Community pharmacy workforce willingness, readiness, and infrastructural capacity to deliver vaccination services: a cross-sectional survey in Nigeria

Abstract

Background

There is a growing need for community pharmacists to support universal health coverage by providing vaccination services to address low coverage, as they are among the most accessible healthcare professionals. In some Nigerian states, community pharmacists were trained in vaccination, but there are concerns about their capacity to enroll as vaccination service providers. This study evaluated the community pharmacy workforce willingness, readiness, and infrastructural capacity to deliver vaccination services in Nigeria.

Methods

We conducted a descriptive cross-sectional study using a self-administered structured questionnaire among community pharmacists in Nigeria using a Google Form and administered through WhatsApp platforms. Descriptive statistics were performed on the collected data using SPSS statistical software, version 21.

Results

Of the 414 community pharmacists sampled, 395 (response rate = 95.4%) were retrieved and included in the final analysis. Although most community pharmacists did not currently practice vaccine administration in their pharmacies (n = 295, 74.9%), most were willing to start administering vaccines (n = 359, 91.3%), participate in routine and supplemental immunization services (n = 373, 95.4%), receive training related to vaccination (n = 374, 95.2%), and encourage patients to get vaccinated in their pharmacies (n = 367, 93.6%). Tetanus vaccine was the most common (n = 158, 40%) among the vaccines administered by the respondents. Infrastructure was inadequate in many critical areas: vaccine-specific equipment (n = 263, 67.8%), safety boxes (n = 216, 55.7%), medical waste bins (n = 178, 45.8%), portable vaccine refrigerators in case of power failures (n = 218, 56.1%), anaphylaxis response kit (n = 340, 87.4%), and anaphylaxis management guidance (n = 346, 88.9%). Barriers to the pharmacists’ willingness to deliver vaccination services were inadequate funds to procure appropriate storage equipment (n = 269, 70.0%), inadequate training (n = 265, 69.1%), conflicts with other professionals (64.4%), concerns about patient safety (n = 185, 47.7%), and handling vaccines and disposal of sharps (n = 182, 47.4%).

Conclusions

Community pharmacists have indicated their willingness to embrace the advanced role of vaccine administration. The government and other healthcare stakeholders should address the infrastructural gaps and other barriers highlighted in the study to help improve vaccine access and availability.

Introduction

Nigeria is grappling with another vaccine-preventable disease outbreak. In June 2024, the World Health Organisation (WHO) reported 1094 new cases of cholera outbreak posing a threat to Nigeria’s healthcare system [1]. Globally, vaccine development has undeniably improved health outcomes [2]. The World Health Organisation estimates that vaccines prevent 3.5 million to 5 million deaths annually [3]. Despite this, immunization coverage in Nigeria remains poor [4, 5], with only 23% of children fully immunized and more than 2300 childhood deaths occurring daily from vaccine-preventable diseases [4]. To mitigate the danger of infectious diseases and enhance vaccination acceptance, numerous countries have broadened the responsibilities of community pharmacists to include administering vaccines [6]. In addition, the International Pharmaceutical Federation (FIP) published a comprehensive worldwide report on the influence of pharmacists on immunization services. The report revealed that out of the 45 countries examined, 13 countries were authorized to administer vaccines in community settings. These countries include Argentina, Australia, Canada, Costa Rica, Denmark, Ireland, New Zealand, the Philippines, Portugal, South Africa, Switzerland, the UK, and the USA [7].

In recent years, there has been growing recognition of community pharmacists’ role in improving vaccination coverage [8,9,10]. As one of the most accessible and frequently consulted healthcare providers, community pharmacists are well-positioned to ensure increased vaccination uptake in communities [10]. The underutilization of globally available vaccines has created an opportunity for pharmacists to be instrumental in improving immunization rates and advancing public health. Community pharmacy-based vaccination services have already increased the number of immunization providers and the number of sites where patients can receive immunizations. The U.S. statistics by the Center for Disease Control (CDC) show that adults who received influenza vaccines in 2016 increased in 2017 from 23 to 28% [11]. However, community pharmacists’ involvement in vaccine administration in Nigeria remains suboptimal [10, 12]. Therefore, community pharmacists must expand their role beyond medicine provision to the patient and expand access to primary care services. In addition, patients in Nigeria require more value-added services from community pharmacists to meet their various health needs [13]. The question remains: are pharmacists willing and ready to embrace the new role in vaccine uptake?

