COVID-19 booster vaccination in rural community pharmacies

Abstract

This study assessed rural community pharmacists’ attitudes about COVID-19 vaccine booster doses and explored whether rural pharmacies offered these booster doses. Of the 80 rural Southeastern U.S. pharmacists who completed the online survey, the majority (n = 68, 85 %) offered boosters and 42 (52.5 %) had received the booster themselves. Alabama and Mississippi offered boosters less often than other states, and pharmacists who had foregone receiving COVID-19 vaccination or booster doses were less likely to offer the booster to their patients. Additionally, many pharmacists reported that they and their patients felt the booster was not needed. Community pharmacies provide access points for the COVID-19 booster in rural areas. Interventions for both pharmacists and patients are needed to address hesitancy and improve booster uptake in these communities.

1. Introduction

Rural residents are at greater risk of serious illness from coronavirus disease 2019 (COVID-19),[1] making the vaccine particularly important in rural areas. For individuals who have received the primary series of the COVID-19 vaccine, a booster dose can significantly decrease the chances of serious illness leading to hospitalization or death from a breakthrough infection.[2] Yet, as of October 20, 2022, approximately-two thirds (66 %) of vaccinated American adults remain unboosted.[3] Booster hesitancy was as high as 57 % in October 2021[4] and in April 2022, 50 % of vaccinated adults said they would either definitely not get a COVID-19 booster or would only get one if required; another 18 % said they would “wait and see.”[5].

Rural community pharmacists have played a crucial role in providing access to COVID-19 vaccines in the United States (U.S.). During the initial vaccine roll-out, West Virginia led the nation in the number of COVID-19 vaccine doses administered by utilizing independent community pharmacies.[6] Additionally, when vaccines first became available to high risk populations (December 2020- February 2021), survey research with rural Southeastern community pharmacies found that the majority would be ready to provide COVID-19 vaccines by that summer.[7] Community pharmacies can be important access points for the booster dose as well. However, pharmacy administration of COVID-19 booster doses in rural areas has not been explored.

A recommendation from a trusted health professional is one of the most effective ways to increase vaccination uptake.[8] While pharmacists are highly trusted,[9] they might not provide a strong recommendation if they themselves lack confidence in vaccines and boosters or if boosters are not available. Previous research found significant associations between community pharmacists’ influenza vaccination status and recommending the vaccine, where pharmacists who had been vaccinated themselves were more likely to recommend the flu vaccine to their patients.[10], [11], [12] In a survey of rural pharmacists, Carpenter et al. reported that 91 % of respondents were ready or actively planning to provide the COVID-19 vaccination series,[7] but their attitudes and plans regarding the booster dose are unknown.

Thus, our project aimed to determine availability of and demand for COVID-19 boosters in rural community pharmacies and assess rural community pharmacists’ COVID-19 vaccination status and attitudes toward boosters.

2. Methods

2.1. Participants

This cross-sectional survey study was conducted with rural community pharmacists from the Rural Research Alliance of Community Pharmacies (RURAL-CP), a multi-state practice-based research network comprised of 112 community pharmacies in seven Southeastern states.[13] Most (98 %) RURAL-CP pharmacies have a Rural-Urban Commuting Area (RUCA) code of 4 or higher, which is considered rural.[14] However, given the limitations of RUCA codes,[15] some additional pharmacies that meet other rural criteria (e.g., a town population of less than 2,500, being a health professional shortage area, county percent rural greater than 50 %) are included.

2.2. Procedures

Participants received an email describing the study and a link to the online 10–15 min Qualtrics survey. Data were collected from February to March of 2022, when a single booster dose of any COVID-19 vaccine was recommended for all adults and of the Pfizer-BioNTech vaccine for individuals 12 years or older.[16] Pharmacists who completed the survey received a $50 Amazon e-gift card incentive. Because the survey instrument did not collect any personal identifiers for pharmacists or patients, the Institutional Review Board at the University of North Carolina determined that informed consent was not required.

2.3. Measures

One item assessed whether pharmacists were offering the booster in their pharmacy (“Yes”, “Not currently, but we plan to”, “No, and we don’t plan to”). For those who answered “No, and we don’t plan to”, an open-ended question asked pharmacists to elaborate on why the booster would not be offered. Alternatively, pharmacists who selected “Yes” indicated the number of booster doses administered in a typical day and whether demand for the booster exceeded supply (Yes/No). These pharmacists also indicated which boosters they currently offered (Pfizer-BioNTech, Moderna, Janssen) and which manufacturers they preferred.

