Article ID: 2025-0007-OA
Japan has the lowest vaccine confidence worldwide. Although community pharmacists are expected to support public health, it remains unclear whether Japanese community pharmacists—who cannot administer vaccines—engage in vaccine consultation and promotion. This cross-sectional study used a paper-based, self-administered, anonymous questionnaire distributed to randomly selected community pharmacists in Japan to investigate their attitudes and experiences regarding vaccination, exploring issues related to the prevalence of the vaccine-related roles of community pharmacists. One thousand pharmacies were chosen, and the valid response rate was 44.6%. While 86.5% of respondents had experience with vaccine consultation, only 59.2% had experience with vaccine promotion. The rate of vaccine promotion was significantly higher among community pharmacists who recognized Japan’s low vaccine confidence and held positive attitudes toward vaccine promotion (P < 0.001). Most respondents (76.9%) desired training to expand pharmacists’ roles in vaccination. Additionally, 62.1% supported pharmacist-administered vaccines, though many were concerned about technical skills (83.3%) and potential anaphylaxis (63.6%). These findings suggest that promoting awareness of vaccine hesitancy and strengthening attitudes toward vaccine promotion could increase the number of community pharmacists involved in such activities. Japanese pharmacists may also need appropriate vaccine administration knowledge and skills to prepare for potential future responsibilities in vaccine administration.
Vaccination is an effective method of preventing diseases such as influenza, pneumococcal pneumonia, cervical cancer, and COVID-19. In 2019, the World Health Organization listed vaccine hesitancy—defined as delaying or refusing vaccination despite availability—as one of the top ten global health threats.1 The major contributing factors include confidence, complacency, and convenience barriers.2 In particular, vaccine confidence correlates highly with vaccination rates.
Japan has the lowest vaccine confidence worldwide.3 This may be associated with rumors regarding the safety of the human papillomavirus (HPV) vaccine and the suspension of proactive HPV vaccination recommendations by the Japanese Ministry of Health, Labour and Welfare (MHLW) from June 2013 to March 2022. Vaccination rates in Japan remain low: only 1.9% of adolescents received the HPV vaccine, and just 13.7% of adults aged ≥ 65 years or 60–64 years with high-risk diseases were vaccinated against pneumococcus in 2019.4 In contrast, HPV and pneumococcal vaccination rates were 49% and 69%, respectively, in the U.S.5,6 and 83% and 37%, respectively, in Canada.5,7 HPV is a cause of cervical cancer, which resulted in nearly 2,900 deaths in Japan in 2021.8 However, pneumonia caused approximately 78,000 deaths in 2020,9 with pneumococcal pneumonia accounting for 20%–30% of these deaths.10 A strategy to increase vaccination rates is therefore needed.
Currently, community pharmacists not only prepare prescription medicines and dispense over-the-counter drugs but also provide health information and contribute to public health. For example, a Japanese study reported that the implementation of a lifestyle advice program in community pharmacies may help reduce blood pressure in local residents.11 Studies in Australia reported widespread provision of oral health advice and consultations by community pharmacists.12 Our previous study found that oral health checkups and guidance on self-care in community pharmacies could alter resident’s oral hygiene habits and dental consultation behaviors.13
In Australia, the U.S., Canada, the U.K., and several European countries, pharmacists are authorized to administer vaccines,14 and many residents receive immunizations at community pharmacies. Numerous studies have examined pharmacists’ attitudes and experiences regarding immunization.15,16,17,18 For example, Scarpitta et al. emphasized the need for improved knowledge and attitudes among health care workers to promote a vaccination culture and foster collaboration among community pharmacists and other health care professionals, including general practitioners and family pediatricians, in Sicily, Italy.15 Valiquette et al. reported that most pharmacists in Quebec, Canada perceived vaccines as having more benefits than risks,16 suggesting that additional immunization training and appropriate remuneration could support pharmacist-led immunization. Pullagura et al. reported that pharmacists in Ontario, Canada had high confidence and knowledge in identifying and addressing influenza vaccine hesitancy, although workload and time constraints limited their involvement.17 High consumer satisfaction with pharmacist-administered vaccination services has also been reported in Western Australia.19
Several studies have reported that vaccine recommendations by pharmacists increase vaccination rates.20,21 A meta-analysis also showed that the involvement of community pharmacists positively affects vaccination rates.22 Although Usami et al. demonstrated that personal advocacy for influenza vaccination by a community pharmacist increased vaccination among adults aged ≥ 65 years,23 it remains unclear whether Japanese community pharmacists help address national vaccine hesitancy and improve vaccination rates through vaccine consultation and promotion.
