2022 national survey of immunizing community chain pharmacists: The case for codifying the PREP Act emergency authorities into practice.

BACKGROUND: Pharmacy-based immunization services have expanded since the mid-1990s but still face multiple challenges. Amendments to the Public Readiness and Emergency Preparedness (PREP) Act broadened patient-care scope and the pool of eligible pharmacy personnel who could administer vaccinations. The expiration of these amendments in 2024 may threaten recent gains in vaccine and other health care access newly available through pharmacies. OBJECTIVES: This study aimed to elicit community chain pharmacists' perspectives on immunization time demands, corporate guidance, data flow and information technology, workflow and workforce issues, and other newly provided services. METHODS: A survey questionnaire was developed, pretested, and electronically administered in mid-2022 to a randomly sampled national database of pharmacists maintained by the American Pharmacists Association. Descriptive analyses of survey responses were performed and findings used to identify salient themes. RESULTS: The survey collected 742 responses from a sample of 7845 community chain pharmacists (9.5% response rate). During the 2021-2022 influenza season, pharmacies administered on average 114 vaccinations daily (range 3-1000), mostly by appointment (51%). Pharmacists expressed somewhat greater preference for administering vaccinations (39%) than dispensing prescriptions (36%), and most (92%) considered it at least as important as other practice responsibilities. However, only 27% of pharmacists had adequate staff support and 67% spent more time addressing patients' vaccination confidence issues than before the pandemic. Most respondents (67%) had access to their patient's vaccination status, but only 51% said their company's computer system gave easy access. Only 49% considered corporate immunization feedback effective at enhancing their practice. Provision of nonvaccine services has expanded. CONCLUSIONS: Frontline community chain pharmacists reportedly preferred administering vaccinations over dispensing prescriptions. The pandemic resulted in an increased responsibility among pharmacists as immunizers. Notwithstanding recent progress, pharmacists continue to face staffing, corporate guidance and feedback, information management, and other structural and process barriers to optimally provide comprehensive immunization services. Survey findings support making permanent and expanding the emergency authorities that pharmacists gained under the PREP Act.

Community chain pharmacists' perceptions of increased technicians' involvement in the immunization process.

BACKGROUND: Over the past 2 decades, pharmacists have positioned immunization services as an important aspect of their expanding role in patient care. OBJECTIVES: To examine how community chain pharmacists view time spent on immunization, available in-store resources and barriers, and pharmacy technician involvement in the context of their views about the achievement of key National Vaccine Advisory Committee (NVAC) Standards of Adult Immunization Practice in their workplace. METHODS: A representative, nationwide survey was administered electronically to chain community pharmacists over a 4-week period. Community pharmacists offering year-round immunization in retail chain, supermarket, and mass-merchant settings, randomly sampled from a database maintained by the American Pharmacists Association. We examined several sets of interrelated relationships regarding pharmacists' perceived achievement of 3 key NVAC standards (assessment, recommendation and administration), time spent on the overall immunization process, the effectiveness of available in-store resources, immunization impediments, and the endorsement of increased technician involvement in community pharmacy-based immunization service (PBIS) delivery. RESULTS: A sample of 590 survey responses was obtained from 9717 e-mails delivered, with 489 deemed eligible (5% response rate). Sizeable numbers of pharmacists acknowledged that several activities integral to achieving optimal immunization levels were not being addressed. Although pharmacists accepted that appropriately trained pharmacy technicians should be able to ask (77%) and assess (66%) patients, only 24% agreed that technicians should be able to administer vaccine doses. Pharmacists satisfied with in-store immunization resources and technicians' involvement were more likely to report achieving the 3 key NVAC standards. Paradoxically, how pharmacists viewed their immunization time expenditures was unrelated to whether they agreed that pharmacy technicians should have an expanded role in asking, assessing, or administering vaccines to their patients. CONCLUSION: Overall, community pharmacies would likely better meet national immunization goals by achieving all 3 key NVAC standards and incorporating expanded roles for appropriately trained and supervised technicians in PBIS.

Optimizing the immunization activities of community chain pharmacists: Insights from a national survey.

