Immunization services offered in Québec (Canada) pharmacies

Abstract

Canadian Pharmacists are easy to reach. Although Québec pharmacists are not allowed to administer vaccines, they can: (1) promote vaccination, (2) counsel patients on vaccination, (3) sell vaccines and (4) provide vaccine administration by a nurse. Our objectives were to describe immunization services given in Québec pharmacies and assess the potential relation between, on one hand, pharmacy characteristics and difficulties perceived by pharmacists and, on the other hand, vaccine administration. In 2008–09, an anonymous questionnaire was mailed to all Québec pharmacy owners (n = 1663). Among the 1102 (66%) respondents, 90% stated that vaccines were sold, 27% that a nurse administered vaccines in their pharmacy and 44% were planning to offer vaccine administration in the next five years. Three out of four stated they were doing vaccine promotion and 65%, vaccine counselling. Half of respondents said they would be willing to administer vaccines themselves if legislative modifications were made. Recommendations for cold chain maintenance were followed in 23% of pharmacies selling vaccines. Presence of another health professional in the pharmacy, higher number of opening hours, not being located in the same building than a medical clinic and having an agreement to collaborate with a public health unit or a medical clinic for immunization were positively associated with vaccine administration in multivariate analysis. Higher perceived difficulties with lack of demand from patients were negatively associated with vaccine administration. Most pharmacists are willing to increase their involvement in immunization. Collaboration between public health professionals and pharmacists should be reinforced.

Keywords: :

• accessibility
• cold chain
• organization
• pharmacists
• vaccination

Introduction

Immunization is a key component of a country's public health program. Traditionally, vaccines were given to infants and young children. Recently, more vaccines were recommended for teenagers and adults. Vaccinating these groups is challenging and organizational efforts have to be made. The health care network has to find new ways to provide vaccination services while enhancing accessibility and improving effectiveness.

Offering vaccination services in pharmacies represents an attractive avenue toward an increased access to vaccination. The fact that there is at least one pharmacy in almost every town and most of them are open on evenings and during weekends make them easily accessible to a large number of people. In Canada, approximately 55% of the adult population visits a pharmacy at least once a week¹ and these visits are, for the vast majority, without prior appointment.

In the United States, there has been a tremendous evolution in the role of pharmacists regarding immunization during the past 15 y. They are involved at three different levels: pharmacist as vaccines advocate, where the pharmacist motivates people to be immunized; pharmacist as facilitator, hosting others who vaccinate, and the pharmacist as immunizer, with the pharmacist himself giving immunizations, as allowed by state law.² In 1994, the first sustained program to train pharmacist-immunizers was developed. The curriculum was reviewed and approved by the American Pharmaceutical Association (APhA) and the Centers for Diseases Control and Prevention (CDC) in 1996. Now, more than 175 000 of pharmacists have been trained in all states and many are actively involved as immunizers in their pharmacy.^3,4 A high degree of satisfaction was reported in the general population being immunized by pharmacists.^5,6

The situation is different in Canada. The Canadian Pharmacists Association has called for expanding the role of Pharmacists for many years.⁷ In three out of 10 provinces, pharmacists can administer vaccines (Alberta, British Columbia and New Brunswick) and that other provinces are considering adding this service.⁸ The Public Health Agency of Canada published in 2008 a handbook laying out the essential topics for effective immunization that are universal to a wide range of health professionals, including pharmacists.⁹ An assessment of immunization education in Canadian health professional programs showed important gaps in the knowledge of graduating pharmacy trainees regarding vaccine topics.¹⁰

Little is published about immunization services in pharmacies in Canada. A pilot project conducted in Nova Scotia¹¹ showed a high satisfaction level in the population immunized by pharmacists and an online British Columbia study suggested that more than 80% of pharmacists were interested in administering vaccines, especially H1N1.¹²