In Japan, pharmacists are not permitted to administer vaccines, although dentists, emergency medical technicians, and clinical laboratory technicians may do so. During the COVID-19 pandemic in 2021, more than 20,000 signatures were submitted requesting that pharmacists be allowed to administer vaccines to increase the number of vaccinators. Pharmacists typically assist local residents with prevaccination health check sheets and participate in postvaccination follow-up. A future pandemic may again prompt discussion about authorizing pharmacists to administer vaccines; however, pharmacists’ attitudes toward assuming this role remain unknown.
This study investigated the attitudes and experiences of Japanese community pharmacists regarding vaccine consultation and promotion to identify issues related to the prevalence of vaccine-related roles. We also examined pharmacists’ attitudes toward vaccine administration.
This cross-sectional study used a paper-based, self-administered, anonymous questionnaire distributed to pharmacists working in community pharmacies in Japan. The sample size was set at ≥ 300 pharmacists to achieve a margin of error of roughly 5% for population estimates at a 95% confidence level. Assuming a 30% response rate, we randomly selected 1,000 Japanese community pharmacies from approximately 60,000 pharmacies listed on the websites of local health and welfare bureaus. Pharmacy managers, who had extensive experience as pharmacists and were familiar with their pharmacies’ operations, completed the survey.
Data collectionA questionnaire, survey explanation sheet, and return envelope were mailed to each pharmacy. The explanation sheet described the study purpose, participant inclusion criteria, and details regarding publication of results. Respondents mailed the completed questionnaire to the Faculty of Pharmacy, Keio University. The survey was conducted from May 26 to July 13, 2022. Participants were excluded if they (1) did not consent to join the study or (2) left more than two of the six questionnaire pages unanswered.
QuestionnaireThe survey used multiple-choice questions in Japanese. A consent checkbox appeared at the beginning of the questionnaire. The instrument contained 31 questions across six domains: (1) attitudes toward vaccination in general; (2) experiences with COVID-19 vaccine consultation and promotion; (3) experiences with consultation and promotion for non-COVID-19 vaccines; (4) attitudes toward vaccine consultation and promotion by community pharmacists; (5) attitudes toward vaccination by pharmacists; and (6) basic characteristics (Appendix 1). Several attitude-related items used a 5-point Likert scale ranging from agree to disagree.
Statistical analysisChi-square tests were used to examine relationships between vaccine promotion experience and awareness of low vaccine confidence in Japan, as well as between promotion experience and attitudes toward vaccine promotion by community pharmacists. Respondents who answered “I knew that” or “I’ve heard that but don’t know much about it” regarding low vaccine confidence were classified as the “Recognizing group,” whereas those who answered “I didn’t know that” were classified as the “Nonrecognizing group.” Those who responded “Agree” or “Somewhat agree” to the statement that vaccine promotion is a community pharmacist’s role were classified as the “Positive group,” while “Somewhat disagree” or “Disagree” responses formed the “Negative group.” Statistical analyses were performed using SPSS software (version 28, IBM, Tokyo). Significance was set at 5%. Missing data were excluded.
