Engagement in Hepatitis C and HIV Prevention: Community Pharmacists’ Knowledge and Attitudes Regarding Non-Prescription Syringe Dispensing Legislation

Since 2010, the incidence of acute Hepatitis C Virus (HCV) infections in the U.S. has nearly quadrupled. Re-use and sharing of syringes among people who inject drugs (PWID) is a significant contributor to increased rates of HCV transmission and a risk factor for HIV infection. Community pharmacists are uniquely positioned to offer harm reduction services that lower the transmission of HCV/HIV by providing sterile syringes to PWID. However, legislation on non-prescription syringe dispensing varies by state and differences in individual pharmacists’ interpretation and attitudes regarding these laws may impact their willingness to participate in harm reduction services. Little is known about the impact of these factors on pharmacist engagement with harm reduction services in central Appalachia, a region particularly hard-hit by the opioid epidemic. The objective of this project is to qualitatively evaluate open-ended responses collected as part of a survey administered to community pharmacists in three central Appalachian states in order to determine: 1) pharmacists’ knowledge and attitudes regarding their state’s non-prescription syringe dispensing laws; and 2) the correlation of attitudes about state legislation to pharmacists’ intent to sell syringes to PWID. A telephonic community pharmacist survey on non-prescription syringe attitudes and behaviors was conducted between April and June 2018 in Northeast Tennessee, Western North Carolina, and Southwest Virginia. Survey responses were obtained from pharmacists practicing in 391 community pharmacies (51% response rate) in the study region. Transcribed responses to open-ended survey questions were extracted from the dataset and a qualitative analysis was completed using a generalized inductive approach. A single investigator coded all qualitative data and a second investigator coded data from a random selection of 10% of the respondents in order to develop themes through consensus. Descriptive analysis was conducted using SPSS version 25 to compare syringe law attitude thematic categories to respondents’ intent to sell syringes to PWID. Preliminary analysis identified discrepancies in pharmacists’ non-prescription syringe law knowledge, state-specific differences in pharmacists’ non-prescription syringe law attitudes, and underlying differences in willingness to sell syringes to PWID based on attitudes. The findings may encourage pharmacists to reflect on personal attitudes and interpretation of state-specific legislation as factors that may influence participation in an evidence-based harm reduction strategy for prevention of HCV/HIV transmission. This study offers preliminary results that will serve as a basis for larger studies and interventions aimed at reducing ambiguity in pharmacists’ interpretation of non-prescription syringe dispensing laws and encouraging pharmacists to counter the spread of HCV/HIV in an evidence-based manner

Preceptor Perceptions of Contemporary Practice Skills Amongst New Graduates Amid Community Pharmacy Transformation

As community pharmacy transitions from a fee-for-service model to a focus on value-based care, the desired skills of pharmacist graduates in contemporary practice is an evolving paradigm. Meanwhile, most student pharmacists pursuing a career in community pharmacy upon graduation rely solely upon their pharmacy school training as preparation for entering practice. Community pharmacy preceptors are stakeholders in a unique position to compare the dichotomy of the current climate of community practice with the preparedness of graduating students to enter this field. Therefore, these preceptors’ perceptions of contemporary practice services and skills essential for new graduates may be useful in identifying methods of educating and assessing PharmD candidates in their preparation to enter the evolving landscape of community practice. The objective of this research was to identify essential skills for new graduates in contemporary community pharmacy as perceived by these current practitioners. To accomplish this, researchers developed an anonymous web-based survey using REDCap which was emailed to active Advanced Pharmacy Practice Experiences (APPE) community preceptors. The survey included 3 sections: (1) preceptor demographics; (2) perceptions of “contemporary” services and an evaluation of services offered at their sites; and (3) essential skills for graduates entering contemporary community practice. Following a 30-day window of the survey being open, 25% of preceptors responded (n = 42). Survey responses provided clarity in comparing the proportionality in services offered versus services viewed as contemporary. This information may be useful in identifying transformations that have already seen implementation in practice compared to emerging areas yet to be implemented. We also found broad consensus in the perceived importance of most skill areas offered in the survey with just a few showing broader discrepancies with a minority of respondents suggesting skills which held less importance. Monitoring fluctuations of these parameters over time may disclose trends in community pharmacy practice transformation, further delineating service areas that are trending toward adoption in contemporary practice. Therefore, continued use of preceptor surveys may offer insights on the incremental progression of community pharmacy curricula