Some of the barriers to Nigerian pharmacists’ involvement in vaccination delivery services include inadequate policies [14], insufficient training [12], and supply chain problems [15]. Nevertheless, most importantly, pharmacists can only practice vaccination/immunization in a suitably equipped community pharmacy with the necessary vaccination-specific infrastructure [16]. In response, several studies have assessed the preparedness of community pharmacies for vaccination services in other countries [6, 17], but similar nationwide research has not been conducted in Nigeria. This study therefore sought to fill this literature gap by assessing community pharmacists’ readiness and preparedness for vaccination delivery services in Nigeria. It assessed community pharmacists’ current vaccination practices, willingness to act as pharmacist-vaccinators, and their pharmacies’ suitability for vaccination/immunization services. It also identified barriers to community pharmacists’ involvement in vaccination and recommended how best to promote the practice among pharmacists in Nigeria.

Methods

Study design

This study is an internet-based cross-sectional survey, conducted anonymously among community pharmacists in Nigeria. We deployed a snowball sampling procedure in which the chairmen of the Association of Community Pharmacists of Nigeria in the 36 states and Nigeria’s Federal Capital Territory (FCT) were requested to complete the form and forward it to their respective zonal coordinators to complete, after which the zonal coordinators forwarded it to all their members to complete. The state officers of the Pharmacy Council of Nigeria were also recruited to share the questionnaire with the registered community pharmacists. A Google Form was used to distribute the semi-structured questionnaire through the various WhatsApp platforms that contain WhatsApp telephone numbers of the registered community pharmacists in the states and the FCT.

Study population

The study population comprised community pharmacists (CPs) practising in Nigeria. As of December 31, 2022, there were 5,538 licensed community pharmacists in Nigeria [18].

Sample size

A sample size calculation was conducted using Taro Yamane’s method [19]. The calculation was based on the total number of registered community pharmacists in Nigeria as of December 2022, which was 5,538 (n = 5,538).

The formula used was $\mathrm{n}=\mathrm{N}/(1+\mathrm{N}(\mathrm{e})^{\wedge}2)$.

N denotes the target population.

The sample size (n) was calculated from this number as 373, with an expected 0.05 degree of error. An acceptable level of statistical analysis was achieved by using a margin of error of 5% and a confidence level of 95%.

Exclusion criteria

The study excluded pharmacists practicing in other areas outside the community pharmacy setting, retired CPs, Nigeran pharmacists who practice abroad, and those who were not actively practicing. Pharmacists who could not be contacted because their contact information had changed and those who declined to participate in the study were also not included.

Instrument for data collection

The questionnaire was designed based on a comprehensive review of literature on community pharmacy, vaccination delivery services, the health workforce, and infrastructural capacity. The draft questionnaire was reviewed by eight pharmacists with at least a PhD in pharmacy or public health, after which it was pretested for clarity and reliability among 20 community pharmacists who did not participate in the data collection. Revisions were made before the commencement of data collection. The reliability of the questionnaire was assessed using Cronbach’s alpha.

The survey’s introduction page provided a concise overview of the background, the survey’s purpose, directions for completing the questionnaire, and a statement of informed consent.

The questionnaire was divided into six domains. The first domain consisted of 8-item questions about demographics such as age, work experience, highest level of education, religion, type of pharmacy, position, pharmacy location, and gender. The second domain contained questions to assess community pharmacists’ willingness to provide vaccination delivery services. Multiple-choice answers were provided for the queries, and CPs had to select their responses to ‘yes,’ ‘no,’ or ‘not sure’ questions. The third domain contained questions to assess the type of vaccination services pharmacists are willing to provide, with seven questions requiring ‘yes,’ ‘no,’ or ‘not sure’ answers. The fourth domain evaluated the technical capacity to deliver vaccination services, including training.

