Community pharmacists workforce readiness to deliver vaccination services: A cross‐sectional study from Jordan

Abstract This study assesses Jordanian community pharmacists’ readiness and willingness to deliver vaccination services in their practice sites. Between February and April 2021, a self‐administered online questionnaire was distributed via social media, WhatsApp messages, and personal communication. The questionnaire targeted practicing community pharmacies. Descriptive and inferential data analysis was carried out. A total of 403 community pharmacists participated in the study. Almost 146 (36%) community pharmacists reported vaccinating patients in their practice sites. However, readiness assessment revealed that only 54 (13.4%) pharmacists received the required training and qualifications. Moreover, 33 (8.2%) study participants worked in adequately equipped and designed community pharmacies. Overall, surveyed participants held positive attitudes toward their involvement in vaccination services: 260 (64.5%) pharmacists were willing to vaccinate patients, and 227 (65.0%) out of unready, unqualified, participants were willing to get needed training and qualifications. According to study participants, regulatory and professional bodies (Ministry of Health, Jordan Pharmacists Association) are influential in supporting pharmacist‐vaccinators. Among the investigated factors, organizational structure and employment status were significantly associated with pharmacists’ readiness to deliver vaccination. This study revealed that further work is needed to increase pharmacists’ and pharmacies’ readiness to deliver vaccination services and that regulators should follow a more active approach in highlighting the importance of training and the impact of training in patients’ safety and satisfaction.

In Jordan, the BPharm and the PharmD academic curricula include pharmacy practice experience (PPE) courses, where students are expected to shadow, observe and be trained by practicing experienced pharmacists in their practice sites, whether community pharmacies or hospital wards. During the PPE courses, students learn and are trained on how to dispense prescriptions, carry out patients' counseling, detect any medicines-related problems and review therapeutic plans. However, the PPE courses do not include training on vaccination administration. Moreover, the majority of pharmacy faculties do not offer training on vaccination as part of their academic programs.
The Jordanian MoH mandated that only sufficiently qualified and adequately trained pharmacists are allowed to administer influenza vaccines. The MoH has also specified the criteria needed to consider a community pharmacy as a suitable vaccine administration site. Therefore, the JPA has published its immunization guidelines, which details the training requirements for pharmacist-vaccinators, and the equipment and tools needed to be within a community pharmacy to be considered as a suitable vaccination site. 16 As per the JPA guidelines, for a pharmacist to be sufficiently qualified, he/she needs to be trained on vaccination administration, first aid procedures and cardiopulmonary resuscitation (CPR) performance and have read the JPA guidelines. Moreover, a pharmacistvaccinator needs to practice immunization in a suitably equipped community pharmacy, which has vaccination specific space, a refrigerator specific for vaccines, temperature monitor, portable refrigerator in case of power failure, anaphylaxis response kit, anaphylaxis management poster, safety box, medical waste bin, materials for hand sanitization and surface cleaning and vaccinated patients record. Pharmacists, who want to be qualified pharmacist-vaccinators, should get training courses offered by the JPA or any other accredited training agencies.

| S TUDY AIM AND OBJEC TIVE S
This study aims to assess Jordanian community pharmacists' current vaccination practices, their readiness to act as pharmacistvaccinators, and their pharmacies' suitability for vaccination services. In addition, the study aims to identify pharmacists' perception of vaccination delivery at community pharmacies and perceived enablers and barriers.

| Study design
This study is a cross-sectional study of licensed and practicing community pharmacists in Jordan. Eligible participants were identified using the Jordan Pharmacists Association (JPA) database and personal connections.

| Study settings and participants
All practicing community pharmacists in Jordan were eligible for this study. According to the JPA 2019 database, 7525 pharmacists work in community pharmacy settings. Therefore, a minimal sample of 366 pharmacists is needed for this study. The sample size was calculated based on a 50% expected frequency and a 5% confidence limit. This minimal sample would give adequate power for bivariate, multivariable analysis to be carried out.