Four questions assessed communication about the booster, including: whether (Yes/No) and how (e.g., email, phone call) pharmacies contacted patients to schedule a booster, methods to verify patient eligibility (e.g., patient self-report, checking vaccination cards), and common patient concerns.

An open-ended question asked pharmacists to describe the impact COVID-19 vaccinations have had on their pharmacy.

Pharmacists answered eight demographic questions (e.g., age, state, type of pharmacy), and indicated their own COVID-19 vaccine status (e.g., “I have not received any COVID-19 shots”, “I have completed the primary series”, “I have completed the primary series and received a booster”).

2.4. Data analysis

We calculated descriptive statistics using IBM SPSS Statistics (Version 25.0, Armonk, NY). To categorize responses to open-ended questions, one coder used Microsoft Excel to identify themes. Complete pharmacist responses were downloaded from Qualtrics into Excel. The coder read through each response and identified the themes present in each response. A single response could have more than one theme assigned to it. The number of times a theme was identified was then tallied across all responses.

3. Results

Eighty of the 112 pharmacists (71 %) completed the survey. A large majority of respondents (n = 68, 85 %) had been vaccinated against COVID-19 with 42 (52.5 %) having been boosted (Table 1 ).

Table 1.

Respondent characteristics (n = 80).

	n	%
Age (years)
18–29	10	12.5
30–39	27	33.8
40–54	33	41.3
55 and older	10	12.5
Gender
Female	52	65.0
Male	28	35.0
Race/ethnicity
White	75	93.8
Black or African American	2	2.5
Asian or Pacific Islander	1	1.3
Multiracial or biracial	1	1.3
Prefer not to answer	1	1.3
Highest level of pharmacy education
PharmD	58	72.5
BSPharm	15	18.8
Other (e.g., AFMC, CPhT)	5	6.3
Did not answer	2	2.5
Length of time worked as a pharmacist
0–3 years	9	11.3
4–11 years	16	20.0
12 + years	52	65.0
Did not answer	3	3.8
Type of pharmacy worked at
Single independent	43	53.8
Multiple independents (i.e., 2 or more stores under same ownership)	27	33.8
Grocery store or regional chain	9	11.3
National chain	1	1.3
Vaccine status
Completed the primary series and received a booster	42	52.5
Completed the primary series (this includes the 1-dose Janssen) but not the booster	26	32.5
Haven’t received any COVID-19 shots	12	15.0
Reasons not vaccinated (n = 12)*
Personal choice	3	25.0
Did not say	2	16.7
Concerned about side effects	2	16.7
Vaccine too risky while pregnant	2	16.7
Religious reasons	1	8.3
Believe in “natural immunity” from having a COVID-19 infection	1	8.3
Don’t trust this type of vaccine (mRNA)	1	8.3
Believe immune system and health is strong enough on its own	1	8.3
Do not believe in vaccines in general	1	8.3
Not necessary/limited benefit	1	8.3
Against vaccine mandates	1	8.3
Reasons not boosted (n = 26)*
Had COVID-19 disease – not eligible or don’t believe it’s needed	11	42.3
Not yet due for the booster	4	15.4
Concerned about side effects	3	11.5
Not needed because healthy and not high risk	3	11.5
Haven’t found the time	2	7.7
No longer trust CDC guidelines	1	3.8
Don’t believe it’s effective against new strains	1	3.8
No reason	1	3.8

^*Reasons were identified in open-ended responses and are not mutually exclusive.

Most pharmacists (n = 68, 85 %) reported offering COVID-19 boosters in their pharmacy. Four pharmacies (5 %) were not currently offering the booster but planned to, while eight (10 %) did not offer the booster and did not plan to (Fig. 1 ). Alabama and Mississippi offered boosters less often. Twelve pharmacists worked at pharmacies not currently offering the booster. Of those 12, less than half (n = 5, 41.7 %) had received a COVID-19 vaccine: four had received the primary series but not the booster, and one was vaccinated and boosted. Reasons pharmacies were not planning to offer the booster identified in their open-ended responses included low demand (n = 4, 50 %), staffing issues or time constraints (n = 3, 37.5 %), not offering any COVID-19 vaccines (n = 2, 25 %), and storage or supply issues (n = 2, 25 %). One pharmacist felt the booster was ineffective against new variants but did not elaborate why or provide evidence. Pharmacists could identify more than one reason for not offering the booster in their response.

Fig. 1.

Number of rural pharmacies offering the COVID-19 booster dose by state (n = 80).

Almost all pharmacists who were offering the booster offered Moderna (n = 66, 97.1 %). Many offered Pfizer-BioNTech (n = 40, 58.8 %) and just over half offered Janssen (n = 35, 51.5 %). Most pharmacists (n = 40, 58.8 %) did not prefer a particular manufacturer for the booster.

