Exploring influenza vaccine hesitancy in community pharmacies: Knowledge, attitudes and practices of community pharmacists in Ontario, Canada

Abstract

Background:

Vaccine hesitancy (VH) remains a prime contributor to poor influenza vaccine uptake. This study explores the knowledge, attitudes and practices of community pharmacists toward influenza VH, including their personal influenza immunization attitudes and behaviours.

Methods:

A web-based cross-sectional survey questionnaire was administered to community pharmacists practising in Ontario, Canada. A 38-question survey tool explored 5 domains, including pharmacists’ personal attitudes and behaviour toward influenza immunization, their self-reported knowledge of influenza, its vaccine and vaccine hesitancy, and their attitudes, practices and experiences with influenza VH at the community pharmacy. The data were analyzed descriptively.

Results:

A total of 5530 survey invitations were e-mailed, and 885 responses were collected (response rate 16%). Two-thirds (n = 568, 65.7%) of the respondents reported receiving the influenza vaccine in the preceding season. The most frequent reasons for personal influenza immunization were prevention of disease transmission to patients, friends and family, and contribution to herd immunity. In addition to their confidence and perceived ability to identify and address influenza VH, respondents’ self-reported knowledge across a 15-item Likert questionnaire was high. Respondents reported coming across an average of 16 (SD 28) individuals hesitant to receive the influenza vaccine each week. Regular workload (n = 419, 65.6%) and insufficient time (n = 406, 65.3%) were reported as the most limiting barriers to engagement in influenza vaccine conversations.

Conclusion:

Facilitating optimal practice scope for pharmacists, and capitalizing on the convenience and accessibility of the community pharmacy setting, presents a promising means to address influenza VH. However, barriers to pharmacist-initiated engagement on influenza vaccine must be explored and addressed. Can Pharm J (Ott) 2020;153:xx-xx.

Knowledge Into Practice.

• Pharmacists, with their vaccine knowledge and position within the community, underrate their impact on influenza vaccine decision-making.

• Vaccine decision-making is not binary—accepting or rejecting a vaccine—and pharmacists can play a role in nudging a patient along this continuum.

• To do this, pharmacists and pharmacy staff should design outreach activities that encourage patients to get the influenza vaccine and answer their questions about getting vaccinated.

• Pharmacist-identified barriers require a rethinking of workflow and workload and a reorientation of vaccine conversations into proactive discussions that address issues of hidden vaccine hesitancy.

Mise En Pratique Des Connaissances.

• Malgré leurs connaissances sur les vaccins et leur position au sein de la collectivité, les pharmaciens sous-estiment leur incidence sur les décisions qui sont prises concernant la vaccination contre la grippe.

• Les décisions en matière de vaccination ne sont pas binaires—accepter ou refuser un vaccin—et les pharmaciens peuvent y jouer un rôle en encourageant un patient à faire ce choix.

• À cette fin, les pharmaciens et le personnel des pharmacies doivent mener des activités de sensibilisation auprès des patients afin de les encourager à se faire vacciner contre la grippe, et doivent répondre à leurs questions concernant la vaccination.

• Les obstacles auxquels se butent les pharmaciens requièrent un réexamen du flux et de la charge de travail, ainsi qu’une réorientation des débats sur la vaccination pour que des discussions proactives soient engagées sur les enjeux liés à une réticence inavouée à la vaccination.

Introduction

Vaccinations remain the most effective way to combat vaccine-preventable infectious diseases. They are effective both at the individual level through direct protection and at the community level through herd immunity.^1,2 Despite extensive scientific evidence backing the safety, efficacy and overall benefits of all vaccines,^3-10 achieving and sustaining high vaccine uptake remains a challenge. Vaccine hesitancy (VH), defined as the voluntary delay or refusal of vaccinations despite availability, is an increasingly prevalent phenomenon with the potential to undo decades of public health progress.^11,12 Consequently, the World Health Organization in 2019 identified VH as a threat to global health.¹³

