Assessment of community pharmacists’ engagement in pharmacy-delivered influenza vaccination: a mixed-methods study

Abstract

Objectives

This study aimed to identify factors contributing to pharmacists’ engagement in vaccination services during the first influenza vaccination campaign in 2019–2020 for the Canadian province of Quebec, led by community pharmacists.

Methods

A mixed-methods study was conducted using a sequential exploratory design. Semi-structured interviews were administered to pharmacists and key informants (n = 23) and data were analysed according to the Consolidated Framework for Implementation Research in community pharmacy. The findings were then used to construct a survey of community pharmacists’ engagement in vaccination, which was tested in a Quebec urban community. The study participation rate was 34.6% (n = 29).

Key findings

Pharmacists expressed positive attitudes towards the implementation of vaccination services, following legislative reform. Factors such as previous involvement in vaccination campaigns and the number of pharmacists on duty were positively associated with engagement in influenza vaccination, whereas staff shortages and logistical problems were a barrier to engagement. Qualitative findings provided in-depth understanding of the value of interprofessional collaboration between pharmacists and nurses.

Conclusions

Vaccination in pharmacies is currently more reflective of individual choice than an indication of collective change in the profession. Logistical factors are key to enhancing the uptake of vaccination in community pharmacies throughout Quebec. External support from professional associations and interprofessional collaboration should be enhanced to promote the implementation of vaccination services in pharmacies.

community pharmacy, professional training, interprofessional issues, delivery of care, pharmaceutical public health

Introduction

Vaccination is known as the most effective way to prevent influenza infections.^[1] In the last decade, community pharmacists have joined the collective effort to improve vaccination uptake, with pharmacies recently surpassing doctor’s offices for the first time as the most popular site for obtaining a flu vaccine in Canada.^[2]

Given their nationwide presence, community pharmacies that provide immunization help to overcome accessibility issues^[3] and increase the availability of vaccination sites.^[4] Moreover, increased engagement by community pharmacists in vaccination delivery improves immunization coverage,^{[5, 6]} reduces costs^[7] and limits the burden of inpatients on health systems.^[8] In Canada, provinces that allow pharmacists to administer vaccines have generally reported higher rates of influenza immunization.^{[9, 10]} Accordingly, Bill 31 was implemented in March 2020, giving Quebec pharmacists the right to prescribe and administer all vaccines, including the influenza vaccine, with certain age restrictions.^[11] Four trainings were mandated under Bill 31: the Protocole d’immunisation du Québec (PIQ: Quebec Immunisation Protocol) for training on vaccines and immunization; the Ordre des Pharmaciens du Québec (OPQ: Order of Quebec Pharmacists) trainings on vaccine administration techniques and cardiopulmonary resuscitation (CPR) training. This has opened the door to interesting opportunities for interprofessional collaboration, as pharmacists may now operate independently, serving as both vaccinator and prescriber, or as prescribers only working in collaboration with nurses. Before the promulgation of the new law, delegating vaccination services to a nurse was the only way to offer vaccines in a pharmacy setting. Moreover, influenza immunizations are fully covered by the Quebec health insurance regime for at-risk populations, and pharmacies are compensated for vaccination services regardless of whether they were provided by a nurse or a pharmacist. However, little information is available regarding whether these changes in legislation and remuneration were sufficient to foster the engagement of community pharmacists in onsite vaccination.

Previous studies have mainly focused on the impact of community pharmacists on vaccination uptake in general. International studies reported mixed results concerning the involvement of community pharmacists in increasing vaccination rates among vulnerable populations, from no change^[12–14] to modest increases in vaccination uptake.^[15] High patient satisfaction was also associated with vaccination by pharmacists.^[14] Interestingly, a survey of community pharmacists in Quebec revealed that half of responding pharmacists would be willing to administer vaccines, if they could do so.^[16] Yet, the movement from good intentions to concerted action in vaccination, and which determinants may influence the engagement of pharmacists in vaccination delivery, have rarely been studied.^[17] To address this gap in the literature, this study aimed to identify the factors contributing to pharmacists’ engagement in vaccination services, in the context of the first Quebec influenza vaccination campaign led by community pharmacists.