Impact on Student Attitudes through Participation in Interprofessional Student Teams at a Remote Area Medical Event in Rural Appalachia

Interprofessional teamwork is being adopted as the best way to care for patients, but it is also important to determine how future healthcare providers view this model of patient care. What are their attitudes and beliefs after having the opportunity to work in an interprofessional team? The primary objective of this study was to determine changes in health profession students’ attitudes toward interprofessional collaboration through participation in a Remote Area Medical (RAM) event in rural Appalachia. Researchers hypothesized that working in interprofessional teams positively impacts students’ attitudes toward interprofessional practice. To explore these variables, RedCap was utilized to collect demographic information, generate a pre/post survey matching code, and administer previously validated interprofessional education (IPE) questionnaires to RAM clinic student volunteers (representing five ETSU health sciences colleges and various undergraduate programs) before and after the event. Students were allowed to voluntarily complete the pre-survey online prior to participating in the event or at sign-in and the post-survey at sign-out or online after the event. The Student Perceptions of Interprofessional Clinical Education-Revised Instrument, Version 2 (SPICE-R2), which is validated for use in pre- and post-surveys, utilized 5-point Likert-type questions (strongly disagree to strongly agree) to evaluate students’ perceptions of their role on the team and the team’s impact on healthcare and patient outcomes. The Interprofessional Collaborative Competency Attainment Scale-Revised (ICCAS-R), which is only validated for use in post-surveys, required students to simultaneously evaluate their ability to perform tangible interprofessional team skills before and after the event using 5-point Likert-type questions (poor to excellent). At the event, students were placed into interprofessional teams to provide care to patients. Faculty members from a variety of professions provided leadership to the teams and guidance as needed. The pre-survey had 107 responses and the post-survey had 108 responses. However, after matching the pre- and post-surveys with student-generated codes, there were 70 valid matched responses. Data analysis was conducted using SPSS version 25. There were no statistically significant changes in SPICE-R2 IPE constructs from the pre-survey to post-survey. However, high pre-survey scores indicated that this student cohort already had a high level of appreciation for interprofessional teams, with mean scores of 4.5 out of 5 for teamwork, 4 out of 5 for roles and responsibilities, and 4.36 out of 5 for healthcare outcomes. The mean overall composite score on the ICCAS-R increased from 3.65 out of 5 on the pre-event portion to 4.03 out of 5 on the post-event portion (p \u3c 0.001) , indicating that students increased their self-evaluated ability to perform tangible skills used in the interprofessional team through participation in the RAM clinic. Findings of this research may allow educators in both classroom and healthcare settings to better understand how hands-on IPE experiences influence students’ interprofessional attitudes and beliefs

Perceptions of Risk for COVID-19 Among Individuals With Chronic Diseases and Stakeholders in Central Appalachia

Coronavirus disease 2019 (COVID-19) pandemic is rapidly evolving and is a serious public health threat worldwide. Timely and effective control of the pandemic is highly dependent on preventive approaches. Perception of risk is a major determinant of health behavior. The current study explores the association between actual risk and perceived risk for one’s self, family/friends and friends, and community. A questionnaire was administered to participants in Central Appalachia (n = 102). The actual risk was based on the number of chronic conditions of the following conditions: hypertension, heart disease, cancer, diabetes, and chronic obstructive pulmonary disease. Participants were also queried about their perception of risk for COVID-19. Generalized Linear Models were used to independently evaluate the likelihood of perceived risk for one’s: self, family/friends, and community, based on actual risk. Actual risk for COVID-19 was significantly associated with higher likelihood of higher perception of risk for one’s self (b = 0.24; p = 0.04), but not with one’s family/friends (b = 0.05; p = 0.68), or one’s community (b = 0.14; p = 0.16). No health insurance was negatively associated with perception of risk for self (b = −0.59; p = 0.04) and family/friends (b = −0.92; p \u3c 0.001). Male gender (b = −0.47; p = 0.01) was also negatively associated with perception of risk for family/friends. In conclusion, individuals’ actual risk for COVID-19 is associated with their own perception of risk. This indicates that one’s perception of risk for COVID-19 is greater for their own health compared to their family/friends or the community. Therefore, monitoring and following up with chronic disease patients and addressing their lack of awareness of risk to others is needed to prevent and curtail the spread of COVID-19