Ethics approvalThe study was conducted in accordance with the Declaration of Helsinki and was approved by the Research Ethics Committee of the Faculty of Pharmacy, Keio University (approval number 220516–1; approval date; May 16, 2022).
A total of 479 pharmacists responded (response rate: 47.9%). Of these, 33 were excluded from the analysis: one did not agree to participate, five left more than two of the six pages incomplete, and 27 did not check the consent box. Thus, 446 valid responses were analyzed.
Respondent characteristics are shown in Table 1. Among the 446 pharmacists, 51.6% were male, and 47.3% had less than 20 years of experience working as a pharmacist. Additionally, 14.1% worked at health support pharmacies, which meet the criteria for providing health support and primary care to local residents. Most of the respondents (90.8%) agreed or somewhat agreed that vaccines are effective for preventing diseases.
| n | (%) | |
|---|---|---|
| Gender | ||
| Male | 230 | (51.6) |
| Female | 214 | (48.0) |
| N/A | 2 | (0.4) |
| Years of practice | ||
| ≤9 | 91 | (20.4) |
| 10–19 | 120 | (26.9) |
| 20–29 | 133 | (29.8) |
| ≥30 | 102 | (22.9) |
| Location of pharmacy | ||
| Near clinic | 216 | (48.4) |
| Near hospital | 111 | (24.9) |
| Not near hospital or clinic | 92 | (20.6) |
| On the grounds of a hospital or clinic | 12 | (2.7) |
| In medical building | 8 | (1.8) |
| Other | 2 | (0.4) |
| N/A | 5 | (1.1) |
| Type of pharmacy | ||
| Health support pharmacy | 63 | (14.1) |
| Regional collaborating pharmacy | 104 | (23.3) |
| Drugstore-attached pharmacy | 47 | (10.5) |
| Prescriptions per day | ||
| 1–19 | 64 | (14.3) |
| 20–49 | 182 | (40.8) |
| 50–99 | 144 | (32.3) |
| 100–199 | 49 | (11.0) |
| ≥200 | 6 | (1.3) |
| N/A | 1 | (0.2) |
| Attitude toward preventive effects of vaccines | ||
| Agree | 264 | (59.2) |
| Somewhat agree | 141 | (31.6) |
| Neither agree nor disagree | 30 | (6.7) |
| Somewhat disagree | 5 | (1.1) |
| Disagree | 3 | (0.7) |
| N/A | 3 | (0.7) |
Most of the respondents (86.5%) had received vaccine consultation requests from people with vaccine hesitancy (Table 2). Nearly all of these respondents reported providing advice on the COVID-19 vaccine (93.5%), while 51.3% had advised on the influenza vaccine and 36.0% on the pneumococcal vaccine. Only 17.1% of the respondents had advised on the HPV vaccine, and 6.2% had advised on childhood vaccines. Meanwhile, 59.2% of respondents had engaged in vaccine promotion: 86.4% provided information during medication instruction, 24.2% displayed posters, and 17.4% distributed government-issued leaflets.
| n | (%) | |
|---|---|---|
| Experience with vaccine consultation (n = 446) | ||
| Yes | 386 | (86.5) |
| No | 59 | (13.2) |
| N/A | 1 | (0.2) |
| Type of vaccine (n = 386, multiple answers allowed) | ||
| COVID-19 | 361 | (93.5) |
| Influenza | 198 | (51.3) |
| Pneumococcal | 139 | (36.0) |
| Zoster | 96 | (24.9) |
| HPV | 66 | (17.1) |
| Vaccine for children | 24 | (6.2) |
| Other | 1 | (0.3) |
| Experience with vaccine promotion (n = 446) | ||
| Yes | 264 | (59.2) |
| No | 144 | (32.3) |
| N/A | 38 | (8.5) |
| Method of promotion (n = 264, multiple answers allowed) | ||
| Provided information during medication instruction | 228 | (86.4) |
| Put up poster | 64 | (24.2) |
| Provided leaflet written by the government | 46 | (17.4) |
| Provided leaflet written by a pharmaceutical company | 19 | (7.2) |
| Held seminar | 2 | (0.8) |
| Other | 12 | (4.5) |
| Knew | Have heard that but don’t know much about it | Didn’t know | |
|---|---|---|---|
| Vaccine hesitancy is a global problem | 331 (74.9) | 95 (21.5) | 16 (3.6) |
| Japan has the lowest vaccine confidence worldwide | 120 (27.1) | 137 (31.0) | 185 (41.9) |
| The pneumococcal vaccination rate is low in Japan | 97 (21.9) | 145 (32.8) | 200 (45.2) |
| The HPV vaccination rate is low in Japan | 308 (69.7) | 87 (19.7) | 47 (10.6) |
| The proactive recommendation of the HPV vaccine has resumed | 285 (64.5) | 92 (20.8) | 65 (14.7) |
Data given as number (percentage).