Methods

Study context

This study was conducted in the Laval area of Quebec, Canada. With approximately 442 648 residents in 2020, Laval represents the third most populous city in the province.^[18] As in other administrative regions, a centralized structure, the Laval CISSS (Integrated Health and Social Services Centre) coordinates the regional influenza vaccination campaign.^[19]

Conceptual framework and variables

The Consolidated Framework for Implementation Research in community pharmacy^[17] was chosen for the analysis of certain mechanisms of pharmacist engagement. This framework (Figure 1) segments professional services into five relevant categories based on a critical review of 45 articles on community pharmacies^[17]: intervention characteristics, inner setting, outer setting, individual characteristics and engagement. We stratified pharmacists’ engagement according to their degrees of involvement in vaccination and the different roles assumed by pharmacists in providing vaccination services such as prescribing vaccines and administering them. Three categories of engagement were created: no role in vaccination (pharmacist does not prescribe or vaccinate), prescriber (pharmacist prescribes but does not vaccinate) and both prescriber and vaccinator.

Figure 1

Conceptual framework, based on Consolidated Framework for Implementation Research (CFIR) (2009).

Data collection

Data collection for this mixed-methods study occurred during the summer of 2020 which coincided with the period in which vaccination was planned in community pharmacies. The study used a sequential exploratory design^[20] which involved combining qualitative and quantitative data collection and analysis in a sequence of phases to allow for a deeper understanding of the phenomenon and better identification of the factors promoting engagement in vaccination.

Using semi-structured interviews, the qualitative phase explored the perceptions of pharmacists and key informants (pharmacy nurses and representatives of pharmacy and public health associations) regarding the engagement of community pharmacists in vaccination following the legislative changes introduced by Bill 31. Key informants were further probed using open-ended questions. A convenience sample of pharmacists and pharmacy nurses was recruited by email and telephone invitation. Representatives of the pharmacy association and public health association were also mobilized using a sample of experts and a snowball recruitment method.

The quantitative phase consisted of a survey sent to all community pharmacies in the Laval health region, regardless of their participation in the 2019–2020 influenza vaccination campaign. Questions were based on the findings from the qualitative phase and organized into three categories: (1) inner setting and individual characteristics (11 questions); (2) intervention characteristics (10 questions); and (3) engagement (3 questions). Data collection was carried out between 18 August and 6 September 2020. Two research assistants conducted the survey using the LimeSurvey platform at l’Université de Montréal, (Quebec, Canada). Ethics approval was issued by the Université de Montréal research ethics board (CERC-20-056-R) and the Laval CISSS (2019-2020/06-01-A). Respondents were approached for potential inclusion in the study by email, through social media networks and faxes sent to pharmacies. The survey was sent to all 90 pharmacies in the Laval region.

Data analysis

Regarding the qualitative phase, interviews were recorded and transcribed, and a thematic analysis of the data was conducted.^[21] A continuous comparison was made between transcripts. Data analysis was conducted by the principal investigator according to categories from the conceptual framework and was overseen by co-authors. Descriptive statistical analysis was performed for the quantitative results of the surveys, according to three degrees of engagement, as defined. Analyses were carried out using SPSS (version 26). The third phase involved the integration of the qualitative and quantitative data^[20] based on our conceptual framework. Appendices 1 and 2 show data collection tools (interview guide and survey).

Results

Descriptive results (qualitative and quantitative)

Figure 2 presents data from the qualitative phase, including pharmacist and key informant interviews (n = 23) and discussion groups (n = 4) held by videoconference or telephone interviews between July and August 2020. Regarding the survey, of the 107 pharmacists invited, 37 agreed to participate, for a response rate of 34.6%. The final sample, excluding partial answers, consisted of 29 respondents.