| Survey design
Data collection was carried out using a questionnaire instrument developed based on an extensive literature review, research aim and objectives, and the JPA community pharmacists' immunization guidelines. The initial draft went through content and face validity assessment exercise. The validity check was carried out over two stages. Stage one: the questionnaire was reviewed by a panel of eight experts; the panel included five academics specializing in pharmacy practice or clinical pharmacy and three practicing community pharmacists who were involved in developing the JPA immunization guidelines. The questionnaire instrument was revised and updated based on reviewers' comments and advice.
Stage two: the revised instrument was piloted on a convenience sample of 17 pharmacists; volunteers were asked to assess the instrument's comprehensiveness, readability, and follow. After piloting, further amendments were considered. Pilot data were not included in the final analysis.
The final questionnaire instrument contained 23 questions grouped into eight constructs as per the following: first construct: pharmacists' demographic data such as age and gender. Second construct: participants' employment details such as type of community pharmacy (independent vs chain pharmacy), number of working hours, and years of experience. Third construct: current immunization practices such as vaccines administered, targeted age group, and requested fees. Fourth construct: participants' readiness to serve as pharmacist-vaccinators in terms of received training and qualifications. Fifth construct: related to the practice site, community pharmacy, suitability to deliver immunization services in terms of available equipment and facilities. Sixth construct: participants' perception toward vaccination. Seventh construct: participants' willingness to act as pharmacist-vaccinators in the near future. Eighth construct: perceived factors that could influence the delivery of vaccines at a community pharmacy setting.

| Survey distribution and administration
The final survey instrument was self-administered using the Qualtrics XM ® platform (Qualtrics, 2020). 20 In the period between February and April 2021, the targeted eligible participants were sent the survey link via email, WhatsApp messages, and text messages.
Different approaches and strategies were deployed to identify and recruit eligible participants; these strategies were: (i) approaching community pharmacists directly by the research team, (ii) posting survey link on social media pages related to the JPA and other Jordanian pharmacists groups, and (iii) contacting community pharmacists through the chairs of JPA regional committees and subcommittees on behalf of the research team.

| Statistical analysis
Following data collection, data were extracted and logged in an Excel ® workbook (Microsoft Office MS, 2013). Before analysis, data cleaning, coding, and grouping were carried out.
A pharmacist's readiness to act as a pharmacist-vaccinator was determined based on the pharmacist's qualifications and certifications. For example, if a pharmacist had received all required training, as per the JPA guidelines, and had read the guidelines, the pharmacist was considered a qualified pharmacist-vaccinator, ready to vaccinate. On the other hand, a community pharmacy was considered suitable to deliver vaccination services if all required equipment and facilities were reported to be available. Finally, pharmacists' willingness to be qualified pharmacist-vaccinators was determined by their preparedness to receive needed training and certificates.
Participants' perceptions toward delivering vaccination services by community pharmacists at a community pharmacy settings were assessed using a five-point Likert scale. However, to facilitate data analysis, the scale was converted into a three-point scale. Therefore, the first two categories (strongly agree and agree) were grouped into one (agree), the last two categories (strongly disagree and disagree) were grouped into one (disagree), the intermediate scale (neither) was left as it is.
Data were analyzed descriptively using frequencies, percentages, and standard deviation, when applicable. Additionally, inferential analysis and logistic regression were used to determine factors associated with pharmacists' readiness to act as pharmacistvaccinators and community pharmacies suitability for immunization services. Data analysis was carried out using STATA ® data analysis and statistical software (StataCorp, 2016).

| Ethical consideration
The Research Ethics Committee at Jordan University of Science and Technology (JUST) and King Abdulla University Hospital (KAUH), Irbid, Jordan, reviewed and approved this study (Reference No.: 17/135/2020).

| Participants demographic and characteristics
In total, 403 community pharmacists participated in this study.
However, as the distribution of this study was based on different approaches to identify and recruit eligible participants, including social media, it was not possible to calculate the response rate.
Out of 403 participants, 261 (64.8%) were females, and almost 40% were located in Amman, the capital of Jordan. The majority of participants, 338 (83.9%), worked at independent community pharmacies, and 256 (64.3%) were employees. In addition, 278 (68.9%) worked more than 36 h weekly, and almost 25% handled more than 20 prescriptions per day. Table 1 summarizes participants' demographics and characteristics.