VH challenges the traditional dichotomous notion of vaccination decisions and outcomes as strictly acceptance or refusal of the vaccine. Instead, it recognizes vaccine decision-making as a complex, context-specific and dynamic process, wherein individuals may display an array of attitudes or behaviours as they transition across a spectrum of possibilities in response to a variety of influences between complete acceptance and refusal.^14-16 While VH can be specific to 1 or all vaccines, influenza VH is of unique interest because of the need for annual reimmunization, seasonal variations in vaccine effectiveness, the self-limiting nature of influenza and the existence of influenza vaccine–specific myths such as “influenza vaccination causes influenza,” among others.^17,18

Although reasons for nonvaccination among people are varied and complex, health care providers remain the most trusted advisors and influencers of vaccination decisions.^17,19,20 Experiences of general practitioners, pediatricians, nurses and midwives with vaccinations have been studied before.^21-26 The previous literature has established that greater knowledge of vaccines, beliefs aligning with scientific evidence and favourable attitudes toward vaccination are associated with a greater intention to recommend and administer vaccines.²⁷ While most health care providers are generally strong supporters of vaccinations, research suggests that vaccine-hesitant attitudes and beliefs may exist in some, affecting their personal vaccine uptake and their likelihood to recommend vaccinations to their patients.^27-30

Proven to increase vaccination rates, pharmacists’ recommendation, education and advocacy on the influenza vaccine are valuable tools in promoting positive vaccine outcomes.^31,32 Their standing within the community as trusted sources of health information, coupled with an opportunity for frequent patient contact by means of easy accessibility and convenient hours of service of community pharmacies, makes pharmacists well positioned to address influenza VH.³³ Pharmacists have fast become an integral part of the immunization workforce, with community pharmacies being the choice destination for influenza vaccine administration in Canada,³⁴ yet the experience of influenza VH in this setting remains unexplored. The current study aims to help bridge this gap by exploring community pharmacists’ personal knowledge and practices related to influenza vaccination and their experiences with influenza VH in practice.

Methods

Study design and population

A cross-sectional, anonymous online survey was administered in English to community pharmacists practising in Ontario, Canada. The survey was distributed by e-mail to pharmacists listed in the Ontario College of Pharmacists membership database who previously provided consent to be contacted for research purposes. Approval for the study was obtained through the Office of Research Ethics, University of Waterloo (ORE#21648).

Survey development and distribution

The survey was designed using a knowledge, attitudes and practices (KAP) approach, which describes the behaviour of an individual in a given context as a linear function of their underpinning knowledge and attitude.³⁵ The KAP framework is widely used in health research to elicit context-specific dynamics describing, identifying and exploring barriers to optimal behaviour in a health care setting.^36-38 The survey questionnaire was built and refined through an iterative process, using existing literature, clinical expertise of the research team and discussions with collaborating immunization researchers from other institutions across Canada.

The survey consisted of 38 questions exploring 5 domains relating to the pharmacists’ (1) professional characteristics; (2) personal attitudes and behaviour toward influenza immunization; (3) self-reported knowledge of influenza, its vaccine and other vaccination-related issues; (4) attitudes and behaviour with regard to influenza vaccinations at the community pharmacy; and (5) experiences with seasonal influenza VH at the community pharmacy (see Appendix 1, available in the online version of the article, for survey instrument). Likert questions followed a 1 to 5 scale, with 1 representing a negative/disagreement score and 5 representing a positive/agreement score.

The face validity of content was assessed by 8 registered pharmacists, 6 immunization researchers and 4 pharmacy practice researchers. Survey flow, functionality and language were refined through a pilot in 10 individuals who were not part of the research team. The survey was distributed using the online survey platform Qualtrics (Qualtrics Labs, Inc., 2016, Provo, UT, USA). The initial request for participation was followed by reminder e-mails to nonresponders at weeks 2, 3 and 4. No incentives were provided for participation in the study.