The Prevalence of Cardio-Metabolic Conditions (Diabetes, Hypertension, and Obesity) Before and During COVID-19 and Association with Health and Sociodemographic Factors

Cardiometabolic conditions, including hypertension, diabetes, and obesity are associated with adverse health outcomes, including increased rates of hospitalization and deaths in patients who are diagnosed with COVID-19. However, little to no evidence is known currently on the cardiometabolic conditions before and during the COVID-19 pandemic. This study utilizes a nationally representative sample of adults in the United States (U.S.) to estimate the prevalence of cardiometabolic conditions, focusing on diabetes, hypertension, and obesity, and determine their prevalence and absolute and relative rates before and during COVID-19 pandemic declaration. Furthermore, the study aims to determine the association between these cardiometabolic conditions and physical activity, tobacco use, anxiety/depression, and sociodemographic characteristics among U.S. adults during the COVID-19 pandemic. Data from the 2019 (N = 5359) and 2020 (N = 3830) Health Information National Trends Surveys (HINTS) on adults were utilized. Dependent variable was cardiometabolic conditions and the main explanatory variable was response before and during the COVID-19 pandemic. We conducted weighted descriptive and multivariable logistic regression controlling for confounders such as age, sex, and intensity of physical activity. While there was a slight increase in the prevalence of cardiometabolic conditions during the pandemic (56.09%) compared to before (54.96%), there was only a slight increase in the prevalence of diabetes (18.10% vs 17.28%) and obesity (34.68% vs 34.18%) and a slight decrease in the prevalence of hypertension (36.38% vs 36.36%). Results showed an increase in the prevalence of cardiometabolic conditions among former smokers (67.91% vs 63.86%), and current cigarette smokers (59.39% vs 55.43%), current e-cigarette users (37.24% vs 28.66%), individuals with mild (59.62% vs 55.43%), or moderate (61.98% vs 57.83%) anxiety/depression, sexual minority (53.50% vs 51.12%) and heterosexual (56.45% vs 54.96%) individuals during the pandemic, compared to before the pandemic. Additionally, people with mild anxiety/depression had higher odds of cardiometabolic conditions during the pandemic (AOR = 1.55, 95% CI = 1.01, 2.38), compared to before (AOR = 1.52, 95% CI =1.06, 2.19), relative to those without anxiety/depression. Similarly, former smokers had higher odds of cardiometabolic outcomes before and during the pandemic (AOR = 1.38, 95% CI = 1.01, 1.87 vs AOR = 1.57, 95% CI = 1.10, 2.25), when compared to never smokers. Odds were lower for current e-cigarette users (AOR = 0.44, 95% CI = 0.23, 0.85) compared to never e-cigarette users before the pandemic. There were no significant differences in odds of cardiometabolic conditions between sexual minorities and heterosexual individuals before and during the pandemic. In conclusion, increased risk for adverse cardiometabolic conditions was higher for individuals with cigarette use and mental health diagnoses during the COVID-19 pandemic, suggesting the critical need for smoking cessation and programs to support behavioral health

Experiences of Care Among Women of Childbearing Age Receiving Medications for Opioid Use Disorder in East Tennessee