As shown in Table 3, 74.9% of respondents knew that vaccine hesitancy is a global issue, 21.5% had heard of it but did not know much about it, and 3.6% were unaware of it. Regarding Japan’s low vaccine confidence, 27.1% of the respondents knew about it, 31.0% had heard of it but did not know much about it, and 41.9% did not know.
Table 4 shows that 36.9% of the respondents agreed and 36.2% somewhat agreed that providing vaccination consultations is a role that community pharmacists should play. In contrast, 17.3% of the respondents agreed and 36.9% somewhat agreed that vaccine promotion should be part of the pharmacist’s role.
| Agree | Somewhat agree | Neither agree nor disagree | Somewhat disagree | Disagree | |
|---|---|---|---|---|---|
| Consultation on vaccination is the community pharmacist’s role | 164 (36.9) | 161 (36.2) | 87 (19.6) | 20 (4.5) | 13 (2.9) |
| Promotion of vaccination is the community pharmacist’s role |
77 (17.3) | 164 (36.9) | 145 (32.6) | 41 (9.2) | 18 (4.0) |
Data given as number (percentage).
Chi-square analyses (Fig. 1A–B) showed that the experience rate of vaccine promotion was significantly higher among community pharmacists aware of Japan’s low vaccine confidence than among those who were not (71.6% vs. 55.0%, P < 0.001). Similarly, vaccine promotion experience was significantly higher among community pharmacists with a positive attitude toward vaccine promotion than among those with a negative attitude (81.0% vs. 25.0%, P < 0.001). Although the vaccine promotion experience tended to increase with years of practice as a pharmacist, no association was found with gender, health support pharmacy certification, or prescriptions per day (data not shown).
Relation to experience with vaccine promotion. (A) Association between experience with vaccination promotion and knowledge that Japanese people have the lowest vaccine confidence worldwide. Those who responded “I knew that” or “I’ve heard that but don’t know much about it” in Table 3 were classified as the “Recognizing group” (n = 236), and those who answered “I didn’t know that” were classified as the “Nonrecognizing group” (n = 171). Chi-square test: ***, P < 0.001. (B) Association between experience with vaccination promotion and attitude to vaccination promotion. Those who responded “Agree” or “Somewhat agree” in Table 4 were classified as the “Positive group” (n =216), and those who responded “Somewhat disagree” or “Disagree” were classified as the “Negative group” (n = 52). Chi-square test: ***, P < 0.001.
