Pharmacists’ readiness and willingness to vaccinate the public in United Arab Emirates community pharmacies: A cross-sectional study

Introduction

Pharmacists are amongst the most accessible and trusted healthcare professionals in the community.^1–3 Community pharmacists are highly trained but possibly underutilised public health professionals.⁴ Pharmacists in the UAE do mostly dispensing of medications as their main function. Providing additional services like vaccination, pharmacist-led clinics, or other clinical services are not common in the UAE community pharmacy sector as per our knowledge.

The coronavirus 2019 (COVID-19) pandemic exposed challenges in the provision of some healthcare services, including vaccination^5,6; yet also highlighted the ability of community pharmacists to remain accessible to the public and provide essential services despite unprecedented demand.^2,5 Allowing pharmacy-based vaccination is a healthcare strategy that many countries followed to enhance access and thus increase vaccination uptake in the community.⁷

Community pharmacies are one of the first points of contact for ambulatory patients and members of the public with relatively mild health concerns,⁸ especially as they are conveniently located and offer extended working hours.^5,9 By virtue of their accessibility and reach in local communities, community pharmacists are ideally positioned to promote and provide vaccination services.¹⁰ Although vaccine administration is not yet a service provided by the majority of community pharmacists in the United Arab Emirates (UAE), studies from Jordan and Saudi Arabia suggest that community pharmacists in the region have shown great willingness to deliver pharmacy-based vaccination services.^9,11,12

As many international studies and regional studies showed willingness of pharmacists to deliver pharmacy-based vaccination services, we decided to conduct a similar study in the UAE. This maybe an initial study in the country as similar studies were not conducted in the UAE. As the vaccination service by pharmacist started in a few pharmacies in the UAE, it was essential to study readiness and willingness of pharmacists in a national level to inform different stakeholders in the country and abroad on this proven initiate as shown in the studies above.

Considering the international and regional shifts towards pharmacy-based vaccinations, the objectives of this study were: i) to assess the readiness of community pharmacies in the UAE to start pharmacy-based vaccination services; ii) analyse if community pharmacists are willing to undertake relevant training; and iii) explore factors influencing pharmacists’ initiation of community-based vaccination.

Methods

Results

The calculated sample size was met in 42 days with 374 quality-checked responses being analysed for the results from a total of 575 pharmacists that responded (i.e., 65% response rate).¹³ Of the 201 respondents not included in the analysis, 186 gave consent but did not finish the survey (32%) while 15 did not agree to the consent form (3%).

Two respondents who completed the survey entered erroneous ages in the demographics questions category. These data were excluded when calculating the mean age, as they were considered to be data entry errors as participants were asked to type in their age. The two respondents’ answers to all other questions were included in the analysis.

The demographic characteristics of the 374 community pharmacists who completed the survey are summarised in Table 1. More than half of the respondents were female. All Emirates were represented in the survey respondents, with almost half (45.4%) being from Abu Dhabi. Over three-quarters of the respondents (78.3%) worked at or were owners of a chain community pharmacy. The majority of respondents (92.8%) stated that they worked in an urban setting, which is representative of the UAE population (2022 population statistics¹⁵). A majority of the participants were BPharm qualified while others held higher PharmD or MPharm qualifications.

More than half of the respondents (55%) had at least six years’ experience working as a pharmacist. Nearly all respondents (94.4%) were employees rather than owners of a pharmacy and more than half (51.6%) either worked in or owned a pharmacy that employed ≥5 people. In terms of customer facing time, almost two-thirds (63.4%) of the respondents reported that they interacted with at least 20 customers per day.

Most of the respondents (85.6%) reported encountering customers who had vaccine-related queries on a daily basis, and 11.2% of respondents provided advice, answers to questions, and/or education on vaccines and vaccination for more than half of their customers. Slightly more than half of respondents (51.8%) reported spending more than five minutes per customer providing an explanation for a vaccine-related question. Respondents answered customer vaccine-related questions about the COVID-19 and influenza vaccine most often and about pneumococci and meningococci vaccines least often.