In contrast, the fifth domain accessed the infrastructural capacity to provide vaccination services with ‘yes,’ ‘no,’ or ‘I don’t know’ questions. The sixth domain addresses the type of vaccines the community pharmacists were administering. In contrast, the seventh domain addressed the barriers affecting community pharmacists’ willingness to provide immunization services using a 5-point Likert scale, which indicates their degree of agreement or disagreement with statements regarding their barriers, with 1 = strongly disagree, 2 = Disagree, 0 = Neutral, 3 = Agree, and 4 = Strongly agree.

Data collection

A Google form was distributed to community pharmacists via WhatsApp platforms to gather responses from an anonymous online questionnaire. The questionnaire was shared on all CPs’ WhatsApp chatrooms in the 36 states plus the FCT of Nigeria through their respective ACPN chairmen and state officers of the Pharmacy Council of Nigeria. We also broadcasted WhatsApp messages through the phones of all team members, with requests for the recipients to forward the survey link to all CPs in their contact list. We paid more attention to states with proportionally low response rates, to elicit more responses and generate a representative sample. Periodic reminders continued as long as the data collection period lasted.

Ethical considerations

We adhered to the scientific requirements and research protocols outlined in the Declaration of Helsinki for recruiting human participants for this study. Ethical approval was received from the Research Ethical Review Committee of the College of Medicine, University of Lagos, with the reference number CMUL/HREC/05/24/1457. Before each survey, informed consent was sought from every participant, and this consent was documented with a Yes/No question.

Statistical analysis

Data from the survey were inputted into a specially designed Excel database and then processed by the lead author to remove any errors or inconsistencies. After this, the data was transferred to SPSS version 21. Descriptive statistics were employed to present the respondents’ demographic characteristics and responses to the survey questions. Continuous variables were reported as means and standard deviations (± SD) for variables that followed a normal distribution. The categorical variables were displayed as frequencies and percentages. Inferential statistics were also conducted, more specifically using the chi squared test to establish the relationship between the demographic characteristics of the respondents and their practice of vaccination. The statistical analyses were conducted using SPSS statistical software for Windows version 21 (SPSS Inc., Chicago, USA).

Results

Response rate

Of the 414 community pharmacists that were sampled, 395 responses were retrieved. In total, 395 community pharmacists were included in the final analysis, which resulted in a response rate of 95.4%. This represents 7.1% of all employed community pharmacists (n = 5538) in Nigeria and meets the calculated sample size expectation (373).

Social demographic characteristics

Majority of the participants were above 40 years old (n = 236, 60.8%), male (n = 230, 58.4%), and pharmacist directors (n = 241, 61.3%) with a Bachelor of Pharmacy (B. Pharm) educational qualification (n = 225, 57.1%) and more than ten years of work experience (n = 235, 59.8%). Majority of the respondents practice in urban locations (n = 178, 45.4%), Table 1.

Table 1 Demographic characteristics of participants

State of practice

The highest participation rates were recorded for Lagos (n = 111, 28.1%). Rivers, Delta, and Edo States had the second-highest participation rate (n = 31, 7.8%). States with the lowest participation rate were Bayelsa, Jigawa, and Zamfara (n = 1, 0.3%), Table 2.

Table 2 State of practice

Willingness to vaccinate

Although most community pharmacists did not currently practice vaccine administration in their pharmacies (n = 295, 74.9%), the majority were willing to start administering vaccines (n = 359, 91.3%), receive training related to vaccination (n = 374, 95.2%), and encourage patients to get vaccinated in their pharmacies (n = 367, 93.6%). Most of the community pharmacists also indicated willingness to participate in routine and supplemental immunization services (n = 373, 95.4%), Table 3.

Table 3 The willingness of community pharmacists for vaccination delivery services

Training on vaccination and vaccine management

Most community pharmacists (n = 222, 56.6%) received no training on vaccination delivery services. Among those who received training (n = 170, 43.4%), the training duration was mostly less than three days (n = 94, 52.8%). Among the various types of training required for vaccination delivery, most community pharmacists had received first aid training (n = 219, 56.6%), and most had not received vaccine adverse event handling and documentation training (n = 226, 57.7%). Professional associations (n = 144, 39.6%) took the lead among the organizations that coordinated training for community pharmacists (Table 4).