Respondents reported that training for pharmacists (76.9%), patient leaflets (64.3%), collaboration with hospitals or clinics (37.0%), education for pharmaceutical students (30.7%), and remuneration (29.6%) were needed to expand the vaccine-related roles of community pharmacists (Table 5).
| n | (%) | |
|---|---|---|
| Training for pharmacists | 343 | (76.9) |
| Leaflets for patients | 287 | (64.3) |
| Collaboration with hospitals or clinics | 165 | (37.0) |
| Education for pharmaceutical students | 137 | (30.7) |
| Remuneration | 132 | (29.6) |
| Consulting space | 64 | (14.3) |
| Other | 15 | (3.4) |
| Nothing | 11 | (2.5) |
Approximately 40% of the respondents agreed (16.8%) or somewhat agreed (20.9%) that they would willingly administer vaccines (Fig. 2A). Among those who responded “neither agree nor disagree” (24.9%), “somewhat disagree” (20.9%), and “disagree” (15.0%), approximately 40% of the respondents agreed (6.3%) or somewhat agreed (33.9%) that they would administer vaccines if requested by the Japanese government (Fig. 2B). Overall, 62.1% (277/446) of the respondents were amenable to pharmacists administering vaccines, whereas 17.0% (76/446) were unwilling even if requested. Respondents cited several concerns: lack of skill in administering vaccines (83.3%), fear of anaphylaxis (63.6%), risk of administration error (59.2%), insufficient staffing (54.5%), and lack of knowledge (52.3%) (Table 6). These concerns were raised by both pharmacists reluctant to administer vaccines and those amenable to the role (data not shown).
Community pharmacists’ attitudes toward vaccine administration. (A) Willingness to administer vaccines if allowed (n = 446). (B) Willingness to administer vaccines if requested by the Japanese government; answered only by those who selected “neither agree nor disagree,” “somewhat disagree,” or “disagree” in Fig. 2A (n = 271).
| n | (%) | |
|---|---|---|
| Lack of vaccine administration skills | 339 | (83.3) |
| Fear of anaphylaxis | 259 | (63.6) |
| Administration error | 241 | (59.2) |
| Lack of community pharmacy staff | 222 | (54.5) |
| Lack of knowledge | 213 | (52.3) |
| Preparation or temperature management error | 86 | (21.1) |
| Conflict with doctor | 37 | (9.1) |
| Other | 21 | (5.2) |
| Nothing | 6 | (1.5) |
Several reports have examined pharmacists’ attitudes and experiences regarding vaccines.15,16,17,18,19,20,21,22 In Japan, however, no prior studies have evaluated the role of community pharmacists in vaccinations. This study is the first to investigate their attitudes and experiences with vaccine consultation and promotion, as well as their perceptions of pharmacists administering vaccines.
The results showed that only approximately 60% of community pharmacists reported experience with vaccine promotion. Our findings suggest that awareness of Japan’s low vaccine confidence and a positive attitude toward vaccine promotion were associated with such experience. Most respondents believed that training was necessary for pharmacists to expand their roles in vaccine consultation and promotion. More than 60% of the respondents were amenable to administering vaccines, though many expressed concerns about limited vaccine administration skills and managing anaphylaxis.
Most of the respondents trusted vaccine effectiveness and recognized vaccine hesitancy as a global issue. However, approximately 40% did not know that Japan has the lowest vaccine confidence worldwide, indicating that some pharmacists did not recognize vaccine hesitancy as a Japanese problem.
Health care providers have been reported to be the public’s most trusted advisors,24 and most respondents had provided vaccine-related consultations. The most common topics were the COVID-19 vaccine, followed by the influenza and pneumococcal vaccines. This likely reflects the survey period (May–July 2022), when COVID-19 vaccination was widespread. Because elderly people commonly visit community pharmacies, consultations on influenza, pneumococcal, and zoster vaccines were more frequent than those on the HPV vaccine or childhood vaccines. Consultations on the HPV vaccine were particularly low because the Japanese MHLW suspended proactive HPV vaccination recommendations from 2013 to 2022.
