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sociated with outbreaks in most places of the world, and unless travel was to a specific country or region of the world where these diseases are endemic, the risk for infection is considered less than 0.0001% per month of travel to a developing country. 12 The yellow fever vaccine had the highest rate of patient acceptance (96.8%) and may have resulted from several reasons. The majority of patients in this clinic traveled to yellow fever endemic areas within South America and Africa, where yellow fever vaccination normally would be indicated and recommended. However, other patients may have required the vaccine because of International Health Regulations because they were traveling through a country with risk of yellow fever on their way to another country and did not have a medical contraindication to vaccination (e.g., pregnancy, allergy to eggs or gelatin, immune suppression, thymus disorder). The fact that yellow fever vaccine is sometimes required for travel may have caused patients to decline other vaccines or medications, thereby reducing our overall patient acceptance rate. However, receipt of yellow fever vaccine predicted acceptance of five other vaccines. The primary reason for patient refusal of a recommendation was self-perceived low risk for infection (52%). Secondary reasons for refusal included interest only in the yellow fever vaccine and cost (14% for each). Cost was a factor because patients typically paid out-of-pocket for this service. Other reasons for refusal, as indicated in Figure 3, ranked lower and, interestingly, nonconfidence in the pharmacist’s recommendations occurred in 7% of responses. Patient refusal may also result from a host of factors, such as past travel experiences, planned activities during travel, or length of stay at destination; however, further analysis is required to determine the source of this perception. PHARMACIST-RUn TRAvEL HEALTH CLInIC SPECIAL FEATURE Limitations Our prospective survey had an overall response rate of 29%, which may be attributable to the fact that this study was implemented 1 year or more after patients visited our clinic. In addition, because travel health services generally involve only one visit to a provider, many patients likely did not recall their specific visit to our clinic. Therefore, our survey results may not be applicable to our larger patient population of 283 individuals who made an appointment in the travel health clinic during the study period. Furthermore, those who completed this survey are subject to recall bias because surveys were based on visits anywhere from 6 months to 1 year before initiation of this study. In addition, those who completed the survey may have been more satisfied with their visit and therefore more likely to complete the survey than others, resulting in a self-selection bias. Patient satisfaction may have also been the result of the patient’s commuting distance to the travel health clinic, which was not factored into our analysis. Analysis of open-ended responses did not reveal any pattern in the responses that could be meaningfully categorized. Lastly, our results may not be generalizable to the larger population of U.S. travelers given the localization of the sample. Conclusion This study examined the outcomes of a comprehensive pharmacist-run travel health clinic within an independent community pharmacy and found a high rate of patient acceptance and satisfaction with the clinic, which supports the adoption of U.S. pharmacists as nontraditional providers of travel health services. Despite limitations of this study, the authors believe that this service can be reproduced within other independent community pharmacies, especially when a strong collaboration exists among the travel clinic pharmacist, pharmacy store Table 3. Principal component analysis: Item loadings Rotated component matrix Component Quality of interaction Convenience of Survey item It was easy to contact the travel clinic to obtain initial information before making an with pharmacist clinic services appointment. 0.153 0.821a The travel clinic’s hours of operation were convenient for me. 0.162 0.843a I was seen in a timely manner upon my arrival to the travel clinic. 0.351 0.674a I was able to receive all the vaccines and/or medications that I needed/wanted for my travel during my appointment. 0.792b The travel clinic pharmacist explained things in a way that was clear and understandable to 0.202 me. 0.892b If I had any additional questions about my medication(s), vaccine(s), or other issues, my 0.233 questions were answered by the travel clinic pharmacist to my satisfaction. 0.908b 0.193 The counseling provided to me by the travel clinic pharmacist was useful/helpful. 0.833b 0.311 The travel clinic pharmacist was professional in his interactions with me. 0.940b 0.165 I was satisfied with my overall visit at the travel clinic. 0.881b Extraction method: principal component analysis. Rotation method: Varimax with Kaiser Normalization. Note: rotation converged in three iterations. aThese survey items belong to the component “convenience of clinic services.” bThese survey items belong to the component “quality of interaction with pharmacist.” 0.299 J o u r n a l o f t h e A m e r i c a n P h a r m a c i s t s A s s o c i a t i o n www.japha.org M a r/apr 2010 • 50:2 • JAPhA • 179 179 3/1/10 12:49 PM
SPECIAL FEATURE PHARMACIST-RUn TRAvEL HEALTH CLInIC owner, and supervising physician. However, for independent community pharmacies to more broadly implement similar travel health clinics, further study of the costs associated with starting up and maintaining such clinics as well as their profitability is necessary. References 1. International Trade Administration Office of Travel and Tourism Industries. US outbound travel by world regions. Accessed at http://tinet.ita.doc.gov/research/monthly/departures/index.html, October 12, 2009. 2. World Health Organization. vaccine preventable diseases and vaccines. Accessed at www.who.int/ith/ITH2009Chapter6.pdf, October 12, 2009. 3. Steffen R. Epidemiology: morbidity and mortality in travelers. In: Keystone JS, Ed. Travel medicine. London: Elsevier; 2004:5–12. 4. Hamer DH, Conner BA. Travel health knowledge, attitudes, and practices among United States travelers. J Travel Med. 2004;11:23–6. 5. International Society of Travel Medicine. Travel medicine examination: about the program. Accessed at www.istm.org, October 16, 2009. 180 • JAPhA • 50:2 • M a r/apr 2010 www.japha.org 6. Jackson AB, Humphries TL, nelson KM, Helling DK. Clinical pharmacy travel medicine services: a new frontier. Ann Pharmacother. 2004;38:2160–5. 7. Helling DK, nelson KM, Ramirez JE, Humphries TL. Kaiser Permanente Colorado Region Pharmacy Department: innovative leader in pharmacy practice. J Am Pharm Assoc. 2006;46:67–76. 8. Gatewood SBS, Stanley DD, Goode K. Implementation of a comprehensive pretravel health program in a supermarket chain pharmacy. J Am Pharm Assoc. 2009;49:660–9. 9. Backer H, Mackell S. Potential cost-savings and quality improvement in travel advice for children and families from a centralized travel medicine clinic in a large group-model health maintenance organization. J Travel Med. 2001;8:247–53. 10. U.S. Travel Association. U.S. travel market overview: demographics. Accessed at www.tia.org/researchpubs/us_overview_ demographics.html, October 23, 2009. 11. U.S. Census Bureau. State and county quick facts. Accessed at http://quickfacts.census.gov/qfd/states/00000.html, October 28, 2009. 12. Steffen R, Amitirigala I, Mutsch M. Health risks among travelers: need for regular updates. J Travel Med. 2008;15:145–6. Enchanted reflections • Lake Navajo, UT • June 1, 2009 • Allison Anne Welder J o u r n a l o f t h e A m e r i c a n P h a r m a c i s t s A s s o c i a t i o n 180 3/1/10 12:49 PM
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