Immunization is a cornerstone of public health through the prevention of infectious diseases and their complications including influenza. One approach used to boost influenza vaccination coverage, has been to expand the scope of practice of CPs beyond dispensing medications towards providing vaccination [8]. This nationwide study is the first known in Lebanon to assess community pharmacists’ willingness to provide influenza vaccine in their pharmacies. It adds to current literature toward vaccinations by exploring the extremely important topic of the knowledge, attitudes, and perceived barriers for the instigation of such process among an appropriate and accurate representation of community pharmacists in Lebanon. It also provides important insights about factors associated with this willingness.
The main findings in our study were that more than third-quarter of the surveyed CPs were willing to administer influenza vaccines in their pharmacies. Comparing to a study conducted among CanadianCPs, only 51 % of them reported willingness to incorporate provision of immunization into their personal practice [10]. Hence, Lebanese CPs showed a strong engagement and interest in expanding their practice scope to include provision of influenza vaccine, which is considered a boosting foundation required to the embarkation of such process.
In regards of CP’s knowledge, the bulk of them owned an overall good knowledge score. They were aware and cognizant in all knowledge domains: general and specific knowledge about the vaccine, side effects, precautions and contraindications and target groups. Our results were inconsistent with the findings of a study conducted in Jordan where pharmacists lack the knowledge of how to carry out a proper assessment before administering the shot or how to handle any adverse reactions after administration and do not have enough knowledge of proper needle disposal [12]. Since good knowledge about influenza vaccine is crucial for CPs to prepare them to provide adequate education to the public and, subsequently, improving their performance and self-reliance in administrating vaccines.
Concerning attitudes, it is notable that this study demonstrated that the bulk of CPs had a positive overall attitude score. They showed a highest perception of the benefits of influenza vaccination as they consider it more beneficial than risky. They also highlighted the importance of vaccination and refused to consider that natural infection or a healthy lifestyle as effective alternatives to vaccines. Additionally, most respondents rated the importance of their role in advertising and promoting vaccination in addition to the increase of vaccination coverage rate among adults rate, likewise, CPs also believed that they should be permitted to expand their practice to include the administration of adult vaccines. This is consistent with the results reported in a study conducted in Italy [13]. Furthermore, a study conducted in the United States exhibited that 89.3% of pharmacists thought that vaccines for adults were one of the top priorities in overall patient management and 96.3% considered vaccinations of adults within their scope of practice [14, 15].
The main components cited by CPs as requirements for the implementation of influenza immunization services, included support from health establishments, patient demand, and legislative reform. However, any expansion of CPs practice scope could not be achievable without a statutory allowance and a fully support from health authorities. Patient demand is also considered as a pivotal factor which is linked to the pharmacy image and the patient attitude toward CPs services. Despite that many studies in many countries such as in Europe, USA, and Canada disclosed a positive overall perception of CP services [16–21].
A study conducted in Lebanon revealed a poor public perception and attitude toward CPs in highly qualified and dedicated pharmacists [22] hence, the importance of upgrading a trust-based patient-pharmacist relationship. In addition, there is a need to a multi-stakeholders collaboration (OPL, MOPH, CPs) to improve public awareness about the role of CP as a healthcare professional and potential immunizer. Indeed, there is a need to assess the attitudes and the perspectives of the Lebanese community towards pharmacy-led influenza immunization.
Additionally, continuous education on vaccine safely administration and management of adverse events and adequate remuneration were also underscored by CPs among needed components. This shed light on the importance of formal certification that addresses the safe and effective administration of vaccines as requisite for allowing pharmacists to be immunizers combined with regular trainings. In regards to adequate remuneration, it should be noted that in Lebanon out-of-pocket influenza vaccine expenses are paid by the citizens, including the vulnerable groups and that the cost involved in visiting a physician for vaccination has additional cost consideration.. Despite that flu vaccines supplied and administered in a pharmacy setting could offers savings and convenience, an adequate and a standardized remuneration of CPs immunization services is crucial for the sustainability of such services.
In regards to barriers for implementing influenza vaccination in pharmacies, the top ranked barriers were the conflicts with other professionals who are eligible to vaccinate. This issue is commonly reported by many countries where a fierce opposition and lack of support from the physicians toward pharmacist-run immunization was indicated [23]. It was defended by the fact that CPs were not adequately or effectively trained to do vaccination or to manage adverse effects following vaccine administration [24–26].
Also, cost of vaccination services provided at physician clinic will includes consultation fees in addition to influenza vaccine price and provision fees makes it expensive for the patient. Hence, such struggle could be originated from financial conflict of interest. Moreover, liability and malpractice concerns and CP’s lack of knowledge of how to manage adverse events after immunizing were also perceived as main barriers. Generally, low rates of adverse events were associated with flu vaccinations; the incidence of anaphylaxis in any clinical setting ranges from 0.7—2 per 1,000,000 doses [27].Although there are few reports of incidence of side effects in pharmacy specifically, in the first season of instigation of flu vaccination in pharmacy in both Portugal (2008/09) and Ireland (2010/11), no incidences of anaphylaxis were recorded [28, 29].
Despite the low risk of serious adverse event, the need of training for CPs still integrates a vigorous component around safety. Recognizing this fact, countries have been proactive and adopted training programs. For example, the American Pharmacists Association (APhA) have developed the Pharmacy-Based Immunization Delivery Training module including vaccine administration skills as well as addressing injection technique, response to anaphylactic incidents and basic life support [30]. Hence, a nationally standardized approach and rolling out of a recognized and accredited training course are recommended. In addition, there is need to maintain CP’s competency through an ongoing service delivery training and yearly updating of skills. Lastly, recertification courses complying with updated guidelines might be required.