OBJECTIVES: To assess (1) the practices, attitudes, and perceptions of immunizing chain community pharmacists regarding implementation of immunization services per the National Vaccine Advisory Committee (NVAC) Standards of Adult Immunization Practice and (2) how community pharmacists view the effectiveness of corporate initiatives toward improving immunization volumes. DESIGN: Following extensive formative research and pilot-testing, a cross-sectional survey was administered electronically to chain community pharmacists over a 4-week period. SETTING AND PARTICIPANTS: Respondents were chain community pharmacists engaged in year-round immunization in the United States, randomly sampled from a list of 9717 maintained by the American Pharmacists Association. OUTCOME MEASURES: Pharmacists' reports of immunization volumes, patterns of time use, perceptions of time spent on the immunization process, immunization attitudes, and confidence in completing NVAC standard components. Pharmacists also evaluated the utility of corporate goals, feedback, and incentives received. RESULTS: The survey yielded 590 responses, with 489 meeting the eligibility criteria (5% response rate) and distributed from across the country. In total, 84% of respondents reported giving 26 or more vaccinations/week during the influenza season, whereas only 6% reported as many outside of the influenza season. Pharmacists spent, on average, 29% of their day addressing the immunization process during the influenza season and 12% outside of the influenza season. Only 29% of respondents were confident that their patients' complete immunization needs were assessed at each patient encounter and only 46% were confident that their patients received strong recommendations regarding their specific immunization needs. Most pharmacists viewed corporate goals and the messages and strategies to achieve them as limited in scope and largely inadequate. CONCLUSION: In the context of their current role expectations, most community pharmacists who responded were not confident that key NVAC Standards were being implemented to improve patient immunization rates and did not view corporate initiatives as effective toward that effort.

Recommend, but also Discuss: Different Patterns of Physician-Perceived Barriers to Discussing HPV Vaccination and Their Association with Vaccine Administration in 11-12 Year-Old Girls.

Objectives We examined variation in primary care physicians' (PCPs') perceptions of barriers to physician-initiated discussion of HPV vaccination, and how this is associated with the rates at which they discuss, initiate and continue to administer vaccination with 11-12 year-old girls. Methods We surveyed 301 PCPs using systematic random sampling. PCP variation in perceived barriers to discussing HPV vaccination was modeled using latent class analysis (LCA). The distinct PCP groups identified were compared with each other using three iterative logistic regression models to predict the likelihood of initiating vaccine discussion and the reported percentages of 11-12 year-old patients who initiated HPV vaccination and received follow-up shots. Results LCA revealed three groups of PCPs who perceived major, moderately significant and relatively minor barriers (17.9, 41.9 and 40.2 % of respondents, respectively). Pediatricians, PCPs who were female, had minority racial/ethnic status and who perceived only minor barriers had significantly higher odds of initiating discussion. PCPs were more likely to initiate HPV vaccination if they had initiated discussion and perceived minor or moderate communication barriers. Increased likelihood to administer follow-up HPV vaccine was associated with having initiated discussion, perceiving only minor barriers and working outside Deep South states, but not with having initiated vaccination. Conclusions for Practice PCPs who discuss HPV vaccination with girls aged 11-12 and their mothers are more likely to start and sustain vaccine administration. However, different PCPs perceive barriers to discussion in different ways. Interventions tailored to different groups of PCPs should assist them in overcoming barriers to discussing their recommendations when necessary.

Immunization costs and programmatic barriers at an urban HIV clinic.

BACKGROUND: Although the increasing number of recommended immunizations is essential for patients infected with human immunodeficiency virus (HIV), the potentially uncompensated costs of expanded immunizations will present significant challenges for clinics and health systems serving HIV-infected patients. METHODS: We estimated costs of providing Gardasil, Prevnar, and Zostavax to eligible patients at a US Ryan White Part C academically affiliated HIV clinic in 2013. Clinic expenditures were calculated using vaccine price and administrative fees. Revenue was calculated using insurance reimbursement data for vaccination and administration. Three scenarios were used: 100% uptake of vaccines, adjusted uptake based on published rates, and adjusted reimbursement according to pre-Affordable Care Act (ACA) insurance status. RESULTS: 2887 patients (27% Medicare, 13% Alabama Medicaid, 26% Commercial, 34% Uninsured), received care with wide variation in immunization reimbursement ($0 to $210) by insurance and vaccine. The net yield (revenue minus expenditure) was calculated for each vaccine. Prevnar was most costly: annual net yield of -$60 691. Provision of all 3 vaccines would lead to a net yield of -$97 122. Adjusting for reduced uptake led to annual clinic losses of $44 119. Using pre-ACA reimbursement for immunization of the uninsured led to reduced clinic losses (-$62 326), attributable to reimbursement via Ryan White funds. CONCLUSIONS: A cost analysis of 3 vaccines shows great variation in insurance coverage, with potential losses of almost $100 000 for one HIV clinic if eligible patients received vaccinations in one calendar year. Adequate, cost neutral reimbursement should be instituted if medical providers and health systems are to achieve Advisory Committee on Immunization Practices immunization recommendations for both HIV positive and negative adults.

