of prescription medications. Additionally, in 40% of ZIP codes in Wayne County, less than 40% of pharmacies offered vaccines. Greater than 95% of chain pharmacies offered vaccines while only 11% of independent and 22% of small chain pharmacies offered vaccinations, respectively. Kelling et al²⁰ conducted a survey among pharmacists in independent and small chain pharmacies that do not immunize in Wayne County inquiring why they do not offer immunization services and reasons cited include doctors’ office administers vaccine, lack of time in the pharmacy, no interest among pharmacy personnel, and not enough physical space in the pharmacy. Review of independent pharmacies in this community is essential, as they are located in ZIP codes of residents with lower income. For instance, in our study, the 5 closest pharmacies to our interview site were independent pharmacies. Our data indicate that patients use pharmacy-based vaccination services, especially when they have an easier time traveling to the pharmacy than a physician’s office. It is prudent to educate public health officials about accessibility to care, specifically transportation challenges in this community, and how local development of pharmacy-based immunization programs may positively impact vaccination coverage.

Study participants spoke positively about communicating with pharmacists regarding medication-related matters. Generally, pharmacists are regarded as trusted professionals in society highly capable of providing information on medication use.²¹ Incorporation of pharmacy-based immunization services and other clinical programs where patients spend more focused one-on-one time with pharmacists helped enhance the professional profile of the pharmacist.²² Additionally, pharmacists have been encouraged to learn advanced communication skills, such as motivational interviewing, to discuss disease states and encourage healthy behaviors.²³ Patients can learn more information about the value of preventative health care services and decide for themselves if they should utilize them when there is effective communication between patients and pharmacists. Within our study, open availability to communicate with a pharmacist was valued among participants.

These patient-pharmacist interactions helped improve the relationship between the patients and the pharmacists. In the past, literature highlighted how the relationship quality between pharmacists and patients in culturally diverse communities needed to improve.^24,25 Keshishian et al²⁴ performed a survey among older adults and concluded participants had lower relationship quality with pharmacists compared with physicians. A major contributor to this was reduced interaction between patients and pharmacists in high-dispensing pharmacies. Our study participants mentioned how consistent interactions with the same pharmacist and pharmacy staff members improved this relationship. Cultivating relationships is useful for patients and pharmacists alike, especially when discussing personal health matters. It is clear from the study participants that pharmacists are in a position to build strong relationships with patients and become a reliable source of information on health and wellness. For these reasons, pharmacists can potentially gain and maintain the trust of their African American patients. Furthermore, patient populations that use fewer vaccines due to cultural beliefs may be more open to discuss these concerns with a familiar pharmacist they trust and have an established relationship within the community.

Within focus groups sessions, participants perceived costs of vaccinations to be less at the pharmacy than at other venues. Lack of affordability reduces vaccination rates and individuals without insurance coverage are less likely to receive recommended vaccines.²⁶ National efforts such as the passage of the Affordable Care Act aimed to increase usage of preventative health care and required coverage of immunizations and other services to keep citizens healthy.²⁷ These efforts have reduced out-of-pocket costs for some individuals but not all patients. However, more pharmacy benefit managers are covering vaccines administered in the pharmacy similarly to prescription drugs.²⁸ Of those who have prescription drug coverage, a single copay for vaccine may be required, which may differ from a physician practice, which may charge separate fees for the office visit and vaccine administration.

Strengths in our study include the partnership with a CBO in recruitment of participants where the majority of participants lived in the community for 20 years or more. All participants identified as African American, which enabled investigators to analyze their unique perspectives in an environment reported to have limited pharmacy-based immunization services. Although 15 individuals participated in our study, it is a limitation that we hosted 2 focus group sessions due to lack of funding and availability of study participants. We aimed to conduct culturally appropriate focus groups as described by Halcomb et al¹³; however, our interpretation of the data may have introduced bias.

Conclusions

We conducted focus groups with African Americans who reside in a community with limited access to pharmacy-based immunization services. They provided in depth insights into their experiences with pharmacy-based vaccination services in their community. Common themes found among participants include that pharmacies are more convenient and accessible than doctors’ offices, there is clear communication with pharmacists, and patients perceived lower immunization fees at the pharmacy compared with doctors’ offices. Overall, participants who received a vaccine in the pharmacy discussed benefits of the service. We encourage pharmacists and pharmacy organizations to implement more immunization services in communities where immunization disparities are prevalent to enhance patient access.

Appendix

Project Title: Experiences Among African American Community Members With Pharmacy-Based Immunization Services in Detroit, Michigan

Rationale

The facilitator will focus on several key questions in each group. The questions are provided below:

Area 1: Describe what you know about the flu/pneumonia vaccines and your experiences with them.

1. Tell us what you know about the flu shot?

2. Tell us what you know about the pneumonia shot?

3. Has anyone ever had the flu or pneumonia shot?

   • a. If yes: Where did you get the shot(s)? Did anyone recommend you get the shot(s)? What was your experience? Would you get it again?
   • b. If no: Why do you choose not to get the shot(s)
4. Do you know others that have received a flu or pneumonia shot?

   • a. If yes: Where did they go? What did they tell you about their experience?
   • b. If no: Did they explain why they don’t get the shot(s)? What did they say?

Area 2: Describe how you feel about pharmacists providing these vaccines in the pharmacy.

1. Tell us what you know about pharmacists giving shots? What do you think about that? Should pharmacists provide this service?

2. Does anyone have an experience with a pharmacist giving them a flu shot or pneumonia shot (or any shot)? What was your experience? Do you know others that have gone to a pharmacist for a shot? What did they say about their experience?

Area 3: Describe what prevents people in the community from becoming immunized and possible pharmacy solutions from community.

1. What would prevent you from getting your flu shot? Or if you do not want to get it, please explain why?

2. What would prevent you from getting your pneumonia shot? Or if you do not want to get it, please explain why?

3. Why do you think people do not go to get their shots (flu and pneumonia)?

4. Should pharmacists teach people about flu and pneumonia shots in your community?

   • a. If yes: Why do you think so? How do you think pharmacists can best teach people in the community? Who can pharmacists work with in the community on this topic?
   • b. If no: Why not? Do you think there are other issues pharmacists should consider for the community?