If local regulations allowed pharmacy-based vaccinations, 68.4% of respondents were willing to administer vaccines. Nearly two-thirds (64.2%) of respondents agreed or strongly agreed that pharmacists should be able to vaccinate the public. In terms of enabling pharmacists to be able to administer vaccines, 82.1% of respondents agreed or strongly agreed that pharmacists should receive appropriate training.

Respondents considered health regulatory authority support (95.2%) and a pharmacy’s ability to accommodate vaccine administration (93.0%) as being highly influential in the decision to administer vaccines at the pharmacy. More than half of respondents (68.4%) agreed or strongly agreed that pharmacists should be remunerated for administering vaccines.

Fewer than one in 10 pharmacists (7.8%) responded that they would not be ready to perform vaccinations within a 6- to 12-month timeframe compared with 42.0% reporting that they would be fully ready (Figure 1).

Figure 1. Readiness of community pharmacists in the UAE to start vaccination service in a 6-month framework.

Regarding willingness to complete training essential to be able to administer vaccines at their pharmacy, the majority of respondents responded ‘Yes’ to each of first aid training, cardiopulmonary resuscitation (CPR) training, and certification to administer vaccines. Overall, 81.8% responded ‘Yes’ to completing all three types of training and 4.0% people responded ‘No’ to all three (Figure 2).

Figure 2. Willingness to undertake essential training.

In terms of the association of readiness with willingness to undertake training, Fisher's Exact Test showed significant readiness by those who were willing to obtain all three essential training regarding vaccination (Table 2).

On further evaluation, the results of the logistic regression model demonstrated that pharmacists with high readiness (≥5.5 of the following: having space for vaccination, refrigerator specific for vaccines, temperature monitor, portable refrigerator in case of power failure, anaphylaxis response kit, anaphylaxis management literature, safety box, medical waste bin, materials for hand sanitisation and surface cleaning, means to store patients’ records, and access to nearby hospital if a patient needs to be referred) were significantly more willing to undergo all essential training (i.e., first aid, CPR, certification to administer vaccines) than were pharmacists with poor readiness (OR 2.647; 95% CI: 1.518–4.615; p=0.001).

Readiness and agreement of pharmacists that pharmacy-based vaccination would be safe (Table 3) was significantly associated with pharmacists at high readiness compared to those at poor readiness (p=0.027).

Discussion

The survey shows that the UAE community pharmacy workforce is well-qualified and has a high degree of relevant customer-facing experience. From the survey responses, many of the community pharmacies in the UAE are adequately staffed and equipped to deliver vaccination services in addition to providing their traditional services. The readiness and willingness expressed by the surveyed pharmacists to vaccinate the public was promising. Collectively, these findings indicate the preparedness of community pharmacies in the UAE to provide vaccination services.

Nearly 70% of respondents supporting payment to community pharmacists for vaccination services was lower than expected. It is possible that respondents misinterpreted the question, e.g., payment to the pharmacy versus to pharmacist directly and/or due to cultural norms pharmacists may be reluctant, as healthcare professionals, to demand payment for providing vaccinations. Additionally, respondents may have believed that vaccine administration was a complementary service to selling the vaccine or that they might not be reimbursed by payers for providing the service. Low or no remuneration for additional pharmacy services could be a barrier for Such services.

The majority of the study population showing readiness to initiate pharmacy-based vaccination services in the UAE is consistent with similar studies conducted in the region.^11,12 In the cross-sectional survey that assessed Jordanian community pharmacists’ readiness and willingness to deliver vaccination services, 64.5% of qualified pharmacists were willing to vaccinate patients and 65.0% of unqualified participants were willing to receive the required training and qualifications to be able to vaccinate.¹¹ Another cross-sectional online survey of Jordanian community pharmacists found that that 86.6% of respondents had a high level of willingness to administer vaccines in the community pharmacy setting.¹²

The proportion of pharmacists expressing willingness to provide vaccines services in our study and the two Jordanian studies is higher than the proportion of community pharmacists (55%) in a Saudi Arabia study who expressed willingness to vaccinate.⁹ The difference between the studies could be explained by the Saudi Arabia survey being conducted earlier in the pandemic, when pharmacists were less certain about what was required to support public health and when they may have been more fearful of contracting COVID-19 themselves and its consequences.¹²

Relevant training is required to equip pharmacists with the skill, knowledge, and confidence to deliver vaccination services.^16,17 A suitably outfitted pharmacy is also required to ensure appropriate and safe delivery of vaccination services. Necessary items include a purpose-built vaccine refrigerator, dedicated vaccination service area, general equipment necessary for vaccine administration, and an anaphylaxis response kit.

