Pharmacists' perceived barriers and facilitators as immunisers: Mapping COM‐B model to support intervention development

Pharmacists were involved in the education and facilitation of vaccine administration, including more recent roles in vaccine administration. Yet there is a lack of reviews about pharmacists' motivation as immunisers to improve understanding of the possible gaps in the uptake of the professional roles.

public health concern. 3,4The coverage for many vaccines is still too low thus the need for continued monitoring of immunization program performance to detect potential gaps and identify appropriate solutions. 5ccines have been traditionally provided in general practitioner (GPs) clinics, public health clinics, and hospitals.7][8] To improve vaccination rates, the introduction of training to nontraditional vaccination providers, such as pharmacists, may potentially be a solution to safely deliver vaccines in their practice settings. 9Over the years, pharmacists have expanded their scope of practice from merely dispensing to other pharmaceutical care services. 10Accessible in various healthcare practice sites (including community pharmacies, inpatient, ambulatory clinics, and nursing care facilities) makes pharmacists ideally positioned to deliver immunization as educators, facilitators, and administrators of vaccines. 11,12armacist-led vaccination has been implemented in the United Kingdom, United States of America (USA), Ireland, and Portugal. 13The pharmacists were trained in aspects of knowledge, skills, and vaccines to ensure their clinical competency in providing vaccination services. 14Implementation of such programs has shown huge benefits in increased public awareness, accessibility, and rates of adult vaccination. 14,15This has impacted public health officials in the United States to recognize community pharmacists as immunisers. 15Similarly, legislation was passed in nine Canadian provinces to expand the scope of pharmacy practice to include the administration of vaccinations which was well accepted by the public and health care providers. 15,16 important factor that will help in advancing the roles of pharmacists as immunisers would be to understand their needs and expectations.Utilizing the Capability, Opportunity, Motivation, and Behavior (COM-B) model for behavior change, this study aims to fill a critical gap in the current literature by investigating the attitudes and perceptions of pharmacists as immunisers, particularly within the Asian region, where limited understanding exists, despite existing research delving into pharmacist-led vaccination from the viewpoints of the public and other healthcare professionals. 12,14,15This paper reviewed the literature to assess the perception and attitude of pharmacists towards vaccine administration in their practice settings.The COM-B model offers a structured approach for investigating pharmacists' attitudes and perceptions as immunisers.The framework enables exploration of factors such as pharmacists' knowledge, skills, training (Capability), the environment they operate in, resource availability (Opportunity), and their attitudes, beliefs, and incentives (Motivation).The mapping findings of barriers and facilitators from literature will provide comprehensive understanding of the factors influencing pharmacist-led vaccination, facilitating the identification of intervention points to inform policymaker interventions in encouraging pharmacists' participation in vaccination programs.

| Search strategy
A comprehensive literature search was carried out to identify all relevant studies investigating perceived barriers and facilitators towards pharmacists administering vaccination in community pharmacy settings.
The following electronic databases were searched: PubMed, Embase, International Pharmaceutical Abstract, and Cumulative Index to Nursing and Allied Health Literature from inception to December 2022.Key search terms included: "Pharmacist" and "Immuni*" or "Vaccin*."All English-published studies were identified and a manual reference review of included studies was screened to include additional studies.

| Study selection
The reference management software tool Endnote was used to manage all the search results exported from the electronic databases searched.Two reviewers independently screened titles and abstracts for inclusion.Full articles were then reviewed using an assessment form to include studies exploring pharmacists' perceptions and attitudes toward their role as vaccinators, where participants could include pharmacists or public.Studies that explored the multifaceted landscape surrounding evolving or novel roles of pharmacists as immunisers, legislative and regulatory frameworks on pharmacists' ability to administer vaccines, and specific barriers and facilitators that impact pharmacists' involvement as immunisers were included.Studies that are not focused on the regular vaccination service specifically provided by pharmacists in their practice sites (such as mass vaccination and vaccination campaigns) were excluded.The reviewers met and came to consensus on all studies included.

| Data extraction and study appraisal
Three independent reviewers participated in the data extraction process, utilizing a developed standardized collection form.This form was thoroughly piloted with a subset of 5 studies to ensure its reliability and effectiveness in capturing pertinent information.Throughout these steps, an iterative and systematic approach was followed.Data extracted from each study were cross-referenced against the constructs of the COM-B model, ensuring accuracy and consistency.In cases where facilitators and barriers spanned multiple constructs, their nuanced interactions were carefully dissected to provide a comprehensive understanding of their impact.

| Search results
Out of potential 5429 publications, twenty-six papers met the inclusion criteria (Figure 1).

| Characteristics of included studies
Twenty-four of the included studies assessed both perceived facilitators and barriers while two studies focused solely on perceived barriers.[38][39][40] All 26 included studies were published from the year 2001 onwards.Studies were conducted mostly in the USA with another 6 in Canada, 14,15,20,23,33,36 and 2 in Saudi Arabia. 29,40One paper was published respectively in the United Kingdom, 18 Australia, 19 Malaysia, 27 and Poland. 2827][28]31,32,36,39,40 Perceived barriers and facilitators of pharmacists-led vaccination were mapped in the 6 components of the COM-B model (Tables 1   and A1).Although studies evaluated the provision of a variety of vaccines by pharmacists, including tetanus 41 and herpes zoster, 42,43 most studies evaluated the provision of influenza and/or pneumococcal vaccines.All studies reviewed demonstrated an increase in interest among pharmacists to improve vaccine coverage.