Table 4 Questions on vaccination training

Infrastructural capacity to deliver vaccination services

While the majority of community pharmacists reported having a vaccination room (n = 196, 50.5%), a medical waste bin (n = 206, 53.0%), and supplies for hand hygiene and surface cleaning (n = 306, 78.7%), the majority lacked other infrastructure such as vaccine-specific refrigerators (n = 222, 57.1%), temperature monitoring equipment (n = 263, 67.8%), portable refrigerators in case of power outages (n = 218, 56.1%), anaphylaxis response kits (n = 340, 87.4%), anaphylaxis management posters/guidance (n = 280, 56.1%), Table 5.

Table 5 Infrastructural capacity to deliver vaccination services

Type of vaccines being administered by community pharmacists

The tetanus toxoid vaccine was the most commonly administered in community pharmacies (n = 158), and the rabies vaccine was the second most commonly administered vaccine (n = 72). Bacille-Calmette Guerin (BCG) was the least common vaccine administered by community pharmacists (n = 3), Table 6.

Table 6 If you are already administering vaccines in your pharmacy, what type of vaccines are you administering? Select all that apply

Barriers affecting community pharmacists’ willingness to provide immunization services

The most highlighted barriers to the pharmacists’ willingness to deliver vaccination services were inadequate funds to procure appropriate storage equipment (n = 269, 70.0%), inadequate training (n = 265, 69.1%), conflicts with other professionals (64.4%), concerns about patient safety (n = 185, 47.7%), and handling vaccines and disposal of sharps (n = 182, 47.4%), Table 7.

Table 7 Barriers affecting community pharmacists’ willingness to provide immunization services

Relationship between demographic characteristics and the practice/willingness to practise vaccination

The chi-squared test was used to investigate the relationship between the demographic characteristics of the respondents and their practice of vaccination. The results showed that only the type of pharmacy had a significant relationship with vaccination practices (p < 0.05) (Table 8).

Also, it investigated the relationship between the demographic characteristics of the respondents and their willingness to practice vaccination. The results showed that gender, position, and type of pharmacy had a significant relationship with the willingness to render vaccination services (p < 0.005).

Table 8 Demographic characteristics. Do you currently practice vaccine administration in your pharmacy?

Discussion

Community pharmacists are a significant first-line contact for many healthcare consumers and intermediaries between physicians and patients, making them indispensable in modern healthcare delivery, and including community pharmacists in advocacy and facilitation of immunization is key to expansion of immunization services delivery [20]. Despite this daunting task, pharmacists are still an underutilized resource in achieving universal health coverage and implementing many healthcare policies. There have been calls for pharmacists in Nigeria to take up their emerging roles in vaccine management and administration. At the same time, there is no legislation mandating pharmacists to engage in vaccination; no law also prevents them from doing so [20]. The COVID-19 pandemic was an eye-opener about the shortage of healthcare practitioners, and community pharmacists have the workforce to help make healthcare services readily available. The Association of Community Pharmacists of Nigeria, in partnership with the College of Pharmacy, Mercer University, United States of America (USA), the Nigerian Association of Pharmacists and Pharmaceutical Scientists in the Americas, the Pharmacy Council of Nigeria, and the Pharmaceutical Society of Nigeria, has conducted certificate vaccination trainings for pharmacists in Nigeria via its seven-module CPR/BLS training programme to enhance pharmacy-based vaccination delivery. Background information about vaccines, vaccine conditions, patient screening, education and consent, storage, handling, delivering, and waste management, and a review of vaccination equipment and supplies, were included in the training curriculum [21]. Also, the International Pharmaceutical Federation, in its agenda to transform vaccination regionally and globally among pharmacists, offers various pharmacy-based immunization certificate trainings [22]. Medicines, Technologies, and Pharmaceutical Services (MTaPS) is actively involved in building capacities of community pharmacies across 16 countries, including Nigeria [23]. Therefore, this study sought to explore the willingness of community pharmacists in Nigeria to engage in vaccination programmes and highlight the challenges community pharmacists face in setting up appropriate vaccine storage facilities and administration in their pharmacies.