Figure 2

Qualitative data collection.

Individual characteristics

Regarding individual characteristics, most pharmacists who responded to the survey were women (n = 18), and more pharmacist participants in the study were owners than pharmacy employees (n = 19). About half of the respondents had more than 15 years of experience as pharmacists (n = 15). In terms of training, some pharmacists had already followed the PIQ (n = 10), OPQ trainings (n = 12) and CPR (n = 13). The fourth training, which involved a brief data entry course on the provincial vaccination database, was planned but, to date, had generally not been followed (n = 6) Finally, only n = 5 pharmacists had followed all four mandatory trainings, certifying them to administer vaccinations. During the interviews, pharmacists criticized the number of trainings and time required to complete them (int. 11) (Tables 1 and 2).

Table 1

Individual characteristics and inner setting of respondent pharmacies and pharmacists (2020–2021)

		N	%
		29	100
Individual characteristics
Sex	Female	18	62.1
	Male	11	37.9
Status	Owner	19	65.5
	Employee	10	34.5
Commercial brands (most frequent)	Jean Coutu	11	37.9
	Uniprix	8	27.6
Professional experience (total, years)	<3	2	6.9
	3–5	3	10.3
	6–10	5	17.2
	11–15	4	13.8
	16+	15	51.7
Training on vaccines and vaccination (INSPQ, 10 h)	Already done	10	34.5
	Planned	10	34.5
	Desired	8	27.6
	No interest	1	3.4
Training on vaccine administration techniques (OPQ, 9 h)	Already done	12	41.4
	Planned	4	13.8
	Desired	4	13.8
	No interest	9	31.0
CPR training (OPQ)	Already done	13	44.8
	Planned	6	20.7
	Desired	7	24.1
	No interest	3	10.3
Training on SI-PMI registration (INSPQ)	Already done	6	20.7
	Planned	13	44.8
	Desired	8	27.6
	No interest	2	6.9
Total training (four mandatory trainings)	Already done	5	17.2
	Not done	24	87.3
Participation in the 2019–2020 vaccine campaign	Yes	22	75.9
	No	7	24.1
If so, the presence of the nurse in 2019–2020 (weekly)	Less than once	2	6.9
	1	4	13.8
	2	9	31.0
	3+	5	17.2
Inner setting
Prescription volume (daily)	0–299	6	20.7
	300–599	13	44.8
	600–1199	8	27.6
	1200+	2	6.9
Number of on-duty pharmacists (total, daily)	1	13	44.8
	2+	16	55.2

Table 2

Themes and codes describing pharmacists’ engagement in vaccination (2020–2021)