Vaccination promotion is identified as a responsibility of health care providers in the MHLW’s “Basic Plan on Immunization.”25. A prior study also showed that influenza vaccination rates increased when community pharmacists promoted the vaccine.23 However, only ~60% of the respondents in our study had experience with vaccine promotion. This may reflect the proactive nature of promotion, in contrast to consultation, which is reactive. In addition, fewer respondents viewed vaccine promotion as part of the community pharmacist’s role compared with vaccine consultation. Promotion experience was significantly higher among pharmacists with a positive attitude toward pharmacists’ involvement in vaccine promotion. A previous study also showed that positive attitudes toward the HPV vaccine were associated with recommending it.18 Therefore, improving community pharmacists’ attitudes toward their role in vaccine promotion appears essential. Raising awareness of Japan’s low vaccine confidence may also increase promotion activity, given the higher promotion experience among those who recognized the problem.
Most respondents believed that pharmacist training is necessary to enhance vaccine-related activities, suggesting concerns about vaccination knowledge. A review of vaccine hesitancy and health care providers reported that health care providers with stronger vaccine knowledge are more confident and more likely to promote vaccination.26 Accordingly, knowledge acquisition is important for increasing pharmacists’ engagement in vaccine promotion. However, current university curricula and pharmacist training in Japan remain insufficient to support this role, indicating a need for educational improvement. Our findings also suggest that pharmacy-distributed leaflets should be improved, as many of the respondents indicated that accessible patient information materials are essential.
The Japanese government does not currently allow pharmacists to administer vaccines. In this study, more than 60% of the respondents were amenable to vaccine administration—either because they were willing to take on the responsibility or would agree if requested by the Japanese government. Allowing pharmacists to administer vaccines during a future pandemic could help address Japan’s shortage of vaccinators. However, many of the respondents, including both reluctant and willing pharmacists, expressed concerns about technical skills, anaphylaxis occurrence, and the risk of administration errors when administering vaccines. These concerns suggest broad anxiety about the technical aspects of vaccination, regardless of their attitude toward the act of vaccination, likely because Japanese pharmacists have no experience administering vaccines. More than half of the respondents also expressed concern about their lack of knowledge, suggesting that pharmacists must have adequate vaccination knowledge. Therefore, to prepare pharmacists for potential future responsibilities, they would need appropriate training in vaccine administration knowledge and skills. In November 2021, the Japan Pharmaceutical Association established the “Vaccination Training Program for Pharmacists,”27 and training sessions have begun in some regions. Several Japanese universities have also introduced preclinical injection-skills training within pharmacy curricula. Such educational initiatives are expected to expand nationwide, and their effectiveness should be evaluated in future studies. Some of the respondents also expressed concerns about staffing shortages in community pharmacies, suggesting apprehension that vaccine administration could increase their workload if added to pharmacists’ responsibilities.
A limitation of this study is the response rate of just under 50%, which may bias the sample toward pharmacists with greater interest in vaccination. Indeed, the proportion of respondents with health support pharmacy certification (14.1%) was higher than the national average (~5%).28 Thus, caution is needed when generalizing the findings. Self-reported data may also be subject to respondent recall and social desirability bias. Another limitation is that the study was conducted during the COVID-19 pandemic, and consultation experience with the COVID-19 vaccine was overwhelmingly higher than for other vaccines. Accordingly, attitudes toward vaccine promotion by community pharmacists may have been influenced by the COVID-19 pandemic, highlighting the need for further investigation of the attitude toward each vaccine.
This study aimed to investigate issues affecting the prevalence of the vaccine-related roles of Japanese community pharmacists to address Japanese vaccine hesitancy and improve vaccination rates. The results showed that the proportion of community pharmacists with experience in vaccine promotion was not high. Our findings suggest that raising awareness of vaccine hesitancy in Japan, improving attitudes toward community pharmacists’ role in vaccine promotion, and providing training may help increase engagement in vaccine promotion. Additionally, more than 60% of the respondents were amenable to administering vaccines. As education and training to improve vaccination skills and knowledge expand in Japan, more pharmacists may become prepared to assume this role if permitted.
The authors would like to express their gratitude to the community pharmacists who participated in this survey. This research was funded by Pfizer Medical Grants (grant number 59204475).
The authors have declared that no conflict of interest exists.