Emphasizing the importance of training, 82.5% of untrained community pharmacists in the Jordanian survey believed that pharmacists should be trained to deliver vaccination services and 80.8% of those working in unsuitably equipped pharmacies believed that community pharmacists should be sufficiently equipped to deliver vaccinations.¹¹ In reality, only 13.4% of the Jordanian pharmacists reported receiving all required training and only 8.2% reported that they worked in adequately equipped pharmacies. In our study, almost all respondents were ready to undertake specific types of training (i.e., first aid, CPR, certification) and pharmacists with high readiness characteristics were more willing to undergo all essential training to start a vaccination service in their pharmacies than were pharmacists with poor readiness.

In the Saudi Arabia survey, 67.4% of community pharmacists stated that concern about patient safety was a barrier to providing vaccination services,⁹ and in one of the two Jordanian surveys, 40.3% of community pharmacists strongly agreed that concern about patient safety was a barrier to providing vaccination services.¹² Safety concerns and vaccine hesitency are barriers that need to be studied further.

In addition to receiving the relevant training, pharmacist-vaccinators need to operate in settings that are equipped to ensure the safety of patients. In one of the two Jordanian surveys, only a quarter (26.6%) of pharmacist-vaccinators reported having anaphylaxis response kits in their pharmacies and only one-fifth (20.3%) had access to anaphylaxis management literature.¹¹

In our study, pharmacists with high readiness characteristics agreed that pharmacy-based vaccinations would be safe. Moreover, the association between high pharmacist readiness and agreement on the safety of pharmacy-based vaccination was statistically significant when compared with poor readiness. In July 2022, the Department of Health (DOH) announced that community pharmacies in Abu Dhabi that have received authorisation on successful completion of a DOH-certified training course would be able to provide COVID-19 vaccination free of charge to eligible adults.^18,19

Evidence of the benefits of pharmacist-administered vaccination is growing internationally and in the region. Substantial evidence of the benefits of pharmacists as vaccinators is provided by a meta-analysis of 36 studies that assessed the impact of pharmacists as educators, facilitators, or administrators of vaccines on immunization rates.²⁰ All studies found an increase in vaccine coverage when pharmacists were involved compared with vaccine services provision by traditional providers. Expanding the role of the pharmacists also has the potential to reduce pressure on other healthcare providers.²¹

It is against this background that a growing number of middle- and high-income countries have expanded the role of pharmacists to incorporate vaccination services, including the US, Australia, New Zealand, and European countries.^8,22 Pharmacist-administered vaccination has also been reported in low-income countries.²³

Vaccination is one of the most cost-effective healthcare interventions for reducing the burden of vaccine-preventable diseases.^24,25 Economic analyses conducted in US have demonstrated a lower mean direct cost per adult vaccination in pharmacies compared with vaccination in physician offices from the healthcare plan and patient perspectives (for zoster, pneumococcal, and influenza vaccination),²⁶ as well as from the societal perspective (for influenza vaccination).²⁷ Using pharmacies to deliver routine influenza vaccination to adults is likely to be either cost saving or relatively cost effective from a societal perspective, depending on the target population.²⁷ Moreover, administering influenza vaccines via pharmacies in addition to traditional locations during an influenza epidemic in the US was found to increase vaccination coverage, avoid up to 23.7 million influenza cases, and yield cost savings up to $US2.8 billion to third-party payers and $US99.8 billion to society.²⁸

Conclusions

The majority of the study population demonstrated readiness and willingness to initiate pharmacy-based vaccination in the UAE. Pharmacists who agreed that pharmacy-based vaccinations would be safe was significantly associated with those who also showed readiness for starting the vaccination service. Importantly, the willingness to undertake essential training was also found among pharmacists who showed readiness. In this case, we recommend dissemination of pharmacy-based vaccination services throughout UAE.