Carbon-Based Functional Nanomaterials as Tools for Controlling the Kinetics of Tribochemical Reactions.

The aim of this article is to experimentally determine the role of the environment, consisting of a base oil (PAO), carbon nanomaterials, and optional other additives, as well as the kind of metal in contact with the lubrication film, in the stimulation of zinc dialkyldithiophosphate (ZDDP) additives' effectiveness during protective film formation. This paper focuses on the role of carbon nanostructures in energy transportation and conversion during tribological processes. An antistatic additive (ASA) (not used in lubricating oils) for jet fuels was added to disturb the process of energy conduction (electric charges) through the lubricant film and thus determine how this disturbance affects the kinetics of the ZDDP triboreaction and, consequently, the linear wear. To achieve this research goal, two types of tribological testing devices were used: an Anton Paar tribometer (TRB) and a triboelectric tribometer (TET). The novelty of the present research is in the use of the method for disturbing the flow of charge/energy through the lubricant film with an antistatic additive for jet fuels, ASA, to influence the impact of this energy on the antiwear properties of ZDDP. The following conclusions were drawn: (1) carbon-based nanostructures, i.e., CNTs, AuCNTs, graphene, and fullerenes, are able to change the rate of chemical reactions of ZDDP during tribological processes; (2) CNTs have the ability to catalyze tribochemical reactions of ZDDP, while graphene and fullerenes are not able to perform this effectively; (3) AuCNT takes the role of an inhibitor during ZDDP's triboreaction; and (4) by discharging electric charge/energy, ASA, in cooperation with CNT and AuCNT significantly reduces the rate of the ZDDP reaction.

Dobbs: Navigating the New Quagmire and Its Impacts on Abortion and Reproductive Health Care.

On June 24, 2022, the U.S. Supreme Court issued its decision on Dobbs v. Jackson Women's Health Organization. By voting to uphold Mississippi's law banning most abortions after 15 weeks, the Court overturned Roe v. Wade, eliminating the federal standard protecting a woman's right to abortion and reversing nearly 50 years of legal precedent. The ruling returned regulation of abortion to the states, which are responding by implementing bans or protecting access to abortion. As political and legal conflicts escalate and individual horror stories emerge, the dangerous mirage presented by this misguided legal fix to a long-standing vexing issue will come into sharper relief. The Dobbs ruling is creating a new uncertain and treacherous landscape for women and health care professionals to navigate.

Hepatitis vaccination adherence and completion rates and factors associated with low compliance: A claims-based analysis of U.S. adults.

Poor compliance with multi-dose vaccine schedules by adults for whom hepatitis (Hep) A and B vaccines are recommended contributes to major Hep A and B disease burdens among high-risk U.S. adults. Evidence on hepatitis vaccine series adherence, completion, timeliness of completion, and factors associated with these outcomes, is limited and not readily generalizable for U.S. adults. This retrospective, observational study examined adherence, completion, its timeliness, and the impact of sociodemographic and clinical factors on these outcomes among a large, geographically representative sample of U.S. adults. We analyzed the Optum Clinformatics SES administrative claims database (1/1/2010-6/30/2020) for recipients of 2-dose (HepA, HepB2) or 3-dose (HepB3, HepAB) hepatitis vaccines. Adherence was defined as receipt of booster doses within specified assessment periods, per label-recommended schedules. Completion (receipt of all doses) was assessed at 6, 12, 18, and 24 months.The study included 356,828 adults ≥19 years old who were continuously enrolled in a medical benefit plan for one (HepB2), six (HepB3; HepAB), or 18 months (HepA) prior to and following the index date (first observed vaccine dose). Adherence and 24-month completion rates were: HepA (27.0%, 28.4%), HepB2 (32.2%, 44.8%), HepB3 (14.3%, 37.3%), HepAB, (15.3%, 33.8%). Kaplan-Meier completion curves plateaued after about 6 months for HepB2 and about 12 months for HepA, HepB3, and HepAB vaccines. Logistic regression analyses showed risk for low adherence/completion was generally associated with male gender, younger age, Black or Hispanic race/ethnicity, lower educational or household income attainment, and more comorbidities. Adherence and completion rates for all hepatitis vaccine series are low, especially for males, younger adults, those with lower socio-economic status and more comorbidities. To our knowledge, this is the largest claims-based analysis of adherence and completion rates for U.S. adults initiating all currently available HepA and HepB vaccines. Findings may inform hepatitis vaccination programming.

