Co-designing clinical decision support to enable proactive HPV vaccination in community pharmacies: a qualitative study using behavioral and implementation science theory and process frameworks

Community pharmacies are accessible, acceptable venues to address suboptimal HPV vaccination among U.S. adolescents, especially in medically underserved populations. Yet awareness gaps, variable staff engagement, and workflow integration challenges limit uptake. We sought to identify and specify clinical decision support systems (CDSS)—operationalized as implementation strategies—to enable proactive delivery of HPV and other adolescent vaccines in pharmacies. From May–September 2023, we conducted eight virtual, audio-recorded focus group discussions with representatives of three Washington State independent pharmacies and two technology companies: PioneerRx (pharmacy software system) and STChealth (immunization information systems). The study was registered with ClinicalTrials.gov (NCT05831540) on March 20, 2023. Semi-structured guides were informed by the Theoretical Domains Framework and the Consolidated Framework for Implementation Research to elicit determinants across workflow steps mapped to the 5 A’s Behavioral Counseling Framework (Assess, Advise, Agree, Assist, Arrange). Sessions (~ 60 min, biweekly) addressed: Immunization Information System (IIS) use; vaccination prompts; screening/consent integration; scheduling; reminder/recall; reporting; and population coverage assessment. We used a framework-guided rapid analysis approach to summarize barriers, facilitators, and recommendations. We catalogued proposed CDSS changes in a modified Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) matrix. Technology company readiness to develop/deploy proposed CDSS was captured at study close. We identified nine priority pharmacy staff behaviors required for a proactive vaccination workflow and specified 19 CDSS to support these vaccination behaviors. Proposed tools included vaccine coverage dashboards, predictive inventory management, expanded health-information fields, tailored provider/patient prompts, digital screening/consent, documentation of refusal/delay, streamlined access to vaccination records, and integrated scheduling and reminder/recall. Technology companies indicated near-term feasibility for a subset of proposed CDSS: PioneerRx deemed 8/11 proposed tools were ready for implementation and 4/11 potentially feasible but not immediately available; STChealth committed to training on 2/8 CDSS with others outside short-term development scope. Tools were explicitly linked to targeted, operationalized implementation outcomes (e.g., adoption, feasibility, fidelity, reach) to support future evaluation. Co-designing and refining CDSS within community pharmacy systems appears promising for shifting vaccination workflows from reactive to proactive, thereby reducing missed opportunities for HPV and other adolescent vaccinations. By coupling tool specifications to behavior targets and implementation outcomes, this formative work delivers turnkey strategies for subsequent hybrid implementation-effectiveness studies.