The findings of this study indicate that community pharmacists in Nigeria demonstrate a high level of willingness to administer and dispense vaccines, expressing their support for this practice. However, the effective deployment of a pharmacist-provided vaccination service is contingent upon proper training, logistics availability, and patient acceptance, which are highly significant considerations. The cost-effectiveness of vaccination services offered by pharmacists vary depending on the healthcare systems and reimbursement mechanisms in place [24]. Several studies have suggested that pharmacist participation in vaccination programmes can be economically advantageous, particularly in cases where pharmacists can charge for their services [9, 25,26,27]. Moreover, data indicates that immunizations delivered via community pharmacies are more economically efficient than those administered in medical settings [28, 29]. This may be the case in Nigeria because of the community pharmacies’ easy access to the public, extended opening hours, and no appointment or registration fees needed to consult a community pharmacist. They are located in the very hearts of communities close to where people live, work, and play [22, 30]. In Lagos State, Nigeria, community pharmacists provided various services to their communities during the COVID-19 pandemic, including the recommended infection prevention and control (IPC) practices to curb the infection spread [31]. The community pharmacists in Oyo State, Nigeria, were outstanding and had administered 91% (6006 out of the total 6582) of all COVID-19 vaccine doses across the four participating states by January 2023 [32]. These forestall the urgent need for the government to put systems and structures in place to empower community pharmacists to provide vaccination services.

The results also show that most community pharmacists do not practice vaccine services. This can be attributed to the fact that although many pharmacists were willing to proceed, they felt inadequately prepared due to insufficient education and infrastructural capacity to incorporate vaccination into their practice [25]. They believed that formal certification should be a requirement to do so. Still, they all demonstrated zeal in engaging in these trainings and certifications that will equip them with the requisite knowledge to practice these services. A similar study conducted in 2023 among community pharmacists in Anambra State, Nigeria, found that lack of training and inadequate storage facilities, such as vaccine-specific equipment, were the major limiting factors to providing immunization services. In spite of these barriers, pharmacists showed willingness to administer vaccines [33]. Another study revealed pharmacists’ positive beliefs that vaccine coverage will improve if community pharmacists are licensed as vaccinators, but lack of government authorization poses a barrier [14]. These findings are similar to the results of our study and similar studies in Lebanon [34] and Saudi Arabia [35], where pharmacists strongly desire vaccination. In both studies, it was observed that there is a deficiency in the knowledge gap in handling possible adverse effects from vaccines; this occurrence is evident in our study, where pharmacists show higher training in vaccine handling than in vaccine adverse event handling and documentation. In order to get the required level of immunisation coverage, it is therefore equally important to have an effective healthcare system with skilled routine immunisation service providers who can administer, supervise, and possess these vaccinations in order to attain the required level of immunisation coverage.

It has been posited that “conducting training in little clusters or batches over a while is more likely to be impactful as compared to a situation where a large number of service providers are trained at the same time.” [36] An important factor contributing to high immunization rates in many developing nations is the presence of enough well-trained healthcare workers capable of efficiently administering vaccines to children within healthcare facilities and during outreach programs [37]. In our study, most pharmacists were trained by their professional society and this shows a dire desire by professional leaders to improve accessibility.

Regarding the relationship between the demographic characteristics of the respondents and their practice of vaccination, only the pharmacy type had a significant relationship with vaccination practices, and chain pharmacies were more likely to engage in vaccination services than independent pharmacies. Also, gender and pharmacy type had a significant relationship with the willingness to render vaccination services; female pharmacists were more willing to engage in vaccination services than male pharmacists. Further studies are recommended in other countries on the relationship between demographic characteristics of respondents and their practice of and willingness to deliver vaccination services, since it was difficult to find similar and specific studies for comparison.

It was observed that community pharmacists frequently encounter common infrastructure challenges while establishing vaccine services, precisely the absence of appropriate vaccine storage equipment, temperature monitoring equipment, anaphylaxis management posters/guidance, and safety boxes. The enduring nature of certain challenges might impact the behavioral aspects of individuals when it comes to accepting pharmacist-administered vaccinations, as it fosters a sense of distrust and portrays pharmacists as lacking competence. Studies have shown the effect of infrastructural defects on vaccine uptake, efficacy, and safety [38, 39]. Hence there is a need for interventional support for pharmacists who indicate interest in establishing vaccine services.