| Current vaccination practice
Out of the 403 participants, only 146 (36.2%) reported that they were, in general, practicing vaccination (pharmacist-vaccinators) in their community pharmacies. Results showed that the majority, 137 (93.8%), of pharmacist-vaccinators were vaccinating adults only, while 30% of vaccinating pharmacists asked for vaccination fees.
The flu vaccine was the most commonly administered, while meningitis vaccines were the lowest ( Figure 1). When it comes to dispensing, the rotavirus vaccine was the least frequently dispensed vaccine. Table 2 summarizes vaccination practices by community pharmacists in Jordan.

| Pharmacists readiness and community pharmacies suitability to deliver vaccination services
Assessing pharmacists' readiness was based on received training courses as reported by the participants themselves. Study findings revealed that 202 (50.1%) received training on vaccination, and 177 (43.9%) participants had read the JPA immunization guidelines. However, the overall readiness assessment showed that only 54 (13.4%) participants were qualified enough to be pharmacistvaccinators; these pharmacists received training on vaccination, CPR performing, and first aid procedures, and had read the JPA guidelines. Furthermore, evidence showed that only 30 (20.5%) out of the 146 pharmacist-vaccinators were sufficiently qualified and trained.
Assessing community pharmacies suitability for vaccination delivery showed that the majority of participants worked in community pharmacies which had vaccination-specific place/room, a refrigerator specific for vaccines and temperature monitor. However, only quarter of participants were working at community pharmacies which had anaphylaxis response kits. Interestingly, out of the 146 vaccination

| Pharmacists willingness to be pharmacistvaccinators
In addition to assessing pharmacists and pharmacies' readiness to deliver vaccination services, the study investigated pharmacists'  Investigating factors that might influence the delivery of vaccination services showed that all listed factors were considered influential by the vast majority of the research participants. Figure 2 summarizes participants' perceptions toward influencing factors.

| Predictors of pharmacists' and pharmacies readiness
Regression analysis showed that the type of area (rural vs urban), type of pharmacy (independent vs chain), or the number of phar- The delivery of vaccination services in community pharmacies is based on four pillars: trained and qualified pharmacists, pharmacies and supply chain suitability, patients' acceptance, and support from regulatory bodies. [24][25][26][27][28][29][30] Each of these pillars influences each other and is necessary to ensure safe and proper delivery of vaccination services in community pharmacies. Figure 3 summarizes pillars of vaccination services in community pharmacies. The last pillar of pharmacy-based vaccination is the regulatory bodies and agencies. Having a legislative and regulatory framework could provide the needed support for pharmacists to deliver vaccination services in community pharmacy settings. 24,29 In addition, an official legal and regulatory framework would define the role and responsibilities of pharmacist-vaccinators and their scope of activity. Based on the previous studies carried out in Jordan, the Jordan Pharmacists Association (JPA) and the MoH were considered to be influential in implementing pharmacy-based vaccination services. 26,27 Similarly, in this study, the majority of the study participants considered the support provided by the JPA and the MoH to be influential or highly influential.

TA B L E 5 Participants' perceptions toward vaccination services and influencing factors
Finally, available evidence showed that pharmacists' readiness to deliver vaccination services was significantly related to orga- The impact of pharmacists' involvement in immunization services is manifested in three main dimensions; the patients, the healthcare system, and the pharmacy profitability. 24

| LI M ITATI O N S
As this study was based on a self-administered questionnaire, there are a number of inherited design-related limitations. These limitations include the absence of open-ended questions, where participants could add aspects related to their experiences in delivering the vaccination services or discuss factors that could enable or hinder the service delivery.
Although this study captured input from community pharmacists working in all governorates in Jordan, the majority of the study participants were located in Amman or Irbid. This did not allow for a meaningful comparison between governorates or between urban and rural locations.

ACK N OWLED G M ENT
The research team would like to thank all the study participants for their participation and support of this study.

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author, Saja A. Alnahar.