Background

Immunizations are recommended throughout the person’s lifetime to prevent vaccine-preventable diseases and their sequelae and are an integral part of communicable disease control worldwide [1]. Particularly, the prevalence of illness attributable to vaccine-preventable diseases is greater among adults than among children [2]. Yet, adult immunization coverage remains low for most routinely recommended vaccines and below targets even in countries such as the United States of America (USA) [1, 2]. As a result of the low uptake of adult immunizations—also resulted in important human and economic consequences—it is now taken as a public health priority [3]. For example, in the USA alone, the economic burden associated with vaccine-preventable diseases was estimated at about $9 billion in 2015, and almost 80% of the financial burden ($7.1 billion) was due to unvaccinated adults [4].

According to the Center for Communicable Disease Control (CDC), eight vaccines have been recommended for adults to protect against 11 diseases, and an additional five vaccines can be used with specific medical conditions or activities [5]. Of all the adult vaccines, influenza vaccine is the only one now recommended for all adults, while other target-specific adult vaccines were based on patient-specific behavior and medical conditions [1]. Although influenza vaccine has been proven to reduce hospital admission and influenza-related complications, the immunization rate worldwide still remains suboptimal [6, 7]. Like the majority of the countries worldwide, adult immunization rate in Saudi Arabia falls below the desired targets, urging the need to expand this service nationally [8, 9]. In the literature, many barriers have been identified as factors that may contribute to this low immunization rate including the lack of patient knowledge and believe about the safety and efficacy of vaccines, inconvenient location and visiting hours for the immunization service, and longer waiting periods [10, 11]. For instance, influenza requires immunization rate of at least 80% to establish herd immunity, and achieving this level of immunization requires a new approach such as increasing community awareness about the importance of immunization and increase accessibility to immunization services [12].

To increase accessibility to immunization services, in the last few years, community pharmacists have been providing immunization services in many developed countries such as the USA, the United Kingdom (UK), Australia, Canada, and New Zealand [13,14,15,16,17]. Community pharmacists are recognized as highly accessible healthcare professionals, and community pharmacies—because of the convenient location and extended working hours—provide a significant venue to provide an immunization service [18, 19]. There is also evidence that pharmacy-led immunization programs can lead to an increase in the uptake of immunizations compared with usual care [20]. Although community pharmacies play an important role in any healthcare system to overcome some of the barriers—for example, among hard to reach groups and those who live in rural areas [21, 22]—and pharmacists can play a key role in facilitating the uptake of immunization services and promoting patient education regarding the importance of immunization. Yet, community pharmacists’ readiness and willingness to provide such services have not been explored in Saudi Arabia. Pharmacists in Saudi Arabia are currently not authorized to administer vaccines. Allowing pharmacists to provide vaccination service is a controversial issue. However, recently, Ministry of Health (MOH) has considered an expansion and authorization in the role of pharmacists in immunization services. Still, it is unclear when this service will be implemented. Thus, the main purposes of this study were to assess the readiness and willingness of the community pharmacists’ to provide an immunization service and to identify the barriers involved in implementing such service in Saudi Arabia.

Methods

Survey development

This study was a cross-sectional paper-based survey that was conducted anonymously in the community pharmacy setting in Riyadh, Saudi Arabia, between February and April 2016. A quantitative questionnaire was developed to determine the pharmacists’ readiness and willingness in providing immunization services. The survey was developed based on an extensive search of the literature. Initially, the first draft of the study questionnaire was voluntarily reviewed by three clinical academic experts (with prior experience of tool development) to review the survey for any suggestions or amendments. The second draft of the survey was then sent to a group of community pharmacists to pilot the survey and sought further changes. Minor changes were received by the two groups and amended accordingly, and then, the survey was finalized for distribution.

Data collection

Data collection included information on participating pharmacists’ demographics and their willingness to provide immunization and the barriers that may potentially influence community pharmacists’ decision in providing immunization services in the community pharmacy setting, that is, participants were made to report the reasons for their willingness, or lack thereof, to provide immunization services, as well as the deriving factors for the implementation of such services. Apart from the background variables, the response to each item in the questionnaire was assessed using a 2-point Likert scale of agreement (1, “agree”; 2, “disagree”).