Survey analysis

Descriptive analysis of the survey data was performed using IBM SPSS, version 22.0 (IBM Corp., 2015, Armonk, NY, USA). Free-text comments were assessed qualitatively and coded into existing quantitative variables as appropriate or used to identify new themes by G.R.P. and cross-checked by R.V. to improve accuracy. To aid interpretation, responses to 5-point Likert-type questions were categorized as positive (scores of 4 or 5), neutral (score of 3) or negative (score of 1 or 2).

The internal consistency of multi-item Likert questions was measured by calculating the Cronbach’s alpha coefficient. A value of ≥0.9 was considered excellent, and a value between 0.9 and 0.8 was considered good.³⁹

Results

Sample demographics

A total of 5530 electronic survey invitations were sent, and 885 responses were collected (response rate 16%). Most respondents were authorized to administer injections (n = 753, 86.6%), held a baccalaureate degree in pharmacy (n = 765, 87%) and practised in pharmacies that offered influenza immunizations (n = 739, 85%). About half the respondents were female (n = 452, 51.5%) and practised in urban locations (n = 467, 53.9%). A third of the respondents worked as full-time staff pharmacists (n = 289, 33%), and a quarter worked in independent pharmacies (n = 219, 25%). On average, 217 prescriptions were dispensed daily at the respondent practice sites, and respondents authorized to administer injections reported administering an average of 158 influenza vaccines in the preceding influenza season. Complete demographic details are presented in Table 1.

Table 1.

Participant demographics

Characteristic	Number (%)
Gender (n = 878)
Male	425 (48.4)
Female	452 (51.5)
Other	1 (0.1)
Education* (n = 879)
BSc Pharmacy	765 (87)
Postbaccalaureate PharmD	19 (2.2)
Entry-to-practice PharmD	26 (3)
Master’s in pharmacy	71 (8.1)
PhD in pharmacy	19 (2.2)
Residency	21 (2.4)
Fellowship	2 (0.2)
Other(s)	71 (8.1)
Experience (n = 877)
Less than 5 years	169 (19.3)
5-10 years	164 (18.7)
11-15 years	94 (10.7)
16-20 years	74 (8.4)
More than 20 years	376 (42.9)
Authorized to administer injections (n = 870)
Yes	753 (86.6)
No	117 (13.4)
Position at primary place of practice* (n = 875)
Pharmacist, manager	244 (27.9)
Staff pharmacist, full-time	289 (33)
Staff pharmacist, part-time	158 (18.1)
Pharmacy owner	178 (20.3)
Relief pharmacist	83 (9.5)
Other(s)	8 (0.9)
Type of pharmacy (n = 876)
Chain (more than 6 stores with 1 owner)	175 (20)
Independent (1 owner up to 6 stores)	219 (25)
Franchise	176 (20.1)
Banner	144 (16.4)
Mass merchandiser/food store	138 (15.8)
Other	24 (2.7)
Location
Rural (population <1000 individuals)	25 (2.9)
Small population centre (1000 to 29,999 individuals)	205 (23.7)
Medium population centre (30,000 to 99,000 individuals)	169 (19.5)
Large urban population centre (>100,000 individuals)	467 (53.9)
Involvement with influenza immunization (n = 869)
Yes, pharmacist(s) administer the vaccine	731 (84.1)
Yes, nurses/nursing agencies contracted by the pharmacy administer the vaccine	8 (0.9)
No current involvement, but planning to participate in the future	52 (6)
No current involvement and no immediate plans for involvement in the future	78 (9)
	Mean (SD)
Average prescription volume per day (n = 847)	217 (147.3)
Influenza vaccines administered in the preceding season (2015-2016) (n = 738)	158 (100)

Pharmacists’ personal attitudes and behaviour related to influenza immunization

Two-thirds (n = 568, 65.7%) of survey respondents reported receiving the influenza vaccine in the preceding season. The most frequent reasons for receiving the influenza vaccine were preventing disease transmission to patients (n = 476, 70.4%) or to family and friends (n = 460, 68%), contributing to herd immunity (n = 434, 64.2%) and to ensure personal protection (n = 434, 64.2%). The most frequent reasons reported by respondents who did not receive the influenza vaccine in any of the preceding 3 seasons (n = 189, 21.4%) were skepticism about the effectiveness of the vaccine (n = 42, 22.2%) and absence of prior personal experience with seasonal influenza illness (n = 38, 20.1%).