| Expansion of role as immuniser
27 Pharmacists who have been administering influenza vaccines were shown keen to continue the service and expand to other forms of vaccinations. 19 Pharmacists alo played the role of an educator to inform patients about the benefits and risks of vaccinations and used these encounters as an opportunity to ask about patients' vaccine status.15 There were evidence of increasing patient demands for vaccination services in community pharmacies 20,37 as well as referrals from other health providers.15,23 Some studies have also reported a lack of interest 37 and awareness 18,19,37 among patients towards pharmacists as immunisers, likely due to limited understanding and misconceptions about vaccine administration.25,38 From a macro context, the promotion of pharmacists in vaccination provision was supported from chain management and professional associations (pharmacy, nursing, and medical).20 However, pharmacists were careful to avoid any conflict from the local GPs that would damage the long-term business relationships between them. 18

| Training and certificate program
Formal certificate program and professional training were heavily discussed in most studies and regarded as one of the main factors in influencing vaccine provision by pharmacists.][34][35]39 This was echoed from the lack of training and education in incorporating vaccination services at their practice location. 14,17,20,22,27,28,33,34,39,40In many successful stories of pharmacy vaccination implementation, the self-confidence among pharmacists was found to be a strong contributing factor 14,33 which included confidence in administering vaccines 20,24,27,30,33 and handling of adverse events. 20,24,30Thus, the need to educate pharmacists about vaccination was shown linked to higher level of comfort in administering vaccine. 14,30

| Physical environment and facilities
The presence and readiness of facilities were found to be both facilitators and barriers to pharmacist-led vaccinations.40 Other barriers include difficulty in keeping track of patients' vaccine status 26,27,31,32,40 and the utilization of electronic systems for screening. 15,25,40 Enrusting pharmacists responsible for monitoring patients' vaccination status capitalized on their specialized knowledge, accessibility to health records, and patient-centered approach. 15In an increasingly complex and interconnected healthcare landscape, where patients may receive care from multiple providers and visit different healthcare facilities, pharmacists are pivotal in ensuring continuity and coherence in vaccination management, ultimately contributing to enhanced patient well-being, safety, and effective healthcare coordination.

| Cost
Two studies found that appropriate financial incentives and streamlined compensation systems supported pharmacists to actively engage in administering vaccinations. 20,30Conversely, other studies disclosed that pharmacists faced logistic difficulties in billing 32,34 as well as obtaining reimbursement from major third-party payers, 22 which primarily impacted the independent pharmacies. 35The recurring themes of the cost of vaccination and insurance coverage formed a complex triad of factors that collectively shape the landscape of pharmacist-led vaccination services. 24,26,30,32,36,38The financial considerations influenced patients' decisions, either serving as motivators or potential barriers in their quest to access and benefit from pharmacist-led vaccination programs.

| Time
The consensus across studies perceived time as the pivotal factor for the provision of pharmacy-based vaccination services underscoring the intricate interplay between efficiency, workload, and the potential for expansion in this domain.Two studies revealed that time constraints were affected by large prescription volume and competing workflow in the pharmacies, in a way where pharmacists must strike a delicate balance in managing their responsibilities while concurrently delivering high-quality vaccination services. 30,36The studies highlighted the symbiotic relationship between resource availability, staff engagement, and the scope for vaccination expansion, suggesting that proactive investment in training and fostering a vaccinationfriendly ecosystem could yield substantial dividends in terms of service accessibility and patient outcomes. 19,25,26,37,38,40Another study reported that pharmacists were generally more agreeable to provide vaccination services only at daytime working hours. 23

| Legislation
Available vaccine information for providers from the local and state health departments was perceived as a facilitator, in addition to the ability to new laws and policy adaptation. 31Legal liability was identified as a significant barrier on pharmacists practicing in both chain and independent pharmacies. 14,22,34,35,39