A convenience sample of community pharmacists across the different geographical parts of Riyadh, Saudi Arabia, was randomly selected and invited to participate in this study. Participated pharmacies varied markedly in space, prescription volume, and the population of serviced areas. Community pharmacies from different geographical locations including Northern suburbs, Southern suburbs, Western suburbs, Eastern suburbs, and Central suburbs in Riyadh were selected for the study. This provided us with sufficient data to enable us to determine the readiness and willingness of pharmacists to provide an immunization service to their community.

Data analysis

Received surveys were entered into a custom-built Excel database and cleaned by the first author before the data were transferred to SPSS. Descriptive statistics were used to illustrate respondents’ demographic characteristics and responses to the survey questions. Continuous variables were presented as means and standard deviation (± SD) for normally distributed variables. Categorical variables were presented as frequencies and percentages. All statistical analyses were performed using SPSS statistical software for Windows version 21 (SPSS Inc., Chicago, USA).

Results

Of the 179 community pharmacists who received the questionnaire, 139 completed the survey (response rate, 77.7%). All participated pharmacists were males, mean age was (31.9 ± 5.5 years), and the majority of respondents hold a bachelor degree in pharmacy, 131 (94.2%). Participants were predominantly from chain pharmacies, 126 (90.6%), and had 7.9 ± 5.8 years of experience (Table 1).

Table 1 Demographic characteristics of participants (n = 139)
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Although the overall response rate for the questionnaire was calculated to be 77.7%, response rates for individual items ranged from 28.8 to 96.8% (Tables 2, 3, and 4). The low response rate (28.8%) was reported from the item “financial reimbursement or adequate remuneration” when community pharmacists (n = 139) were asked about the most important elements needed for implementation of immunization services, whereas the highest response rate (96.8%) was recorded from the item “lack of training” when only unwilling pharmacists were requested to express their reasons (and/or barriers) for providing immunization services.

Table 2 Reasons for community pharmacists’ willingness to provide immunization services
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Table 3 Barriers affecting community pharmacists’ willingness to provide immunization services
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Table 4 Community pharmacists’ (willing and unwilling) responses to elements needed for implementing immunization services
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Of the 139 pharmacists, 76 (55%) of the respondents expressed their willingness to administer vaccines and readiness to establish an immunization service in their current pharmacies. Those pharmacists who were willing and ready to provide immunization services were asked about the reasons why they are best suited for the immunization. Many believed that community pharmacists are easily accessible to the community (56/57, 98.3%) and can possibly increase the rate of immunization among the certain age group of patients, such as the elderly (47/51, 92.2%) (Table 2).

On the other hand, community pharmacists who were totally unwilling to provide immunization services (63/139, 45%) were asked about the barriers hindering their willingness to provide vaccinations in the community setting. Multiple limiting factors to provide immunization services by community pharmacists were identified and were mainly a lack of training to deliver these services (46/61, 75.4%) and the belief that patient safety may be compromised (31/46, 67.4%) (Table 3).

Finally, all pharmacists (willing and unwilling) were also requested to report the most important elements for the implementation of immunization service in their premises, and were found that continuous professional education and training workshop on immunization (60/63, 95.2%) and pharmacist’s interest (45/49, 91.9%) have been agreed frequently (Table 4).

Discussion

This is the first study to explore the community pharmacists’ readiness and willingness in providing immunization services in Saudi Arabia. More than half of the participated pharmacists showed their willingness to provide this service. In addition to the easiness of accessibility, community pharmacists believed that they have a strong role in increasing the rate of immunization particularly for older patients besides to their role in advertising, promoting, and improving the vaccination service through community setting. On the other hand, several limiting factors were also identified in this study—for example, lack of training and maintaining patient safety was a concern which requires better education and training in vaccines for both undergraduate pharmacists as well as practicing pharmacists. These results are consisting of several studies that demonstrate the benefit of authorizing the pharmacist to administer vaccines in community settings [22, 23].

