We all learn early on that one way to sidestep arguments is to avoid religion or politics. Check. But, hold on: vaccinations have gotten tangled up with both. And that makes bringing up vaccinations risky – who knows what conversational dark alley you might get dragged down. 

What got us thinking about conversational alleys was this comment in last month’s article about the new vaccine hesitancy (note the use of the word “opinions”) –

“Primary care is overwhelmed. Do they have time to do a comprehensive vaccination screening? Probably not. The vaccinations guidelines have changed so much that it’s hard to keep up with them, and now patients have opinions about vaccines – do you want to open that can of worms?”

That quote is from pharmacist Bianca Daisy-Bell, someone working to close vax gaps, and one of her solutions was involving community healthcare workers (CHWs) in the conversation, saying “They provide a different kind of voice compared to a person in a white coat.”

That made us want to know more about CHWs and vaccinations and specifically an ambitious program in Missouri to involve them in the conversation. What we heard about CHWs may surprise you, including “every pharmacy should have one.”

First, some history…

CHWs

You know something is valuable when it starts with church volunteers, and what they do is so useful that big organizations start offering to pay them to do more of it.

And church volunteers are one origin of Community Health Workers: these were commendable church members, mostly in minority communities, helping one another with health, who were “discovered” by those with admirable aspirations and with budgets. (Indeed, the old Spanish name from 1950s California for those helping migrant farm workers with health issues is still in use: “Promotores,” as in “promoters” or “advocates.”)

Such volunteers were the folks who were recruited to help with critical health equity projects, including HIV education, tobacco cessation, and, recently, Covid vaccinations. One study counted 250 titles for such useful individuals (including “health navigator,” patient liaison,” “family educator,” and “health advocate”), but now coming together under the Community Health Worker designation, or simply, CHWs.

Meanwhile, CHWs have played a major role in many foreign health systems and it’s common for them to take the lead in vaccination programs. One 2023 study* reported that 75 countries have documented CHW programs and in 20 0f those, CHW are vaccinators, as we see in this quote from Global Health Science and Practice: 

In some countries, like Pakistan and Malawi, CHWs also administer vaccines that have been critical to reaching underimmunized and zero-dose communities. CHWs in Pakistan administer the oral polio vaccine (OPV) as well as bacille Calmette-Guerin, measles, and COVID-19 vaccines in some provinces, while in Malawi, they administer all routine immunizations. There are precedents for CHWs administering injections; in at least 20 countries, CHWs administer injectable medication such as contraceptives.

At the end of this article we’ve included some photos from an excellent UNICEF article with videos, including the link, but for now, here’s one screenshot from a section on Pakistan.

CHWs and VACCINATIONS in the U.S.

Covid vaccination programs brought more attention to the role CHWs might play, but this was not their first involvement. For instance, an effort in Arizona called Arizona Health Start was studied from 2006-2016: CHWs worked with childhood immunizations in “historically disadvantaged subgroups” and vax rates lifted by five percentage-points.

CHWs in Pharmacies

The idea of having pharmacy techs also be CHWs has been percolating up in Southeast Missouri for a few years now. 

Annie Eisenbeis (photo above), Director of Practice Development for the Missouri Pharmacy Association, described how it happened: “It started four years ago. Tripp Logan [of SEMO Rx Pharmacies] had heard of CHWs and had one of his techs get the training. He quickly realized it could make a huge difference. We at the MPA got involved. Thanks to a grant-funded program from the Missouri Department of Health and Senior Services, we offer scholarships for CHWs and we specifically added ones for pharmacy technicians to become CHWs. There were community college classes but none were ideal for pharmacy techs, so we created a course. Bianca Daisy-Bell (quoted earlier and shown administering an at-home vaccine in the photo below) put together the curriculum. But we realized it was bigger than Missouri. We worked with CEImpact [a continued education organization] and we had our first cohort specifically for pharmacy technicians, all from Missouri. Then, by our second cohort, we had 22 states represented.”

We spoke with one of the people who has led the effort at CEImpact, Jake Galdo, who explained the logic of combing the two set of qualifications: “It’s about what services you can offer. When it comes to vaccine hesitancy counseling, the scope of practice for a pharmacy tech does not include counseling – that would have to be the pharmacist. BUT, the scope of practice for CHWs does allow for counseling. So if you have someone who didn’t get the Covid shot, as a CHW you can ask ‘why not?,’ but not as a tech.”

Moreover, there are multiple avenues to getting reimbursed for that counseling time: health education programs from the CDC, Medicaid and Medicare.

THE CHW/TECH: THE “HUB FOR CONNECTING RESOURCES”

Cindy Litterest [photo below] was working as a Pharmacy Tech when she heard talk of CHWs becoming a larger part of pharmacies, and that included the offer of a scholarship to become certified as a Community Health Worker. She said of the decision to take that offer, “I’m a busy mom with four kids, but I committed to a two-hour class, once a week for 15 weeks. My boys knew that Tuesdays was ‘Mom’s got class – it’s a crock-pot night.’”