Pharmacists’ self-reported knowledge

Fifteen items exploring the respondents’ self-reported knowledge on various aspects of influenza vaccination, including influenza, its vaccine and administration and other vaccination-related issues demonstrated consistently high scores (Table 2). The knowledge areas most frequently rated high (scores of 4 or 5 on a 5-point Likert scale) across all respondents were adverse reactions to the influenza vaccine (n = 679, 81.2%) and its dosing and indications (n = 677, 81%). Among pharmacists who were authorized to administer injections, knowledge of influenza vaccine administration technique (n = 655, 91.4%) was most frequently rated to be high. Knowledge areas least frequently rated high were annual influenza vaccine updates, such as updates on circulating strains and vaccine match (n = 409, 49%), composition of the influenza vaccine (n = 424, 50.8%) and vaccine communication frameworks (n = 438, 52.6%).

Table 2.

Pharmacists’ self-reported knowledge

		Frequency of responses*
Knowledge item	Median	Low (n [%])	Average (n [%])	High (n [%])
Influenza disease
Pathophysiology	4	49 (5.8)	300 (35.8)	488 (58.3)
Pharmacotherapy	4	23 (2.8)	210 (25.1)	603 (72.1)
Influenza vaccine
Dosing and indications	4	43 (5.1)	116 (13.9)	677 (81)
Formulations	4	86 (10.3)	213 (25.5)	537 (64.2)
Composition	4	119 (14.3)	292 (35)	424 (50.8)
Interactions	4	55 (6.6)	221 (26.5)	558 (66.9)
Pharmacology	4	53 (6.4)	222 (26.6)	559 (67)
Adverse reactions	4	20 (2.4)	137 (16.4)	679 (81.2)
Contraindications	4	29 (3.5)	147 (17.7)	656 (78.8)
Influenza vaccine administration†
Administration technique	4	8 (1.1)	54 (7.5)	655 (91.4)
Management of anaphylaxis	4	39 (4.7)	168 (20.3)	621 (75)
Other vaccination-related issues
Vaccines and autism	4	112 (13.4)	210 (25.2)	511 (61.3)
Vaccine hesitancy	4	66 (7.9)	264 (31.7)	502 (60.3)
Annual influenza vaccine updates	3	94 (11.3)	331 (39.7)	409 (49)
Vaccine communication frameworks	4	94 (11.3)	300 (36.1)	438 (52.6)

^*Row totals may not add to 885 because of nonresponse to any of these items.

^†These questions were provided only to pharmacists authorized to administer injections. Cronbach’s alpha (15 items) = 0.919.

Attitudes and behaviour of community pharmacists

Most respondents (n = 494, 59.5%) reported recommending the influenza vaccine to at least half of all patients accessing their pharmacy. Two-thirds (n = 800, 66.2%) of all vaccine recommendations were described as being made specifically to patients at high risk of influenza and its complications. Respondents authorized to administer injections estimated that at least 2 of 3 (n = 465, 66.3%) individuals getting the influenza vaccine at their pharmacy made an active request for it. Most (n = 507, 61.7%) believed that at least 7 of 10 individuals receiving the vaccine had made their decision prior to discussion with a health care provider. Interestingly, almost half the respondents (n = 371, 44.8%) did not consider their ability to influence patients’ vaccination decisions to be high.

Influenza VH at the community pharmacy

Survey respondents most frequently described individuals expressing hesitancy as those who did not trust the vaccine and immunization services (n = 576, 69.1%) or as those who received the vaccine without being completely convinced of its benefits (n = 399, 47.9%; Table 3). Respondents reported that the most frequent reasons for delay or refusal of influenza vaccination at the pharmacy were related to misinformation (n = 485, 60.5%) and poor patient perception of influenza vaccine’s risks and benefits (n = 467, 58.4%). Reasons reported least frequently included concerns about the community pharmacy as a vaccination setting (n = 26, 3.3%) and community pharmacist as the immunizer (n = 26, 3.3%; Figure 1).