In 1997, the American Public Health Association (APHA) encouraged all pharmacists to embrace a level of involvement in providing immunization as either an instructor (promoting vaccinations to patients served), facilitator (adopting for vaccine distribution), or as immunizer (administering immunizations inconsistent with government law) [24]. In order to decrease the risk of infectious diseases and promote vaccine uptake, many countries have expanded the role of pharmacists working in the community pharmacy to provide vaccines. The International Pharmaceutical Federation (FIP) released a global report on the impact of pharmacists on immunization services and indicated that 13 of the 45 countries allowed pharmacists to administer vaccines in the community setting, including but not limited to: Argentina, Australia, Canada, Costa Rica, Denmark, Ireland, New Zealand, Philippines, Portugal, South Africa, Switzerland, UK, and USA [25]. These countries have recognized the importance of permitting vaccination by pharmacists and have allowed them to provide an immunization service to their communities. This move was supported by several studies which have demonstrated that the addition of pharmacists as immunizers potentially increased the overall immunization rate among the studied populations [19, 22].

Given the large number of visits by a broad range of social class and age groups of both the sick and healthy people, its accessibility and extended opening hours, and potentially low medical cost, community pharmacies offer a unique place for immunization services; there has also been evidence that vaccination through community pharmacies is cost-effective compared to a medical setting [26]. In this era of growing healthcare expenditure, the cost of vaccination may impose a financial burden on the government budget. Hence, the benefit of getting vaccines at a community pharmacy will remarkably reduce this pressure on the government budget and have many advantages over other healthcare settings, including but not limited to: extended opening hours, easy access to professional knowledge, convenient locations without requiring an appointment or waiting, and do not charge visit fees [27, 28].

In general, several barriers have been identified as the factors that can contribute to the low immunization rate in any age of adult population and setting. This may include inadequate patient knowledge and erroneous belief about the safety and efficacy of vaccines, longer waiting time, and inconvenient location and working hours of the clinic that provides the immunization services [29]. Therefore, providing vaccination through community pharmacies is an opportunity to overcome this hurdles. Yet, this is hindered by several challenges. Barriers noted include inconsistent reimbursement and compensation mechanisms, limited plans on offer to cover all recommended vaccines, lack of professional development for community pharmacists, and minimal educational programs and certifications, as well as obstacles in accessing health information technology due to the lack of shared patient record systems [24].

While there has been a limited number of published articles and poor quality of available studies in the Kingdom of Saudi Arabia—and this makes it difficult to directly compare pharmacist interventions to other strategies for improving immunization coverage—however, it is clear that vaccination at community pharmacies will likely make a significant contribution towards strengthening immunization programs to the adult population. According to the law regulating Saudi pharmacy practice, there are 12,506 licensed pharmacists working in approximately 7322 community pharmacies [8]. Like many of the countries that adopted community pharmacy-based immunization programs, expanding the role of community pharmacists to adult immunization in Saudi Arabia would be a great opportunity to overcome the low immunization rate in the country. However, this may require changing the patients’ behavior by providing adequate knowledge on vaccinations, and thus, the role of community pharmacists in providing such service is timely and very important for Saudi Arabia. In order to successfully implement such service in Saudi Arabia, it would be beneficial to start with a small-scale exploration of the views of service providers before pharmacy vaccination programs are available to a large public. Before success is evident, this may also be a step taken to find out any gaps that currently exist or may follow in introducing this new role in the community pharmacy. For example, a great attention should be paid to the development of a guideline that embraces pharmacist’s immunization practice in the community. This guideline may consists of a range of issues such as requirement for practice (e.g., licensure, certification, and training), vaccines and patients involved (e.g., influenza vaccine, oral, adult), confidentiality of the vaccination data, and how such data would be stored and used to evaluate the effectiveness of pharmacy vaccination programs. Furthermore, the guideline should include policy details regarding the potential safety and severe complications of vaccination service provided by pharmacists and how they will deal with it when this happened.

Conclusion

Community pharmacies offer a unique place to provide a vaccination service. Implementation of an immunization service may increase the number of adults that would be vaccinated and ultimately improve their overall health by reducing vaccine-preventable diseases. However, there is a lack of studies of the community pharmacists’ perspective regarding readiness and willingness to provide immunization services. The findings of this study indicate that community pharmacists working in Saudi Arabia are willing to provide immunization services. However, overcoming barriers (e.g., lack of training) identified in this study is a key to success, and this, in turn, provides the guidance for future planning and implementation of immunization services. Future larger studies are needed to explore the patients’ willingness and acceptability to receive immunizations from their community pharmacists.