Introduction: The consequences of the opioid epidemic and various prevention, mitigation, and treatment strategies have a strong hold on Appalachian communities. However, limited research has been conducted to understand the experiences of special populations impacted by opioids in this region, such as women of childbearing age living with opioid use disorder (OUD) prior to and during pregnancy. The objective of this review is to summarize existing literature on the care experience for women of childbearing age receiving treatment with medications for opioid use disorder (MOUD) in rural east Tennessee. This literature review will allow for better understanding of current treatment practices, potential gaps in care, and needed care system improvements for this patient population. Methods: A systematic PubMed search identified studies focused on MOUD and pregnancy in the rural eastern Tennessee region. Search results were screened to remove publications older than five years or from outside the region. Relevant information concerning the MOUD care experience for women of childbearing age in the area was collected from these studies. Results: Five studies were included: four surveys and a systematic review. All were published within the last five years and described experiences spanning preconception to postnatal care as well as Tennessee opioid laws that affect women of childbearing age. Two studies detailed the pre-pregnancy care experience, including information about prior pregnancies, intention of conception, contraceptive use, and perceived barriers to contraception access among women receiving MOUD. Two studies described the care experience during pregnancy and its evolution in recent years with changes in acceptance of insurance for MOUD treatment, rates of MOUD-positive prenatal drug screens, and MOUD tapering practices during pregnancy. The final included study reviewed several Tennessee opioid laws enacted over the years to combat prenatal substance use and neonatal abstinence syndrome (NAS). Notably, while total reported cases of NAS have decreased statewide in recent years, the highest rates continue to be observed in east Tennessee, with a majority of cases linked to MOUD exposure. The requirements and enforcement of NAS-related legislation in Tennessee have changed over time but their existence may deter pregnant women from seeking treatment due to fear of punitive consequences. Conclusion: The evidence compiled in this literature review points to many areas in which the care experience can be improved for women of childbearing age receiving MOUD in east Tennessee. There are concerns regarding pregnancy planning, contraceptive access, availability of evidence-based OUD treatment, cost of treatment, and fear of actual or potential negative repercussions from opioid use during pregnancy. These findings suggest multiple efforts can be undertaken by clinicians, researchers, and policymakers to enhance the experience of care for women of childbearing age living with OUD, and consequently improve the health of the population in general, in this region of Appalachia

The Impact of Transitions Related to COVID-19 on Pharmacy Student Well-being

Objective. To characterize the impact of COVID-19 transitions on first professional year (P1) students’ domain-specific and overall well-being. Methods. All P1 students (N=74) enrolled at one college of pharmacy self-reported their career, community, financial, physical, social, and overall well-being on a weekly basis from January 6 through April 27, 2020. Parametric statistical tests and effect sizes were used to compare well-being scores pre-transition and post-transition and to compare well-being scores to a previous cohort of P1 students. Results. Mean well-being scores decreased when comparing pre-transition vs post-transition scores, with effect sizes ranging from dav=.16 for financial well-being to dav=.84 for social well-being. The average percent of students that reported struggling increased by 86.1% (16.8% vs 31.2%) post-tran-sition, and the average percent of students that reported suffering post-transition was 351% higher (1.3% vs 6%) than pre-transition. Conclusion. Pharmacy students’ domain specific and overall well-being significantly decreased with COVID-19-related transitions. The percentage of students reporting struggling or suffering significantly increased post-transition

The Impact of Transitions Related to COVID-19 on Pharmacy Student Well-Being

Objective. To characterize the impact of COVID-19 transitions on first professional year (P1) students’ domain-specific and overall well-being. Methods. All P1 students (N=74) enrolled at one college of pharmacy self-reported their career, community, financial, physical, social, and overall well-being on a weekly basis from January 6 through April 27, 2020. Parametric statistical tests and effect sizes were used to compare well-being scores pre-transition and post-transition and to compare well-being scores to a previous cohort of P1 students. Results. Mean well-being scores decreased when comparing pre-transition vs post-transition scores, with effect sizes ranging from dav=.16 for financial well-being to dav=.84 for social well-being. The average percent of students that reported struggling increased by 86.1% (16.8% vs 31.2%) post-tran-sition, and the average percent of students that reported suffering post-transition was 351% higher (1.3% vs 6%) than pre-transition. Conclusion. Pharmacy students’ domain specific and overall well-being significantly decreased with COVID-19-related transitions. The percentage of students reporting struggling or suffering significantly increased post-transition