In the province of Québec, pharmacists are offering pharmaceutical services in more than 1600 community pharmacies.¹³ Although pharmacists are not allowed to administer vaccines themselves, they can play an active role in immunization. They can promote vaccination with posters, flyers and other publicity; can counsel their patients on immunization issues; can sell vaccines to be administered later by a nurse or a doctor; and vaccines can be administered directly in their premises by a nurse. Indeed, since 2003, in the province of Québec, all nurses (not only public health nurses) have independent prescribing and administrating authority for vaccines and participate in vaccination operations under the Public Health Act.¹⁴ Nurses can vaccinate without a medical prescription in compliance with the Québec Immunization Protocol (PIQ).¹⁵ Despite the fact that several Canadian provinces have certified pharmacists as vaccinators, in the province of Québec, pharmacists are still not allowed to vaccinate by their own and describing vaccination services offered by community pharmacies and factors associated with delivery of vaccination services in this context, appears helpful.^8,16 Focus groups held in Québec City showed that the public would appreciate if more immunization services were given in pharmacies.¹⁷

The objectives of this study were to (1) describe vaccination services given in Québec pharmacies, (2) assess the intention of pharmacists to vaccinate in their premises (3) Assess the association between, on one hand, pharmacy characteristics and difficulties perceived by pharmacists and, on the other hand, vaccine administration.

Results

All respondents

A total of 1106 questionnaires were received (response rate: 66.5%). Four questionnaires were excluded because of incompleteness. Thus, 1102 questionnaires were included in this analysis. More than half (60%) of the respondents were located in cities, 19% in rural areas and 21% in semiurban settings. The vast majority of respondents (93%) were affiliated to a pharmacy chain.

Vaccine promotion was defined as having posters, folders or publicity regarding vaccination; 3 out of 4 respondents said that they were doing vaccine promotion (Table 1). Vaccine counseling was defined as giving recommendations and advices related to vaccination to their patients; 65% said they were doing so. Nine out of 10 respondents were selling vaccines directly to patients and nurses. Eleven percent of them said they would not continue to sell vaccines in the next five years, but 19% of those not selling vaccines at the time of the study said they intend to start offering this service in the future. Twenty-seven percent of respondents said that vaccines were administered by a nurse in their premises and 44% were planning to offer this service in the next five years. Half of respondents would agree to administer vaccines themselves if legislative modifications were made.

Table 1. Proportion of pharmacies where vaccination services were offered at the time of the survey and proportion of those planning to offer them in the next five years

Type of service	At time of survey (n = 1102)		Planned to be offered in the next 5 y (n = 1091)
	n	%	n	%
Promotion of vaccination	802	73	845	78
Counselling on vaccination	721	65	792	73
Sale of vaccines	990	90	893	82
Administration of vaccines by a nurse	301	27	476	44

Potential difficulties related to vaccination were listed in the questionnaire and all respondents were asked to specify the importance of these difficulties in their work (Fig. 1). The three difficulties which ranked highest were: having trouble returning unused vaccines (where and how), loss of unused vaccines (have to pay for them) and lack of demand for vaccination by their patients.

Figure 1. Difficulties related to vaccination as perceived by all pharmacists respondents (n = 1042).

Professional publications (such as Québec Pharmacie), the Compendium of Pharmaceutical and Specialties (CPS), Internet and vaccine monographs were the most frequently used (Fig. 2).

Figure 2. Frequency of utilization of various vaccine information sources by pharmacists (n = 1101).

Pharmacies where vaccines were sold

Vaccines most available for sale in the 990 pharmacies selling vaccines were those against hepatitis A and B (99% of pharmacies), human papilloma virus (HPV) (83%), vaccines for travelers, others than hepatitis (79%) and childhood vaccines (including rotavirus vaccine, not publicly-funded at the time of the study) (54%) (Table 2).