Although pharmacist-provided vaccination programmes have achieved universal popularity and have had a favorable impact, numerous barriers remain. Our study highlighted inadequate funds to set up a designated space or procure an appropriate storage facility by the community pharmacist as the significant barrier encountered by community pharmacists, followed by a lack of training and conflicts with other professionals currently empowered by the law to vaccinate. Most barriers community pharmacists face are systemic, which often does not lie within the means of pharmacists alone to solve. A study conducted in Canada among traditional vaccinators revealed only moderate support for pharmacists delivering vaccines. The survey reported that 32% of nurses and 46% of physicians disapproved of this practice [40]. Similarly, fewer than 50% of the questioned nurses and physicians would recommend their patients to a pharmacist for vaccine administration; the reasons for this hesitation and lack of support were mainly concerns regarding the adequacy and effectiveness of pharmacists’ training in handling adverse effects that may arise from vaccination administration [40]; this lack of support should be reproved knowing that community pharmacists who administer vaccines do not seek to engage in a conflict over payment or infringe upon other healthcare practitioners’ professional responsibilities, but instead, pharmacists as healthcare professionals have been equipped with the proper knowledge and can engage in vaccination to improve Universal Health Coverage as common with other nations where evidence exist of improved coverage of immunization by pharmacists. Instead, the crucial aspect is to engage in collaborative efforts as members of an integrated healthcare team to facilitate patients’ seamless access to this critical healthcare service. To overcome the multiple hurdles and barriers to pharmacist-led vaccines, a collaborative effort from all members of the healthcare team and policymakers is necessary. Efforts like the collaborative practice agreement in the United States, where the pharmacist’s role has advanced, should be emulated [41]. In this regard, the pharmacy profession should partner with the government and other health professional organizations to advocate for policy and regulatory reforms that would enable vaccine delivery services in the community pharmacies. Other actional strategies include infrastructural development such as cold chain facilities through microfinancing, and collaborating with health management organizations and the government to develop and adopt enabling standard guidelines and protocols. Also, the Pharmacy Council of Nigeria, through the Faculties of Pharmacy and other similar training institutions, should ensure continuous professional education to increase pharmacists’ readiness to provide vaccination services.

Limitations

This study is not without limitations; firstly, it was designed as a cross-sectional study “The primary limitation of the cross-sectional study design is that because the exposure and outcome are simultaneously assessed, there is generally no evidence of a temporal relationship between exposure and outcome” [42]. Hence, establishing a genuine cause-and-effect link is unattainable without longitudinal data. It is recommended that further studies, such as longitudinal studies, be conducted to provide more evidence for this result. Secondly, the snowballing procedure of data collection might be seen to have restricted participation to the telephone contacts of the pharmacy leaders and research team members who distributed the survey tool links across the country. However, pharmacy leaders that distributed the tool have access to their respective state whatsapp platforms which contain contacts of majority of the pharmacists in their states. The internet-based data collection method might have disenfranchised some potential participants who may not be adept with completing online questionnaires or who do not have smart or other internet-ready devices. In addition, majority of the respondents were from the southern region of the country. This is not surprising, as according to the Register of the Pharmacy Council of Nigeria, more than 70% of registered pharmacists in Nigeria are located in the south, and the registered community pharmacists in Lagos State alone constitute almost 30% of all the registered community Pharmacists in Nigeria [18].

Conclusion

This study emphasizes that despite the inadequacies in infrastructural capacity, community pharmacists are willing to embrace the advanced role of vaccine administration. Pharmacists have the potential to expand their role in delivering public health services by safely and effectively administering injectable medications and managing adverse drug reactions with the proper training and legislation. The government and health management organizations should recognize the critical roles of pharmacists in improving community vaccination rates through increased accessibility. The pharmacy profession can implement targeted short term interventions such as intensified capacity building programs, provision of anaphylactic kits, cold chain equipments and other vaccine-specific equipments to enable community pharmacists to deliver effective vaccination services. In the long run, appropriate legal frameworks, interprofessional team building and collaborations, infrastructural development, and public - private partnerships are key in expanding nationwide vaccination access through the community pharmacists.