Shades of gray in vaccine decision making: Understanding, exploring, and addressing the challenges of influenza vaccine hesitancy in Ontario community pharmacies

Abstract

Background: Two-thirds of Canadian adults currently do not receive the annual influenza vaccine. Vaccine hesitancy (VH), the voluntary delay or refusal of vaccination services despite availability is a significant contributor to the poor uptake of several vaccines including the influenza vaccine. The overarching intent of this thesis was to gain a nuanced understanding of the community pharmacists’ experiences with influenza VH and explore means to best address it. Methods: This thesis is comprised of three studies. The first study was a quantitative descriptive analysis of an exploratory cross-sectional online survey of 885 pharmacists. This study aimed to provide an overview of pharmacists’ perceived knowledge, attitudes and practices pertaining to influenza VH. The second study was a qualitative interpretive analysis of in-depth semi-structured interviews with 22 pharmacists. An implementation science lens was then used to examine the results from the first two studies to guide the selection of a behavioural target and inform intervention design. Based on these findings, the third study included a cost-utility analysis of a novel remunerated community pharmacist consultation service on influenza vaccination for Ontario seniors from a provincial payer perspective. Results: Pharmacists’ self-reported knowledge of influenza vaccine and disease, their confidence and ability to identify and address influenza VH was generally high. Pharmacists’ engagement with patients on the influenza vaccine was found to be modulated by a complex and mutually reinforcing constellation of attitudes and behaviours which included: a binary (pro-vaccine or anti-vaccine) perception of patient vaccination decisions; a conflation of those expressing hesitancy with those that are anti-vaccine; and a passive approach to patient engagement. Despite possessing the requisite knowledge and skills, workflow barriers such as limited time, inadequate staffing, and poor remuneration were found to restrict optimal patient engagement on influenza vaccinations. Offering pharmacists a CAD $15 consultation fee to engage with seniors on the influenza vaccine was estimated to be both cost-effective and clinically effective. Conclusion: Facilitating optimal practice scope for pharmacists, and capitalizing the additional convenience and accessibility offered through the community pharmacy setting presents a promising means to address influenza VH. Conventional tools to aid health professionals in addressing influenza VH rely on augmenting the vaccine provider’s knowledge and skills; however, our analysis suggests that reorienting efforts to enhance the provider’s motivation and opportunity to engage with patients on influenza vaccine conversations are likely to be more effective in the community pharmacy setting.