Table 2. Vaccines sold and administered in pharmacies

Type of vaccine	Proportion of pharmacies where this vaccine was sold (n = 916)*	Proportion of pharmacies where this vaccine was administered (n = 235)
Hepatitis A or B	99%	68%
HPV	83%	45%
Vaccines for travelers, other than hepatitis	79%	34%
Childhood vaccines	54%	18%
Pneumococcal polysaccharide	48%	32%
Influenza	44%	84%
Diphtheria/tetanos	13%	18%
Pertussis acellular	6%	11%

*Among the 990 pharmacies where vaccines were sold, 916 provided information on this question and among the 301 pharmacies where vaccines were administered, 235 provided information on this question.

Only 23% of respondents followed entirely the cold chain recommendations issued by the Québec Order of Pharmacists (Table 3).

Table 3. Proportion of pharmacies where recommendations on cold chain maintenance were respected

Recommendation of the Québec Order of Pharmacists	Proportion of pharmacies where this recommendation was applied (n = 921)
Give information or advices on how to maintain the cold chain when selling vaccines	97%
Icepack always available in pharmacy	94%
Icebox always available in pharmacy	68%
Storage of vaccines not directly on ice	64%
Refrigerator temperature checked twice a day	50%
All these recommendations are observed	23%

*Among the 990 pharmacies where vaccines were sold, 921 provided information on this question.

Pharmacies where vaccines were administered

More than 1 out of 4 respondents (27%) said that vaccines were administered by a nurse on their premises. Main vaccine types offered for administration in pharmacies were those against influenza (84% of pharmacies), against hepatitis A and B (68%), and against HPV (45%) (Table 2).

Vaccines were administered in 29% of chain pharmacies, compared with 8% of independent pharmacies. Vaccine administration was offered during evenings and weekends in 44% and 27% of the pharmacies, respectively. Regarding the characteristics of the clientele being vaccinated in their pharmacy, respondents stated that they were mostly 18–64 y old (78%) and ≥65 y old (19%). Few respondents reported that children (< 11 y old) and teenagers (12–17 y old) were their largest clientele (4%).

Most respondents stated that they decided to administer vaccines in their pharmacy because they were asked by their clientele (76%). The second most frequent reason given by respondents was because they felt this initiative was supported by their chain (40%).

Factors associated with vaccine administration

Presence of another health professional in the pharmacy, higher number of opening hours per week (>60), not being located in the same building than a medical clinic and having an agreement to collaborate with a public health unit or a medical clinic for immunization were positively associated with vaccine administration in pharmacies, in multivariate analysis (Table 4). On the other hand, higher perceived difficulties with lack of demand from patients were negatively associated with vaccine administration in pharmacies.

Table 4. Factors independently associated with the administration of vaccines in pharmacies

	Multivariate Analysis (n = 973)
Factors	Proportions ratio	(CI 95%)	p-value
Higher number of opening hours per week (> 60 vs. ≤ 60)	1.7	(1.2 – 2.6)	0.0065
Presence of another health professional in the pharmacy*	3.5	(2.8 – 4.5)	< 0.0001
Being located < 1 km of a medical clinic (vs same building)	1.3	(1.0 – 1.6)	0.0204
Being located > 1 km of a medical clinic (vs same building)	1.4	(1.2 – 1.7)	0.0011
Having an agreement to collaborate with a public health unit or a medical clinic for immunization	1.3	(1.2 – 1.6)	< 0.0002
Higher perceived difficulties with insurance cost**	0.8	(0.6 – 1.0)	0.0858
Higher perceived difficulties with lack of demand from patients	0.7	(0.6 – 0.8)	< 0.0001

* *Nurse, auxiliary nurse or nutritionist. **Québec pharmacists have to pay insurance when they keep vaccines in their premise in case of problems like cold chain defect.