Cindy discovered that her new combo-role in the pharmacy, as Tech and CHW, meant that “I became the hub for connecting resources. I have a whole binder full of resources. So everyone in the pharmacy knows that if they hear someone say, ‘I can’t pay my bills, so I can’t get my medicine,’ they think, ‘Wait, we have a CHW’ and they send that person to me and we’ll figure out how to get them help.” That’s led her to this conclusion: “Every pharmacy should have one.”

She also feels that pharmacies are becoming the logical place for vax discussion, saying, “We’re to the point where there’s more talk at the pharmacy than the doctor’s office – they are too pressed to get to the next patient.”

She went on to explain the bigger picture: “The CHW program has inspired the pharmacy to expand its role. We now have a list of programs to offer and all are completely free to patients. It’s 110% that any pharmacy that wants to survive should add CHWs – it’s groundbreaking for a pharmacy.”

One of the programs that Cindy has found most helpful is the vaccine hesitancy program. “When we contact patients we check to see what they need, so I’ll call and say, ‘We have your atorvastatin ready… but I see that you’re due for your second shingles shot. Let’s go ahead and get that scheduled.’ And they’ll say, ‘Sure, let’s do it.’”

When it comes to vaccination programs, Cindy explained the monetary side:  “Everyone knows that reimbursements for local pharmacies are terrible, but in most of these vaccination programs have some sort of acceptable reimbursements.”

Talking to Cindy left this impression: “Speaking of improving health: CHWs might just be the key to improving the health of the nation’s pharmacies, particularly pharmacy vaccination programs.”  

So the combination role makes sense on multiple levels; but, when it comes to improving vax outcomes…

DOES IT WORK?

Annie Eisenbeis and the folks at the Missouri Pharmacy Association are studying the effects of having CHWs in pharmacies. They track “interventions” – these are situations during normal workflow where the Tech/CHW identified a vaccination gap and had the opportunity to offer a 5-15 educational conversation. While there are two universities involved and their researchers will do full analysis of the study, Annie was able to give us some early results: “We rolled out Phase One in December, basically starting around the first of the year; by late May we were five months in and we’ve had 18,000 interventions that included 13,000 patients and most received follow-up education. Of those patients, over 10% had at least one vaccination gap closed.”

The study also includes follow-up with those who did not get the recommended vaccination in an effort to boost the gap-closure rate even higher. And the study will also expand into more types of vaccination patients, and will eventually involving educational clinics, health fairs and other community events.

CONCLUSION

We opened with what amounted to this question: Who wants to risk “opening a can of worms” by talking with “patients with opinions” about getting vaccinated? We can answer that question: Someone with the time, the training and the reimbursement to do so. That would be the new hybrid, the Pharmacy Tech who is a Community Health Worker, the PT/CHW.

Link to an excellent article on international CHW programs:

https://www.unicef.org/stories/community-health-workers-heartbeat-global-primary-health-care

Photos below from Nigeria, Nicaragua and Ecuador

*Glob Health Sci Pract. 2023 Feb 28; 11(1): e2200307.

Community Health Workers as Vaccinators: A Rapid Review of the Global Landscape, 2000–2021

Emily Gibson, Mariam Zameer, Rebecca Alban, and Luc Mahougbe Kouwanou

* * * *

STATS OF THE MONTH

Born after 1966?  If YES, you should read this!

By Bill Davenhall, Geospatial Advocate

Living arrangements are something we all get an opportunity to undertake, but how we go about doing so is getting more complicated than you might think! I discovered an interesting statistical Census Bureau Table that’s very helpful in understanding how various living arrangements are affecting society. You might ask yourself, “Why should I read this? I think I already know the answer.” Not so fast.

For starters, you will possibly confirm what you have already been noticing in “real life.” Who else might be noticing — other than the US Census Bureau and possibly all the organizations that serve “children and families”?!  Some aspects of our desired or preferred individual living arrangements probably began early in our life while others not so predictable – but you need to look at the change America has undergone over the last 57 years  for yourself. You may also wonder what your kids and the children they might have will undertake in the future.

Perhaps you will be surprised by what you see in this data or maybe not so much – depends on your view of how well you think the 18–24-year-olds over the last 57 years have been doing with their various “living arrangement experiments” described in the he Census Bureau table below.  For example, you might wonder about the societal impact of these trends, or you might think about needed “innovations” to consider. You might also spend some time thinking about how these trends might increase or diminish lifelong behaviors related to events like getting an immunization or registering to vote. Will you need to rethink your marketing strategies for providing services to “families” or communicate differently to the various audiences described herein more effectively?

Here’s my take-away from this table of statistical data about us: While families might still prefer to live in “traditional households,” the data suggests that our definition of “family household” is evolving before our very eyes.

I always appreciate a 2^nd opinion!