Real-world evidence on adherence and completion of the two-dose recombinant zoster vaccine and associated factors in U.S. adults, 2017-2021.

INTRODUCTION: Poor compliance with adult vaccination recommendations contributes to substantial disease burden. Evidence on adherence, completion, and completion timeliness for the 2-dose recombinant herpes zoster vaccine (RZV) and factors associated with these outcomes is limited and not readily generalizable for the entire U.S. METHODS: This retrospective, observational study examined adherence, completion, and the impact of sociodemographic, clinical and geographical factors among U.S. adults ≥ 50 years receiving RZV (4/20/2017 to 3/31/2021), using a large, geographically representative administrative claims database. Continuous enrollment in a medical benefit plan for six months prior to and following the index date (first observed vaccine dose) was required. Adherence was defined as receipt of the 2nd dose within 2-6 months, per label recommendation. Completion (receipt of all doses) was assessed at 6, 12, 18, and 24 months. RESULTS: Among 726,352 adults included, the adherence rate was 71.8%. Among 208,311 adults with 24-month follow-up, the completion rate was 72.3% after 6 months and 86.2% after 24 months. Logistic regression showed low adherence/completion was associated with younger age, Black or Hispanic race/ethnicity, lower income, lower educational attainment, and possessing commercial rather than Medicare healthcare insurance. Recipients identified using pharmacy claims had much higher adherence (74.0%) than those identified using medical claims (48.0%). CONCLUSIONS: Adherence and completion rates for RZV are suboptimal, especially for adults aged 50-64, racial/ethnic minorities, individuals with lower socio-economic status and those without Medicare insurance. More research and public health efforts are needed to understand and address potential barriers to RZV uptake, adherence and completion.

Assessing male condom failure and incorrect use.

BACKGROUND: It has not been well established whether common indices of male condom failure are valid predictors of biologically meaningful exposure during condom use. METHODS: To address this gap, the authors compared self-reported condom malfunctions (i.e., breakage and slippage) and incorrect condom practices to 2 following objective measures of failure: prostate-specific antigen (PSA) detected in vaginal swabs collected after condom use and structural integrity of used condoms. The study, conducted in 2000-2001, evaluated 635 male condoms used by 77 women attending an outpatient, reproductive-health clinic in Birmingham, AL. RESULTS: Women reported breakage or slippage for 7.9% of condoms; 3.5% of postcoital swabs had moderate or high levels of PSA; and laboratory testing of used condoms revealed breaks (1.1%) and leaks (2.0%). Self-reported breakage and slippage was associated with moderate/high PSA concentrations in postcoital swabs only when the malfunctions were not accompanied by reports of corrective actions to reduce exposure (adjusted odds ratio [aOR], 6.9; 95% confidence interval [CI], 1.8-26.2). Defects observed in postcoital laboratory testing were related to PSA detection (aOR, 8.0; 95% CI, 1.5-42.6). Incorrect practices defined on the condom label were frequent, but not all types were associated with semen exposure. Furthermore, other practices not currently label-defined were associated with semen exposure: touching the tip of the penis with his hands (aOR, 6.2; 95% CI, 2.3-17.0) or with her hands (aOR, 2.8; 95% CI, 1.1-72) before donning the condom. CONCLUSIONS: Used correctly, male condoms afforded good protection based on objective measures of failure.

Tribochemical Interactions between Graphene and ZDDP in Friction Tests for Uncoated and W-DLC-Coated HS6-5-2C Steel.

If a lubricant contains structures capable of conducting energy, reactions involving zinc dialkyldithiophosphate (ZDDP) may take place both very close to and away from the solid surfaces, with this indicating that ZDDP can be a highly effective anti-wear (AW) additive. The central thesis of this article is that the tribocatalytic effect is observed only when the energy emitted by the solids is transmitted by ordered molecular structures present in the lubricant, e.g., graphene. The friction tests were carried out for 100Cr6 steel balls in a sliding contact with uncoated or W-DLC-coated HS6-5-2C steel discs in the presence of polyalphaolefin 8 (PAO 8) as the lubricant, which was enhanced with graphene and/or ZDDP. There is sufficient evidence of the interactions occurring between ZDDP and graphene and their effects on the tribological performance of the system. It was also found that the higher the concentration of zinc in the wear area, the lower the wear. This was probably due to the energy transfer resulting from the catalytic decomposition of ZDDP molecules. Graphene, playing the role of the catalyst, contributed to that energy transfer.