Themes	Codes	Verbatim samples
Individual characteristics	Experience with intervention	‘[Vaccination] is so well implemented, it’s practically second nature for the pharmacy’ (int. 8)
Individual characteristics	Knowledge of intervention	‘What needs to be done to practice the injection technique is not done through a video conference, but the rest which is more theoretical can be done at home or elsewhere or whenever time permits, no need to spend 10 or 8 consecutive hours and lose a day on that’ (int. 11)
Inner setting	Structural characteristics	‘I am sure that it’s the same for all chains and banners, they see it like a business opportunity, and want pharmacies to provide a maximum number of doses’ (int. 7)
Inner setting	Available resources	‘Especially if you don’t do it at first … I invested in renovation, but now one has to invest in a consultation room, you need a fridge … so the majority of pharmacists don’t do it because of that, if you don’t have the space. It can take 10 years to make your consultation room profitable’ (int. 11)
Intervention characteristics	Logistics	‘Ordering vaccines with public health is not complicated. I have been talking to other pharmacy owners for years (…) and I see how complicated it can be, some don’t receive their vaccines; they order 200 doses, they take appointments and finally they receive half, I don’t want to get into that’ (int. 8) ‘I also have many demands from patients (…)’ (int. 8)
Intervention characteristics	Remuneration	‘Quebec fees are very very low for dispensing prescriptions, lower than everywhere in the country considering the cost of human and material resources. And pharmacists were afraid that vaccination fees would be for example as low as in Ontario which is very very low. We are not at the same level as Alberta which is at the appropriate fee, and as we don’t know if we will deploy these acts at negative profit, it’s difficult to plan to do them’ (int. 4)
Intervention characteristics	Implementation and change management	‘The biggest stake is change management in pharmacy. It’s new. So, humans need to create new habits. And, in general, to become good in the act, one needs to do it twenty times. So, there is always inertia, which is natural. But pharmacists have responded well to vaccinating once their questions were answered’ (int. 4)
Intervention characteristics	Logistics	‘It is already fluid. Only now we will have to review at what interval we schedule appointments and how to do the cleaning process. So, this is what is left to validate’ (int. 7)
Intervention characteristics	Implementation	‘And then there is the online vaccination record; we need help with that (…)’ (int. 4)
Outer setting	Unions	‘The Quebec Pharmacist Owners Association has succeeded in upgrading the remuneration taking into consideration the additional time associated with the exceptional measures as well as spending on individual protection equipment and on disinfection (…)’ (int. 4) ‘It’s the collaboration between the Quebec Pharmacy Owners Association, the Quebec Chain and Banner in Pharmacy Association, the Quebec Pharmacy Distributor Association that will give the power to pharmacists to operationalize vaccination and increase the vaccination uptake for priority clienteles’ (int. 4)
Engagement	Pharmacists both prescribe and vaccinate	‘It’s quite a challenge to vaccinate, to do the action at least once. I will do it according to profitability’ (int. 12)
Engagement	Pharmacists prescribe and nurses vaccinate	‘The hourly rate that I would have to pay to be replaced versus the hourly rate of a nurse, even if there is a higher fee by the government for pharmacists, is not cost effective, it’s not worth it for me to get involved with vaccines’ (int. 8)

In terms of knowledge and experience, most pharmacies had participated in the 2019–2020 influenza campaign (n = 22), with nurses providing the vaccinations twice a week in most of them (n = 9). Pharmacy owners seemed to rely on the vaccination history from previous years for determining vaccination capacity. Indeed, study participants who offered vaccination services through a nurse tended to offer vaccinations for the current year through a similar setting, qualifying it as a routine activity (int. 8).

Inner setting

In terms of inner setting, almost all respondents were affiliated with a pharmacy chain or banner (n = 28). Jean Coutu was most widely represented in the sample (n = 11). Qualitative data suggested that banners play a role in promoting vaccinations as a business opportunity (int. 7). The largest proportion of respondents worked in pharmacies that dispensed 300 to 600 prescriptions per day (n = 13), and roughly half of the respondents worked in pharmacies that had at least two pharmacists on duty at any given time (n = 16). Qualitative data also indicated that interprofessional collaboration played a role in the organization of vaccination services. The presence of auxiliary nurses was another useful resource for vaccination delivery according to respondents (int. 4). Finally, qualitative findings noted the importance of physical space for providing vaccination services in pharmacies. Some pharmacists stated that material resources (fridges, etc.) and physical space were possible predictors of pharmacist engagement (int. 11) as well as the geographic location of their pharmacies (int. 10 and 12) (Tables 1 and 2).

Another structural element reported across all categories of engagement was insufficient remuneration for vaccination (n = 15). Some pharmacists stated that the remuneration associated with vaccination was too low for them to engage in this activity (int. 4). Pharmacists compared their remuneration with that of pharmacists in other provinces like Alberta, where remuneration was considerably higher than in Québec (int. 4). The same respondent expressed his inability to fully engage in vaccinations, if ‘the sustainability of the service is at stake and is not able to generate a reasonable profit margin’ (int. 4). Another respondent emphasized the view that even if the government were willing to pay pharmacists more than nurses to perform this identical task, ‘the remuneration from vaccination does not allow the pharmacist to break even. Nurses will therefore continue to give most of the shots’ (int. 8). These different perspectives suggested lack of profitability as a reason for low engagement.