One noteworthy finding is that the remuneration was perceived simultaneously by CPs as main component for the instigation of pharmacy-run immunization and as main concern. The payment for provision of flu vaccination is related to the type of healthcare system. In Lebanon, such service can be provided privately, where the patient pays the provider directly, and will not be reimbursed to the patient.
Our findings showed that the willingness of CP’s to provide influenza vaccine was positively associated with younger age, higher education level (more than diploma in pharmacy), previous experience in immunization and urban location of pharmacy. This could be explained that higher education level could be associated with acquirement of additional knowledge related to vaccinology, therefore making CPs more confident in expanding their role. Similarly, previous experience in immunization could enhance their self-reliance as immunizer, hence increasing their intention to administer vaccine.
Interestingly young CPs were more likely to administer influenza vaccination than their counterparts who were older and having greater period. This could be understood in the light of the data that showed that Lebanon has a pharmacist to population ratio of 20.3 pharmacists per 10 000 population [31] which is quite high compared with the 2017 median global density of pharmacists to population and even higher than the average pharmacist to population ratio reported by OECD Health report in 2017 (8.2 pharmacists per 10 000 population). The experience of other countries shows that this may enhance the risk of unemployment among pharmacy graduates or it may force pharmacists’ income down [32]. Hence, the newer CPs higher interest in embracing expanded scope of practice and their tolerance of more pressure concerns could be for the sake of obtaining and maintaining professional employment.
Similarly, CP’s having extensive working hours, and working in pharmacies that are operating round-the-clock were more willing to be involved in influenza vaccination. CPs are already recognized for their convenient locations with more accessible opening times than traditional immunizers, and these have been identified as reasons for patients choosing to attend pharmacy rather than their family doctor for their flu vaccination [33].
Additionally, CPs showing positive attitude towards immunization and towards benefits of provision of influenza vaccines were more likely to be influenza immunizer. Our results are consistent with a study conducted in Canada regarding attitudes and beliefs, where 82% of the Canadian health care providers have a positive attitude toward the expansion of the pharmacists' scope of practice to include provision of vaccines to adults [34].
On the contrary, CPs who perceived patient privacy as barrier had a lower willingness to administer influenza vaccine. This finding is consistent with the result of a study conducted in Lebanon which displayed that lack of privacy constitutes a barrier for patients and this was due to the absence of privacy area inside the pharmacies [22]. However, this might be a major barrier for patient to refer to the CP for seeking immunization service. Hence, we suggest that Lebanese CPs take this aspect into consideration.
Another concern perceived by CPs that affect negatively their intention to administer influenza vaccine was related to the time and cost associated with professional development of CPs. This could be addressed through the designation of an accredited public institution or academy or third party provider to deliver such efficient and recognized courses and training that meets requirements specified by OPL, MOPH and other stakeholders, in affordable prices during short duration of time. A success story was reported in Portugal where using a standardized approach and rolling out of 3 months training in a short space of time, allowed 1273 Portuguese pharmacists (48% of pharmacies) across the country completed the training [35]. Additionally, CPs who considered that patients have a trust issue towards them were less likely to incorporate such service in their settings. In a study assessing patient perspectives toward pharmacy practices in Lebanon, the relevant identified aspects were respect, empathy, friendly staff, listening carefully, giving quality time, responding quickly to their needs and respecting their privacy. Focusing on those aspects through a multifaceted approach is required to enhance pharmacy image and build a longtime confident relationship. to encourage patients to come to pharmacy for their flu vaccination [11]. Extensive awareness of the role of CPs as health care provider, strong engagement of CPs in a firm reliable rapport with their customers are among the most important drivers of success of pharmacist-led flu vaccinations. Similarly, remuneration impacted negatively the CP’s intention to vaccinate. However, appropriate remuneration is one condition for effective instigation of vaccinations in pharmacies, which should encourage CPs to provide this kind of service and to further develop pharmaceutical care. Similarly to Lebanon, the costs of influenza vaccinations are borne by patients in Portugal [23]. Without adopting a cost-benefit approach combined to a standardized remuneration among pharmacies, CPs could lose their interest and shift to be reluctant to expand their practice scope.
In summary, Community pharmacy as a profession is travelling a complex journey, beginning as a profession concerned with dispensing medicines, and evolving into provision of vaccination services. With limited public health budget, accompanied with a rising in at-risk groups and ailing population, engaging CPs in preventive actions including immunization presented an opportunity to increase influenza vaccination coverage rates and herd immunity, and thus has a significant benefit on public health. In addition, using CPs as immunizer could increase the state of readiness for action in the face of any pandemic, to lower the costs of treatment of infectious diseases and the subsequent complications. Although multiple strategies are required to implement such a service in community pharmacy, including training, marketing, stakeholder engagement and regulatory frameworks, community pharmacy boost the coverage of the target populations and improve patient health.
Limitations
Several limitations should be acknowledged in the present study. First, our study relies on community pharmacists’ self-reported information, which makes it prone to the disadvantages of desirability biases. Furthermore, this online questionnaire might have favored a selection bias since it might only allow the participation of community pharmacists who have access to online resources to participate. Results may not be generalized to community pharmacists in other countries.
Implications:
Prior to instigate a community pharmacies-led for influenza vaccination, there is a need to build CPs competencies and skills by establishing well-structured training and under the supervision of competent dons. Simultaneously, it is important to target other healthcare providers to find a framework where they could cooperate with pharmacists in order to reduce any conflict of interest. For future research, it is important to explore community pharmacists’ knowledge and attitudes related to immunization provision. Exploring the perspectives of patients towards receiving influenza vaccines in community pharmacies is recommended.