Medium-term response of the natural grassland soil biota to multiwalled carbon nanotube contamination.

Although the soil environment can potentially be exposed to contamination by carbon nanotubes (CNT), its impact on soil biology is poorly understood. In this study, we investigated the effect of the multiwalled CNT (MWCNT) contamination on different groups of soil organisms (microbial, micro- and mesofaunal communities) as well as the soil enzyme activity. The experimental mesocosms included the intact soil cores that were collected from a natural grassland. The MWCNTs that were pristine (pCNTs) and functionalised (fCNTs) at a concentration of 500 µg g-1 of soil were applied in the form of water suspensions to the surface of the mesocosms, while ensuring the soil was not mixed after the treatment. Soil samples were taken at 3, 6, and 15 weeks after CNT application. The CNT soil contamination highlighted differences in the community dynamics within the studied groups when compared to the control (non-contaminated soil). Among the faunal groups, nematodes were found to be more sensitive to the CNT impact than mites. The most pronounced response of the nematodes was observed in the subsoil at week 6, when their numbers were 3- (pCNTs) and 4-fold (fCNTs) higher than the control mesocosms. Both types of CNTs influenced the relative abundance of the bacterial- and hyphal-feeding nematodes, where pCNTs significantly and negatively affected the predatory nematodes. Moreover, CNTs temporarily, but significantly, decreased the diversity of the nematode communities. In addition, the values of the nematode Structure Index confirmed a strong transitional disturbance effect of CNTs in the soil food web, while the Channel Index in the pCNTs indicated an increasing share of fungi in the decomposition pathway. Hence, we can infer that although the impact of CNTs seems to be temporary, the shifts in the soil community abundance and structure that it induced may have long-term consequences for soil functioning, including nutrient cycling.

Barriers to diaphragm use: the views of advanced practice nurses.

BACKGROUND AND METHODOLOGY: Women have used the contraceptive diaphragm for decades. Although use has recently declined, the diaphragm may find a new role in STI/HIV and dual-prevention programmes when microbicides become available. We developed a questionnaire to examine seven provider issues identified as possible barriers to diaphragm use among advanced practice nurses (APNs) specialising in women's health. The perceived degree to which each issue represented a barrier was examined. Non-parametric correlations were calculated between diaphragm fitting history, demographic and practice characteristics, and the response ratings for each issue. RESULTS: Responses were analysed for 204 APNs who averaged 15 years' experience in women's health care; 87% had fitted a diaphragm at least once, but 40% had not prescribed one in the past year. The degree to which each issue was perceived as a barrier varied. Based on respondents' ratings of a 'more than moderate barrier,' diaphragm non-promotion by women's health providers, effectiveness doubts, unfamiliarity and lack of access to educational materials were more often perceived as impeding diaphragm use. Other results indicated that APNs with recent diaphragm fitting history perceived five of the seven issues to be less of a barrier: non-promotion by women's health providers, lack of access to educational materials and to a fitting set, unfamiliarity, and inadequate reimbursement. DISCUSSION AND CONCLUSIONS: Formulation of successful strategies to reintroduce the diaphragm will depend on better identification and understanding of provider-perceived barriers. This paper offers new insights about such barriers and guidance for the development of strategies for diaphragm reintroduction.

Tribochemical Interactions between Carbon Nanotubes and ZDDP Antiwear Additive during Tribofilm Formation on Uncoated and DLC-Coated Steel.

The data from the authors' earlier investigations show that molecules of zinc dithiophosphate (ZDDP) added to a lubricant can absorb energy emitted by a solid surface, which is where triboreactions occur. If the lubricant contains structures able to conduct energy, the ZDDP reactions can occur even at a relatively large distance from the solid surface, which should increase the effectiveness of ZDDP as an antiwear additive. The purpose of this paper was to verify the thesis that the tribocatalytic effect depends on the ability of the solid surface to emit electrons/energy and the ability of ordered molecular structures, such as carbon nanotubes (CNTs), to conduct energy and, most likely, to enhance the energy transfer. The tribological tests were performed using a TRB3 tribotester for 100Cr6 steel balls and uncoated or a-C:H coated HS6-5-2C steel discs. Polyalphaolefin 8 (PAO8) and PAO8 mixed with ZDDP and CNTs were used as lubricants. The results of the tribological tests suggested that: (a) the effect of the interactions between ZDDP and CNTs was clearly visible; (b) the structure and properties of the solid surface layer had a significant influence on the antiwear action of the ZDDP additive.