| Perceived benefits
Pharmacist-provided immunisations have shown to improve access to patient care 24,31 and role advancement among pharmacists. 27,29,35,37sponses collected from these studies also showed benefits in promotion of public health 28,37 and consumers' convenience. 24,39,40wever, there was no significant agreement in pharmacists' professional satisfaction or image, increased profit in vaccine provision, and perceived impact. 24,34,37 | DISCUSSION This study's findings demonstrated the multifaceted landscape of facilitators and barriers that shape the role of pharmacists as immunisers.5][56][57] Champions from successful implementation can act as a reference for local pharmacy boards and stakeholders to advance their vaccination scope of practice. 12,58,59Furthermore, there is a huge opportunity for pharmacists to augment the service alongside GP due to its convenient locations, long opening hours, and preference of patients for the pharmacy environment. 46,60,61The inclination of pharmacists to assume the role of immunization should not be driven by a pursuit of monetary incentives or an intent to encroach upon the professional purview of fellow healthcare providers.Rather, it is grounded in cultivating a synergistic and cooperative ethos within an integrated healthcare paradigm, with the overarching objective of amplifying patient access to this essential healthcare service.
Even though pharmacist-led vaccination services have achieved widespread success, various challenges continue to exist.While the public viewed pharmacist as qualified immunisers, 44,[61][62][63] their confidence relied largely on the competence and knowledge of pharmacists in providing vaccination services. 43Findings of this review echoed the notion that pharmacists must develop the necessary competence and be adequately trained to implement the service.Besides the support from professional organizations in advocating for service provision, learning objectives aligned with the planned vaccination service should be clearly defined.5][66][67][68][69][70][71] By providing academic diplomas that match the level of training, the credibility of the qualifications can be enhanced through endorsements from universities.
5][66] In the United States, practicing pharmacists and pharmacy students are formally trained through recognized programs as vaccine experts and have become routinely accepted as an important role of the pharmacist. 67dressing environmental factors, such as physical space and proper vaccine storage, is crucial to facilitate pharmacists' engagement in immunization services. 68,69Time management emerged as a vital factor, encouraging considerations such as appointment-based vaccination services and patient education. 72The mapped COM-B model highlighted minimal system-level support in regulatory consistency and patient vaccination data accessibility. 69,73Several countries have adopted various solutions although a complete immunization registry system with all stakeholders (healthcare professionals, patients, payers) 5][76][77] Access to health records is essential for pharmacists to confirm patient vaccination and health status, as well as appropriate measures to guarantee safe vaccine administration.
There are several limitations to this review.Most of the studies included were conducted in developed Western countries where pharmacist-led vaccination was implemented.Thus, extrapolation of implementation strategies may be challenging without a proper policy put in place.Gray literature, including unpublished reports, policy briefs, and implementation documents, has been excluded from this review due to the absence of existing implementations and corresponding policy briefs in the subject area.In addition, variations between population and practice characteristics may influence the trends observed.Despite these limitations, the review provided meaningful answers to the "why," "how," and "what" facilitates pharmacist-led vaccination.Collaboration with healthcare providers, schools, and public health agencies.
• Most indicated recommending HPV vaccination was within their role.
• Pharmacists reported HPV vaccination should be a priority for adolescent health but it was not a priority in their workplaces.
• The potential to be seen as competitive with local health care providers.
• Pharmacists reported liability in administering the HPV vaccine.• 78.5% were not confident that they would be comfortable in providing vaccination.
• Inadequate level of training by community pharmacists to administer vaccines (89.9%).
• Community pharmacists with master's degrees had a significantly higher knowledge level (p = 0.01) as compared to community pharmacists with bachelor's degrees.

based vaccination program
Barriers: • The level of knowledge towards vaccination (76.6%) • Concern for public's safety (70.2%) • Community pharmacists with master's degrees had a significantly better attitude (p = 0.037) compared to community pharmacists with bachelor's degrees.
• Lack of support from other vaccine providers (69.3%) • The study was conducted at a specified time.(Continues) From the selected articles, key study parameters, research designs, and outcomes were meticulously extracted, ensuring a comprehensive and accurate representation of the research findings.In alignment with the COM-B model, mapping facilitators and barriers within the data extraction and study appraisal was meticulously orchestrated, ensuring a comprehensive analysis of each construct: 1. Capability mapping: Facilitators and barriers related to the pharmacists' capability to engage in immunization services were identified (such as knowledge, training, and skill development).Relevant information pertaining to the enhancement or hindrance of pharmacists' capabilities was extracted, including the level of training provided, any reported gaps in knowledge, and the availability of skill-building opportunities.2. Opportunity mapping: Extracted data delved into resource availability, facility accessibility, and collaboration with other healthcare professionals that could enable or constrain pharmacists' involvement in immunization services.3. Motivation mapping: This involved closely analyzing reported attitudes, beliefs, and motivations that either supported or hindered their engagement in immunization services.Extracted data illuminated whether positive attitudes, intrinsic motivation, or external incentives played a role in encouraging or deterring pharmacists from taking on this role.

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CONCLUSION Despite facing obstacles like limited support from other healthcare providers and inadequate training, community pharmacists show potential in enhancing immunization rates due to their accessible and convenient role as immunisers.This underscores the necessity for collaborative efforts among healthcare professionals, organizations, and the public to ensure proficient pharmacy-based vaccination services.By incorporating these insights into the COM-B framework, a comprehensive roadmap emerges to guide policymakers in aligning strategies for effective pharmacist-led vaccinations.ACKNOWLEDGMENT Open access publishing facilitated by Monash University, as part of the Wiley -Monash University agreement via the Council of Australian University Librarians.APPENDIX A T A B L E A 1 Mapped barriers and facilitators on COM-B model.
Summative flow diagram for selection of studies.Mapped perceived barriers and facilitators into the COM-B model.
which generally demonstrated positive attitudes in the uptake of a new role as F I G U R E 1