Outer setting

Some external elements were mentioned in the qualitative data. Financial incentive, such as the COVID premium pay,^[22] was clearly perceived as a strategy for encouraging pharmacists to engage in vaccination (int. 4). The announcement of this bonus seemed to reassure many participants about vaccination profitability. Professional associations acted as facilitators between pharmacists and the government in the introduction of this bonus (int. 4) (Table 2).

Intervention characteristics

Respondents declared almost unanimously their intention to participate in the influenza vaccination for the upcoming season (n = 28). On average, pharmacists had pre-ordered 378 vaccines per pharmacy for the 2020–2021 season (median: 350). Those that were covered under the public health system could be obtained at no cost and were given precedence in pharmacy orders, as the financial risk of left-over vaccines would be lower, compared with vaccines not covered under the public health criteria (int. 12). Pharmacists expected to provide the service 2 days a week as the median (Table 3).

Table 3

Intervention characteristics related to pharmacists’ vaccination (2020–2021)

		N	%
		29	100
Participation planned for 2020 vaccinations	Yes	28	96.6
	No	1	3.4
Pre-ordered vaccines (total)	Mean	378
	Median	350
Pre-ordered vaccines (public doses)	Mean	342
	Median	300
Vaccination data entry	Pharmacists	9	31
	Pharmacy technicians	7	24.1
	Nurses	11	38
	No answer	2	6.9
Vaccination estimated capacity (number of days per week)	<2	8	27.6
	2+	16	55.2
	No answer	5	17.2
Anticipated issues	Staff shortage	10	34.5
	Insufficient remuneration	15	51.7
	Public health instructions	18	62.1
	Lack of time (data entry)	16	55.2
	Lack of time (training)	11	37.9
	Operational issues (number of rooms, …)	17	58.6
		CAD
If insufficient remuneration, what would be the desired remuneration level:	Prescribe (mean)	15
	Prescribe (median)	15
	Vaccinate (mean)	24
	Vaccinate (median)	20

Many issues were expressed in the face of the upcoming vaccination campaign. Pharmacists were mainly concerned about compliance with public health instructions (n = 18), logistical issues (n = 17) and lack of time, for example, for data entry in the register (n = 16). Public health instructions were often viewed as vague, or overly complex, such as the process for ordering public doses (int. 8). Some COVID-19-related logistical issues were also raised, such as extra sanitation measures (int. 7). Some pharmacists had mitigated their operational barriers, as appointment systems were now better organized for other services, easing the process for vaccination (int. 7). Lack of time was also confirmed in the qualitative data, with one respondent reporting that administrative duties were an important challenge in the vaccination process (int. 4). A final challenge concerned change management. Pharmacists needed to make time in their schedules for vaccination-related activities (int. 4).

Engagement

The highest proportion of pharmacists both prescribed and vaccinated (n = 13), whereas some pharmacists planned to let nurses perform both evaluations and vaccinations (n = 8). This dichotomy was also identified in the qualitative results, with pharmacists very reluctant to vaccinate due to the challenges previously mentioned, while others underlined the positive social impact of vaccinating (int. 12) (Tables 2 and 4).