Eight pharmacies (11.9 %) proactively contacted patients to schedule a booster, with phone (n = 7, 87.5 %) and in-person (n = 4, 50 %) outreach the most frequently cited methods. To verify patient eligibility for the booster, nearly all pharmacists checked COVID-19 vaccination cards (n = 65, 95.6 %) or checked the immunization registry or Immunization Information System (IIS) (n = 62, 91.2 %). Many pharmacists also relied on patient self-reported vaccination status (n = 49, 72.1 %).

Pharmacists reported that the most common patient concerns about the booster were: side effects (n = 56, 82.4 %), ineffectiveness against new variants (n = 42, 61.8 %), pregnancy or breastfeeding concerns (n = 11, 16.2 %), and not needed because of “natural immunity” (n = 32, 47.1 %) or belief the primary series was sufficient (n = 19, 27.9 %). These concerns were not mutually exclusive since pharmacists could select more than one. For the 12 pharmacists who had not received any COVID-19 vaccinations, reasons for being unvaccinated included: personal choice, believing the vaccine was not needed, concern over side effects including while pregnant, and generally being against vaccines or vaccine mandates. Reasons for not getting the booster, provided by the 26 pharmacists who had received the primary series of the COVID-19 vaccine, were similar (Table 1).

Sixty-six pharmacists described the impact of COVID-19 vaccinations on their pharmacy. Many had positive comments, including increased foot traffic and as a result, gaining new customers. Additionally, pharmacists reported increased revenue and respect of the pharmacy profession. On the other hand, half mentioned increased workload, extra time burden, and workflow strain.

4. Discussion

This article offers new insights into COVID-19 vaccine booster administration at rural community pharmacies. In early 2022, 46 % of rural adults and 40 % of rural parents reported that they received their most recent dose of the COVID-19 vaccine from a pharmacy, indicating that pharmacies are important booster access points.[17] While most rural pharmacies in our sample were offering boosters, a few pharmacies were not. Because a pharmacy may be the only healthcare facility in a rural community, access to the booster could be severely limited when a pharmacy does not provide COVID-19 vaccinations. More in-depth exploration into the reasons for and barriers to offering COVID-19 vaccines at these pharmacies is warranted.

There is a paucity of data on COVID-19 booster dose rates of healthcare workers. But, the percentage of pharmacists in our sample who had received a single booster (n = 42, 52.5 %) is higher than the national booster rate of nursing facility staff from the same timeframe (44 %).[18] Still, almost half of our sample had not received a booster and 15 % (n = 12) had not received any COVID-19 vaccinations. More than half of the 12 unvaccinated pharmacists worked at pharmacies not offering the booster, suggesting that the personal views of pharmacists may affect the vaccination services the pharmacy provides. Personal vaccination decisions could also influence how pharmacists communicate with their community members about the vaccine.

Consistent with the U.S. trend of decreasing demand for the first COVID-19 booster,[19] half of the pharmacists in our sample who did not plan to offer the booster cited low demand as a reason. Low demand of the COVID-19 booster can be attributed to low vaccine confidence.[4], [20] U.S. adults with lower vaccine confidence are more likely to be hesitant towards a COVID-19 booster,[4], [20] and side effects and ineffectiveness were main patient concerns reported by pharmacists in our sample. Additionally, there seems to be misinformation about the need for the booster. Approximately half of the pharmacists in our sample who had not received the booster felt it was not necessary. Among the general U.S. population, the top reason recently reported for not getting the booster was feeling they had enough protection from either the primary series or a prior infection.[5].

4.1. Limitations

The generalizability of our results is limited, as the rural pharmacists in our sample reside in seven Southeastern U.S. states and primarily work at independent pharmacies. Additionally, there were very few responses from pharmacists in MS, GA, and TN, which limits generalizability in those states. Survey responses were recorded in February and March of 2022 and pharmacists’ opinions or plans to offer the COVID-19 booster could have changed. For example, pharmacies that were not currently offering the booster could now be offering it. Also, since the survey period, the bivalent booster has become available; pharmacists’ opinions about the bivalent booster could be different.

5. Conclusion

Most pharmacies in our sample were offering the COVID-19 booster and serving as important vaccine access points in rural areas of the Southeast. However, patient demand for the booster was not high. Interventions aimed at increasing vaccine confidence and understanding the importance of the booster are needed at both the pharmacist and patient level. Qualitative studies with rural pharmacists could provide additional insights into their specific vaccine concerns and suggestions for tailored intervention approaches to increase booster uptake.

Disclosures

The authors have no conflicts of interest to declare.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.