Discussion

Results of this survey indicate a high level of pharmacists’ implication and interest toward vaccination services. The response rate of 66% obtained in this survey is high, when compared with other surveys assessing health professionals’ opinion.^18-21 Half of Québec’s questioned pharmacists would agree to administer vaccines themselves if legislative modifications were made. This proportion is the same as the one found in Canadian pharmacists in a study presented in 2006.²²

Even if pharmacists are not allowed to administer vaccines in the province of Québec, they play an important role in immunization services. Having 9 out of 10 respondents selling vaccines is an illustration of their involvement. It seems that pharmacists are less involved in their role as promoters and counselors (73 and 65%, respectively). The impact of pharmacists’ recommendation was demonstrated in a Japanese survey,²³ where influenza vaccination rates were higher for elders having received information from their pharmacists. In the present study, as well as in others conducted in the United States,^18,24 influenza vaccine was the most offered type of vaccine for administration in pharmacy settings.

It is well known that improving accessibility has an important positive effect on vaccine coverage.²⁵ The results of multivariate analysis showed that the number of opening hours was positively associated with vaccine administration. However, our results also pointed that in less than half of pharmacies, nurses were available to administer vaccines during evenings or weekends and that this nurse’s availability was not associated with the number of opening hours. Pharmacies opened during more hours could only be the glint of those more involved in preventive services (pharmacies adding immunization and nutritional services to the drugs sale) and accessibility to vaccine administration services during less favorable hours could then remain challenging.

Not being located in the same building or near a medical clinic was another factor significantly associated with vaccine administration in pharmacies. In Québec, vaccines are often administered in medical clinics.²⁶ Pharmacists see certainly less importance to offer immunization services when a medical clinic is nearby and it could also explain the perceived lack of demand from patients for immunization services.

Less than one out of 4 respondents selling vaccines (23%) respected all recommendations of the Québec Order of Pharmacists regarding cold chain maintenance. Cold chain maintenance is a complex issue. Keeping immunizing products at the good temperature is necessary to fully benefit from their preventive capacity. It is essential to stress the importance of these recommendations in future communications with pharmacists, in order to keep vaccine effectiveness at the highest level.

In addition, vaccines are sold to clients to be administered elsewhere in an important proportion of pharmacies. If the respect of all recommendations to maintain the cold chain is not optimal among pharmacists, it is probably worse among clients. When a person buys a vaccine in a pharmacy and brings it to a doctor or a nurse for administration a few days later, one can presume that this product has not always been kept in optimal conditions and thus has lost at least partially its efficacy. This issue was stressed in a previous survey describing adult vaccination services given in medical clinics in Québec.²⁷ One solution would be to administer vaccines in the premises where they are sold, to optimize effectiveness as well as patient convenience.

This study showed also that pharmacists rarely used national and provincial immunization guides and protocols to stay up to date on immunization^15,28 topics. These resources have to be available for pharmacists. At the same time, specific articles on immunization should be published in professional magazines, as they are the most read by pharmacists.

This first study on that topic in the province of Québec has limitations. The respondents might not be representative of all Québec pharmacists, even if our survey list came from an official organization and all pharmacy owners were invited to participate. Although the survey had a high response rate for a study on health professionals, 34% of pharmacists did not respond. The telephone contact with these nonrespondents allowed us to observe that some were selling or administering vaccines, which refutes the hypothesis that nonrespondents were inactive in vaccine selling or administration.

In some Canadian provinces, pharmacists have authority to vaccinate hoping to increase accessibility to immunization services, especially when vaccination is not a nursing act. In the province of Québec, pharmacists are still not allowed to immunize by themselves.¹⁶ Potential conflict of interest if pharmacists were authorized to administer vaccines themselves was raised among the issues against this practice by some of its opponents in Québec.^29,30

In conclusion, this study showed that Québec pharmacists are actively involved in immunization. Although pharmacists perceived important difficulties, many showed interest in increasing their involvement in immunization. Recommendations on the maintenance of the cold chain should be enhanced in all premises where vaccines are kept. The ways of improving immunization accessibility must continue to be carefully assessed in order to improve vaccine coverage.

