A community pharmacy vaccination nudge intervention: Final results of a nationwide study

Community pharmacy is involved in an increasing number of clinical services, although this has been hindered by barriers related to workload and workflow. Borrowing from theories in behavioral economics, "nudges" aim to influence behavior through non-conscious decisions. One large area of potential impact for "nudge" theory is provider-facing screening and recommendations for vaccinations, but the manner in which these mechanisms have been adopted over time is not well understood. To date no evidence exists on the effectiveness of these "nudges" in the community pharmacy setting.

The objective of this study is to report on final results of a pharmacist-targeted behavioral "nudge" to improve second dose completion rates for herpes zoster (HZ) vaccination. A secondary objective was to explore pharmacist acceptance of the nudge-based intervention.

A multi-methods approach was used to assess this quality improvement exercise in a large community pharmacy chain, including vaccine uptake counts and semi-structured interviews with community pharmacists. Changes in second-dose completion of a two-dose HZ vaccine were abstracted from the pharmacy dispensing system and assessed over 17 months once the clinical decision support (CDS) intervention became active. The qualitative arm of the project involved semi-structured, in-depth telephone interviews with pharmacists. Qualitative data was assessed using the Consolidated Framework for Implementation Research (CFIR) to assess contextual barriers and enablers to the intervention. Linear trend analysis examined both series completion and dosing intervals over the observation period.

Thirty-six states were represented across 2271 pharmacies. Despite initial declines in completion percentages and increases in the vaccine dosing windows once the CDS system was implemented, overall improvements in both measures were realized over the course of the observation period (p < 0.01 for completion percentage trend; p < 0.001 for linear trend in mean inter-dose window). Themes derived from a total of 12 in-depth interviews included that the "nudge" positively impacted pharmacist performance expectancy, facilitated patient screening and recommendation process, integrated seamlessly into existing clinical workflows, and social influence positively impacted acceptance of "nudge."

Community pharmacies may further their impact on public health via the use of "nudges" and other clinical decision support tools to support workflow integration. Pharmacists generally regard such interventions positively given their desire to provide more clinical services but not having adequate time to screen patients within workflow. To engage community pharmacies future research should identify means for technology to overcome workload constraints, such as "nudges" aimed at increasing screening and adherence.