Table 3.

Pharmacists’ description of individuals expressing VH (n = 833)

Someone is vaccine hesitant when*:	n	%
They do not trust the vaccine and immunization services	576	69.1
They are accepting of a vaccine while not being entirely convinced of its benefits	399	47.9
They’ve had negative experiences with immunizations in the past	376	45.1
They refuse a vaccine	373	44.8
They’ve had an uncomfortable and/or inconvenient vaccination experience	338	40.6
They believe they have a low risk of contracting a vaccine-preventable disease	334	40.1
They delay receiving the vaccine	331	39.7
They cannot get the vaccine due to an insufficient vaccine supply and/or lack of trained personnel to administer the vaccine	8	1

^*Respondents were asked to select all applicable options.

Figure 1.

Patients’ reported reasons for delay or refusal of influenza vaccination

Cronbach’s alpha (19 items) = 0.872.

Pharmacists’ experiences with and attitudes toward influenza VH

On average, respondents reported encountering 16 (SD 28.2) individuals hesitant to receive the influenza vaccine each week in the preceding influenza season. Most respondents considered engagement with these individuals on the importance of vaccination as either “very” or “extremely” important (n = 643, 78.3%). However, 84.2% (n = 507) of pharmacists authorized to administer injections estimated that upon engaging, fewer than half of the individuals expressing hesitancy ultimately received the vaccine at their pharmacy.

Self-reported confidence in addressing patient queries on issues of influenza vaccine safety (n = 619, 82.3%) and efficacy (n = 619, 82.3%) was generally high, with the lowest levels of confidence reported for addressing questions involving conspiracy theories (n = 338, 47.7%) and hidden ties to pharmaceutical organizations (n = 406, 54.2%). Most respondents also reported their ability to identify hesitant individuals (n = 745, 65.5%), determine the cause of their hesitancy (n = 741, 60.1%), engage in conversation (n = 741, 59%) and respond to their concerns (n = 740, 64.7%) as high.

Addressing influenza VH at the community pharmacy

Among 13 approaches identified in the literature to address influenza VH, respondents reported that the most effective strategies included the provision of information on safety (n = 388, 54.4%) and efficacy (n = 353, 54.4%) and educating patients on the risks of nonvaccination and the benefits of vaccination (n = 373, 54.4%). Specialized vaccine communication tools (such as the ASK tool⁴⁰ and recommendations from the National Advisory Committee on Immunization guidelines³) were rated the least effective (n = 367, 25.3%; Figure 2).

Figure 2.

Effectiveness of current practices in addressing VH

Cronbach’s alpha (13 items) = 0.903.

Barriers to optimal immunization service delivery

Respondents rated regular workflow (n = 419, 65.6%) and insufficient time (n = 406, 65.3%) as the most limiting barriers to optimal immunization service delivery. In contrast, items such as the quality of immunization training received (n = 56, 8.8%), privacy (n = 100, 11.3%) and space (n = 115, 17.9%) were infrequently reported to be barriers (Figure 3).

Figure 3.

Barriers to optimal immunization service delivery reported by respondents authorized to administer injections (n = 753)

Cronbach’s alpha (8 items) = 0.780.

Discussion

Our study is the first to investigate pharmacists’ experiences with influenza VH in the community pharmacy setting using a large provincial sample. Our findings indicate that influenza VH is frequently encountered in community pharmacy practice. Pharmacists’ self-reported scientific knowledge on influenza and its vaccine was high; however, the perceived effectiveness of communication tools to structure discussions with individuals expressing hesitancy appeared to be low. Further, pharmacists’ engagement in discussions with those expressing hesitancy appeared to be limited in nature and compounded by barriers relating to the available time and regular workload in community practice.