Methods

Study design

This cross sectional study was conducted in the province of Québec in 2008–09. Survey instruments (postal questionnaire, cover letters, return postcard, reminder) and survey conduction followed Dillman’s recommendations.³¹ The survey was anonymous and the study protocol was approved by the Research Ethics Board of Centre hospitalier de l’Université Laval (# 121.05.02). The survey was endorsed by the Québec Order of Pharmacists and financially supported by the Québec Ministry of Health and Social Services. No financial or material incentives were offered to respondents.

Study population

All 1663 pharmacy owners in the province of Québec were invited to participate. If a pharmacist owned more than one establishment, he was invited to fill a questionnaire for each pharmacy owned. The “Association québécoise des pharmaciens propriétaires” (AQPP) provided the list of pharmacy owners. This Association also published in its regular magazine an announcement inviting members to complete the survey.

Survey instrument

A 12-page questionnaire was designed by the research team with the collaboration of pharmacists and experts in immunization. It was pretested with a focus group of seven pharmacists and modified according to their suggestions. There were three different sections in the questionnaire. Questions were essentially checkboxes and yes/no answer.

The first section was designed for all pharmacists and asked about characteristics of their setting as well as their intention to administer vaccines themselves if legislative modifications were made. The perceived difficulties encountered with the offer of vaccination services in general (not at all/slightly important, somewhat/very important, not applicable) and the vaccination services offered and planned to be offered in the next 5 years were also collected as well as their main source of information on vaccination.

The second section had to be fulfilled only by pharmacists selling vaccines. Questions on the type of vaccines sold and the fulfillment of a list of cold chain recommendations were asked.

The third section was designed for pharmacies where vaccines were administered (the nurse being the person vaccinating). It asked questions on type of vaccine administered, vaccine administration during evenings and weekends, age of clientele vaccinated, reasons to start immunization services and specific difficulties related to vaccine administration.

Data collection

A return postcard was included in the mailing (September 2008). Respondents had to send back this postcard separately to maintain their anonymity. One month after the first mailing, the same questionnaire with a different cover letter was sent to nonrespondents. Two months later (December 2008–January 2009), a telephone call was made to nonrespondents and another questionnaire was sent to those requesting it. The questionnaire and the cover letters are available upon request.

Statistical analysis

Frequency distributions were computed for variables pertaining to vaccination services and pharmacy characteristics.

In order to identify factors independently associated with the administration of vaccines in pharmacies, we conducted multivariate log-binominal regressions, where the outcome was a dichotomous variable indicating if the pharmacy offers vaccine administration services or not. Whereas in logistic regression models levels of a factor are compared through odds ratios, they are compared through proportions ratios (PR) in log-binomial models. The complete model that included characteristics of the pharmacy and difficulties encountered to the offer of vaccination services was simplified by eliminating one by one factors least associated with the administration of vaccines until all remaining factors were statistically significant at a 5% level according to the omnibus (“type 3”) likelihood ratio test. The COPY method was used when convergence problems were encountered in log-binomial models.³² Likelihood ratio-based 95% confidence intervals (CI) and p-values were calculated for each PR. All statistical analyses were performed using SAS 9.2 for Windows.

Acknowledgments

The authors would like to thank the Ordre des pharmaciens du Québec, the Faculté de Pharmacie de l’Université Laval and the Association québécoise des pharmaciens propriétaires (AQPP) for their collaboration. We also thank all the pharmacists who responded to this survey. We acknowledge the participation of Josiane Rivard and Émilie Carrier in data entry and analysis. The project was made possible through a grant from the Québec Public Health Institute and the Québec Ministry of Health and Social Services in the context of the subsidy program in public health for study and evaluation projects. The funding sources had no involvement for the conduct of the study and the preparation of the article.

Conflict of interest

CS reported receiving payment and travel expenses for presentations, not related to the topic of this work, from GlaxoSmithKline and Merck. ED received unrestricted research grants, not related to the topic of this research, from GlaxoSmithKline. JM is leading the Chair on adherence to treatments which is supported by unrestricted grants from AstraZeneca, Merck Canada, Sanofi-Aventis, Pfizer and the Prends soin de toi program. RB, FL and MM had nothing to declare.