Community Pharmacist Engagement in HIV and HCV Prevention: Current Practices and Potential for Service Uptake

Background: The central Appalachian region is at an elevated risk for HIV/HCV outbreaks, primarily due to injection drug use. Regional risk assessments highlight gaps in the evidence-based continuum of primary, secondary, and tertiary prevention strategies to minimize HIV/HCV transmission. One potential strategy for increasing the reach of HIV/HCV prevention efforts in rural areas is through provision of services at community pharmacies. Objective: To qualitatively describe community pharmacists\u27 HIV/HCV-related prevention behaviors, attitudes, and beliefs in a 3-state central Appalachian region. Methods: Key informant interviews were conducted with 15 practicing community pharmacists. Theory of Planned Behavior-based questions probed for perceptions about the role of pharmacies in preventing and reducing HIV/HCV outbreaks in rural areas through activities such as syringe services, screening for HIV/HCV, and linking people to treatment when appropriate. Investigators applied thematic analysis to deductively and inductively generate themes from the interview transcripts. Results: Two overarching themes regarding pharmacist engagement in HIV/HCV-related prevention services were generated: 1) current approaches to primary prevention through nonprescription syringe sales (e.g., gatekeeping behaviors) and 2) potential for uptake of the continuum of HIV/HCV-related prevention services in community pharmacies. Future engagement of community pharmacists in the continuum of HIV/HCV-related prevention services comprised 2 subthemes as possible underlying factors: general and specific willingness to provide services and perceived fit within the pharmacy profession. Conclusions: Central Appalachian community pharmacists express a general willingness to help patients who may benefit from HIV/HCV-related prevention services, but current engagement, willingness, and perceived fit for offering specific prevention services in the community pharmacy setting is variable. This has potential immediate implications, such as prioritizing the introduction of more widely accepted services (e.g., provision of HIV/HCV-related prevention education) to community pharmacy practice, and longer-term implications, such as the integration and framing of HIV/HCV-related prevention services as helping behavior within the pharmacist professional identity

Explaining Pharmacy Students’ Dispensing Intentions in Substance Abuse-Related Gray Areas Using the Theory of Planned Behavior

Objective. To examine the extent to which theory of planned behavior (TPB) constructs and demographic characteristics explain pharmacy students’ dispensing intentions in ethically or legally gray areas involving potential substance misuse or abuse. Methods. Two cohorts of third-year Doctor of Pharmacy (PharmD) students (n5159) were provided with five written cases describing common “gray area” dispensing scenarios in community practice involving medications and devices with potential for misuse or abuse (eg, long-term buprenorphine maintenance prescription without evidence of tapering, early refill of a narcotic for an out-of-town patient, non-prescription sale of pseudoephedrine). Students completed a 12-item survey instrument for each case. Items assessed whether the student would dispense the medication or device in the given scenario, how many times in 10 similar scenarios the student would dispense the medication or device, attitudes regarding dispensing, and subjective norm and perceived behavioral control beliefs. Results. Wide variation in the percentages of students who would dispense the medications or devices was noted across the five scenarios (14% in the buprenorphine scenario to 61% in the pseudoephedrine scenario). Attitude scores significantly predicted dispensing decisions in all scenarios (p,.001), whereas subjective norm and perceived behavioral control beliefs were significant predictors of dispensing only in select case scenarios. Gender and community pharmacy work experience did not consistently predict dispensing intentions. Conclusion. Student attitudes consistently predicted intent to dispense across five gray practice scenarios. These findings can be used to inform development of educational interventions that influence students’ attitudes and self-awareness in community practice decision-making scenarios involving potential substance misuse or abuse