Personal influenza immunization rates reported among pharmacists in our sample (65.7%) were higher than those reported in other Canadian health professionals such as nurses (57%), dentists (44%) and specialist physicians (59%) but were lower than that of general practitioners (72%).⁴¹ The reasons pharmacists cited to be vaccinated, such as prevention of disease transmission, to patients, family and friends were consistent with those expressed by other health care providers.²¹ Despite the relatively high vaccination rates, 1 in 5 responding pharmacists had not received the influenza vaccine in any of the 3 previous influenza seasons, suggesting the presence of influenza VH in some pharmacists. Reasons for not receiving the vaccine, assessed through the 5C scale of psychological antecedents of vaccination behaviour (confidence, complacency, constraints, calculation, collective responsibility),⁴² revealed confidence (skepticism on vaccine effectiveness) and complacency (not suffering from seasonal influenza before) as the prime domains shaping behaviour in vaccine-hesitant pharmacists. Interventions aiming to improve personal influenza vaccine uptake among community pharmacists should therefore focus on these domains.

Self-reported measures have been previously used to gauge knowledge and competence of health care providers in other settings.^43-47 Our results illustrate pharmacists’ self-reported knowledge of influenza disease and its vaccine and their confidence and ability to identify, assess and address patient vaccine concerns to be generally high. These results align with previous Canadian literature reporting high perceived preparedness among general practitioners and nurses when dealing with hesitant individuals.²¹ Interestingly, communication frameworks exclusively designed to assist health professionals in steering vaccine conversations were ranked as being the least effective strategy in addressing influenza VH. However, it is unclear whether this ranking actually reflects low perceived effectiveness or is rather a reflection of the respondents’ unfamiliarity with such tools. Future programs should focus on improving awareness of vaccine communication tools among pharmacists and assessing their utility in the community pharmacy setting.

With accessible locations and convenient hours, community pharmacies provide frequent opportunities for pharmacist-patient interaction.³³ However, our results suggest that most vaccinations administered at the pharmacy are done upon patient request, suggesting that provider-patient engagement on influenza vaccination at the pharmacy is primarily passive and patient driven. The phenomenon of VH recognizes vaccination attitudes and beliefs across a dynamic continuum of possibilities.¹¹ However, given the lower likelihood that individuals who are ambiguous or complacent about influenza vaccination will initiate vaccine conversations, this approach to influenza vaccine conversations likely results in missed opportunities to identify and positively nudge vaccine-hesitant patients along this continuum.

The passive approach to vaccine conversations is also reflected through a low reported frequency of encounters with those expressing influenza VH, relative to (1) a low population uptake of influenza vaccine,³⁴ (2) literature describing those refusing all vaccines without doubt as only a small fraction of the overall population,^11,48 and (3) the high prescription volume at respondents’ practice sites. While the overarching stressors of limited resources such as inadequate time and insufficient staffing contribute to pharmacists’ passive approach to patient engagement on vaccinations, further research is imperative to understand other determinants of this behaviour and strategies to best address it.

Limitations

The use of convenience sampling and a response rate of 16% may result in selection bias. As such, the results described in our study may not be representative of all Ontario pharmacists and, by extension, Canadian pharmacists. Inherent to the nature of voluntary participation surveys, nonresponse bias cannot be evaluated. The use of subjective, self-reported measures may also result in recall bias and information bias. Finally, the use of a primarily quantitative survey and analysis does not allow us to further explore contextual factors and personal beliefs affecting the responses observed. Future research will use the results of this survey as a framework to further explore pharmacists’ experiences with VH in practice through qualitative methods.

Conclusion

Pharmacists’ self-reported knowledge, confidence and ability to address influenza VH at the community pharmacy was high. Facilitating the optimal practice scope for pharmacists and capitalizing on the convenience and accessibility offered through the community pharmacy setting presents a promising means to address influenza VH. In addition to addressing environmental barriers to pharmacist-led initiation of vaccine conversations, future programs to assist pharmacists must explore strategies that encourage active pharmacist-patient engagement on influenza immunizations. ■