The Indirect Tribological Role of Carbon Nanotubes Stimulating Zinc Dithiophosphate Anti-Wear Film Formation.

Experimental studies reveal that the simultaneous addition of zinc dialkyl dithiophosphates (ZDDPs) and multi-wall carbon nanotubes (MWCNTs) to a poly-alpha-olefin base oil strongly reduces wear. In this paper, it is shown that MWCNTs promote the formation of an anti-wear (AW) layer on the metal surface that is much thicker than what ZDDPs can create as a sole additive. More importantly, the nanotubes' action is indirect, i.e., MWCNTs neither mechanically nor structurally strengthen the AW film. A new mechanism for this effect is also proposed, which is supported by detailed tribometer results, friction track 3D-topography measurements, electron diffraction spectroscopy (EDS), and Raman spectroscopy. In this mechanism, MWCNTs mediate the transfer of both thermal and electric energy released on the metal surface in the friction process. As a result, this energy penetrates more deeply into the oil volume, thus extending the spatial range of tribochemical reactions involving ZDDPs.

Husband-wife agreement, power relations and contraceptive use in Turkey.

CONTEXT: In Turkey, contraceptive use has become more widespread, but little is known about the concurrence of spousal reports or the relative influence of communication, decision making and power differentials on method use. METHODS: Data from the 1998 Turkish Demographic and Health Survey (DHS) for 1,546 married couples were tested for concurrence between spousal reports on fertility and family planning variables. Multivariate regression analyses based on wives', husbands' and joint reports of current contraceptive use were used to assess the association between such use and various background, communication and interspousal variables. RESULTS: Spousal reports on most fertility and contraceptive use measures demonstrated moderate to high concordance, whereas reports of approval of family planning showed only fair concordance. After adjusting for background factors, models based on wives' and husbands' reports showed that current contraceptive use was positively associated with the number of methods known (odds ratios, 1.2 and 1.1, respectively) and perception of spousal approval (3.3 and 2.0, respectively), and in the husbands' model, with approval of either spouse or both (3.8-5.8). In the combined model, contraceptive use was positively associated with both partners approving of family planning (2.4), and negatively associated with both partners wanting more than three children and with only wives wanting three or fewer (0.4 and 0.6, respectively). CONCLUSIONS: Discrepancies between spousal reports were less significant in Turkey than in most developing countries with DHS data, but the differences were not inconsequential to explaining how spousal attitudes and preferences influence contraceptive use. No evidence was found associating interspousal power differentials with method use. Further research is needed to improve the testing and modeling of such dyadic processes.

Using Internet-based nominal group technique meetings to identify provider strategies for increasing diaphragm use.

BACKGROUND AND METHODOLOGY: The diaphragm, once the most commonly used female contraceptive method, is being re-evaluated for prevention against some sexually transmitted infections (STIs), including HIV. However, provider views about this prescription-based method are poorly understood. Using expert panels, this study aimed to identify facilitative strategies to increase diaphragm use. The nominal group technique (NGT) was employed using a novel web-based interface to systematically elicit and prioritise responses to a specific question about what can be done to encourage providers to recommend diaphragm use. Two NGT sessions were convened with 15 geographically dispersed panelists who had extensive knowledge and experience with the diaphragm. Participants were identified using purposeful and snowball sampling. RESULTS: Panel 1 identified 22 strategies for encouraging providers to recommend diaphragm use, with seven perceived as relatively more important (67% of the total available votes). Panel 2 identified 31 strategies, nine of which accounted for 77% of the votes. Both sessions highlighted that to make the diaphragm a more plausible option, educational materials and tools are needed to better inform providers and patients about the method and its specific advantages. CONCLUSIONS: The enhanced, Internet-based NGT offers the family planning and reproductive health care field a powerful and inexpensive tool for systematically collecting and analysing expert opinion. Results are being used to develop a questionnaire to further examine strategies that may help promote diaphragm use and to refine ideas for intervention design. This will facilitate method reintroduction, if the diaphragm is proven effective against STIs/HIV, especially when used with a microbicide.