Table 4

Degrees of engagement related to pharmacists’ vaccination (2020–2021)

		n	%
		29	100
Anticipated degrees of pharmacist engagement	No pharmacists’ engagement (nurses both evaluate and vaccinate)	8	27.6
	Pharmacists prescribe (nurse vaccinate)	7	24.1
	Pharmacists both prescribe and vaccinate	13	44.8
	N/A	1	3.5

Variables associated with engagement

Individual characteristics and inner setting variables

Pharmacist owners reported the strongest engagement in vaccination (n = 9). The fact of having to follow mandatory trainings, especially the one from INSPQ, also seemed related to more complete engagement (n = 6). Previous engagement in the 2019–2020 campaign showed some surprising patterns, with little distinction between those who participated and those who did not. There was even a tendency for some non-participants in the previous campaign to be fully engaged in vaccination for community pharmacies (n = 6). Degrees of pharmacist engagement also seemed to be influenced by pharmacy size. In pharmacies with one pharmacist on duty during the day, both prescribing and administering roles were favoured for pharmacists (n = 9). However, in pharmacies with more than 2 pharmacists available daily, a higher proportion adhered to prescribing roles as compared with other roles (n = 6). Anticipated challenges for 2020–2021 were other variables related to degrees of engagement. Pharmacists who intended to engage in both prescribing and vaccinating identified impending logistics issues, while perceived staff shortages were associated with lower engagement, that is, only prescription, for others (n = 6) (Table 5).

Table 5

Variables associated with pharmacists’ engagement in vaccination (2020–2021)

	No engagement (n)	Prescription (n)	Both prescription and vaccination (n)
Status
Owner	5	5	9
Employee	3	2	5
Trainings
Training on vaccines and vaccination (INSPQ, 10 h)	3	1	6
Participation in previous vaccine season
Yes	8	6	8
No	0	1	6
Number of pharmacists (total, daily)
1	3	1	9
2+	5	6	4
Anticipated issues
Operational issues	1	6	10
Public health instructions	4	6	8
Staff shortage	6	1	3

Discussion

Nearly all pharmacist respondents in this study anticipated their participation in the 2020–2021 vaccination campaign, and a high number of public doses were ordered in the previous year. Yet self-declared engagement does not ensure commitment, judging from the small number of pharmacists who completed all four mandatory trainings. A gap seems to remain between words and actions, suggesting that the scope of enhancements was perhaps insufficient to generate engagement among pharmacists to provide vaccinations in community pharmacies.

This study was based on the experience of pharmacists anticipating the first influenza vaccination campaign in Quebec. As such, the main strength of the study was to collect original and diversified data, based on a conceptual framework, regarding the views of Quebec pharmacists in light of legislative change whereby they could lead the campaign. However, since our results represent anticipated engagement only, they do not provide retrospective data on the 2019–2020 influenza campaign. Moreover, due to the timing of the study in terms of COVID-19 restrictions and legislative uncertainties, poor response rates limited the power of the study. In the subsequent months, logistical support was offered by head offices of pharmacy chains, which may have altered the intentions of pharmacists towards vaccination. These findings may therefore not be representative of the wider views of Quebec pharmacists, considering the voluntary nature of study participation, which may have overrepresented highly engaged pharmacists.

Even if, theoretically, ‘pharmacists [may] have established themselves as advocates, educators, facilitators as well as qualified providers of vaccinations’ ^[23]), the Quebec legislation allowed pharmacists to choose whether they wished to become certified and offered many alternative forms of collaboration for those who declined to prescribe and vaccinate. The fact that new graduates from Quebec universities will henceforth receive injection training during their program^[24] may shed new light on the idea of becoming vaccinators, perhaps reducing barriers for new pharmacists. Training may nevertheless have appeared as a higher barrier to becoming a vaccinator for pharmacists who would not have completed all their trainings due to the timing and circumstances surrounding our study, even though a grant was available throughout the first summer of the COVID-19 pandemic and may have enticed pharmacists to get their certifications).^[25]

Considering individual characteristics, having participated in previous influenza campaigns was linked with high engagement. This finding is logical, as it is easier to pursue a previously established service than to implement a new one. Even before the change in legislation, many pharmacies in Quebec were involved in providing vaccinations through their nurses and were experiencing high demand for convenient locations where the influenza vaccine could be dispensed.^[26] According to our data, professional status and experience did not considerably alter the engagement of pharmacists, even if slightly more owners seemed to report high engagement. Previous studies showed that being a manager or owner, or a newer pharmacist, were some of the most important factors in opting for vaccination certification.^[27]

Alternatively, support from the pharmacy chain or banner reportedly had an influence on pharmacists’ engagement, unlike the situation of pharmacists working in independent pharmacies.^{[17, 27]} This association did not emerge clearly in the quantitative results of our study but was mentioned in some interviews (int. 4 and 7). In the Quebec context, the 2019–2020 campaign saw a high degree of participation by most pharmacies, but their anticipated role varied according to the number of pharmacists on duty day-to-day. Small pharmacies showed greater engagement by their pharmacists towards vaccination, a result consistent with other studies.^[17] On the one hand, one would think that larger pharmacies could mobilize more resources and afford better collaboration with nursing services. Yet, on the other hand, our data suggested that vaccination practices are easier to deploy on a small scale, or because of an optimal location, for instance, pharmacies situated near retirement homes. There was, however, little evidence on engagement in the combined prescriber and vaccinator category, which would be logical to implement in a small pharmacy. In sum, more research on the role of pharmacy chains and brand names is necessary to better understand their influence on vaccination initiatives.

In terms of intervention characteristics, certain challenges limited the engagement of pharmacists, including lack of time, staff shortages and inadequate workspace. These findings were also reported for other Canadian provinces,^[12] while many pharmacists mentioned that only one factor would need to change for them to be willing to vaccinate. ^[28] Adequate remuneration is a powerful motive for pharmacists who, as small business owners, weigh the profitability of providing vaccinations against providing existing services such as medication dispensing^[29]). Hence, some pharmacists will continue to delegate vaccination to nurses as a way of cutting costs (int. 8), while others, paradoxically, will only undertake the prescriber role as a cost-saving alternative, adding complexity to the organization of pharmacy services in the process of adding nurses as vaccinators. This result may thus be seen as a call out for more interprofessional collaboration between nurses and pharmacists to improve organizational efficiency related to vaccination in pharmacy settings.^[30]

Surprisingly, clear information on the influenza campaign (labelled as ‘public health instructions’) emerged as the most frequent complaint among Quebec pharmacists in our survey but has not surfaced in other studies. There seems to be a demand from Quebec pharmacists for more transparent communication with public health and ministry officials regarding organization of the annual influenza campaign. As pharmacists prove to be valuable partners in public health campaigns, they should be further solicited in the planning and organization of large-scale vaccination campaigns in other to minimize many of the barriers identified in this study.

Conclusion

This mixed-methods study explored the influence of implementation variables on community pharmacists’ engagement in pharmacy-delivered vaccination. Quebec pharmacists seem divided on this question. Vaccination in pharmacies seems to depend more on personal or organizational intentions rather than collective change or responsibility in the profession. Individual characteristics, such as previous experience with vaccination and inner setting variables, such as the number of daily pharmacists on duty and location, were associated with pharmacists’ engagement. These elements should be considered when implementing new strategies to enhance vaccination by pharmacies. As well, some outer setting factors, such as professional associations, should be further mobilized to facilitate vaccination and promote pharmacist collaboration with public health decision-makers.

Acknowledgements

We would like to thank Judith Sabetti for the editorial revision.

Author Contributions

P.M.D.: initiated the project; A.C. and M.G.: responsible for design and methodology; P.M.D. and A.C.: supervised the project; A.C. and M.G.: wrote the final draft; P.M.D., A.C., M.G. and A.R: reviewed the final draft.

Funding

This work was supported by Chaire Sanofi en soins pharmaceutiques ambulatoires de l’Université de Montréal.

Conflict of Interest

None declared.

Data availability

The data underlying this article are available through request to the corresponding author.

Author notes

They were joint first authors.