Discussion

Main Results

This national survey was conducted to explore the perceptions and attitudes of future pharmacists on their new missions in vaccination since the role of community pharmacists has been recently strengthened by the authorization to administer and prescribe all vaccines of the vaccination calendar for people aged 11 and over. Of the 24 faculties of pharmacy in France, 18 were represented in this survey, which was completed by 231 students. Almost all students were favorable to vaccination in general (99%) and were up to date with mandatory vaccinations for health students (>96%). Regarding the pharmacist’s new vaccination missions, most students were in favor of administering (97%) and prescribing (92%) vaccines in pharmacies, mainly mentioning the valorization of the pharmacist’s profession (>88%) and easiest access to vaccination for patients (>90%). Moreover, a large majority of respondents (89%) felt well trained to promote and administer vaccination after graduation. More than half of the students (68%) have already had professional experience in promoting and/or administering vaccines, mainly in community pharmacies (97%), which was significantly associated with their willingness to promote vaccination after graduation (p<0.0001). We found that students were eager to continue training in vaccination after they had graduated (>93%), which was associated with their motivation to ensure the pharmacist’s new missions in vaccination (p<0.001). Vaccines’ Administration by Pharmacists

In a previous study conducted in 2013, 75.3% of French finalyear pharmacy students surveyed were in favor of administering vaccines in pharmacies [14]. Students’ interest seems to evolve according to the professional and political environment in which they practice because, a decade later, 97% of final-year pharmacy students (who participated in the present survey) were in favor of vaccines administration in pharmacies. Indeed, four years after the generalization of vaccination in pharmacies and the gradual extension of the target patients and vaccines that can be administered by pharmacists, this new mission is no longer a novelty for pharmacists, students, and the population, who are therefore more in favor of it. This has been observed in other countries where the administration of vaccines by pharmacists is very well accepted by pharmacists themselves and the population [15, 16]. Furthermore, the accessibility offered by pharmacies, pharmacists’ availability, and their relationship of trust established with patients were often mentioned as factors in favor of vaccination by the pharmacists [11, 17, 18]. Ultimately, providing vaccination in community pharmacies has shown to be effective to increase vaccination coverage, as in England, where flu vaccination coverage among people aged over 65 increased from 59% in 2005 to 76% in 2008, after pharmacists were authorized to vaccinate [17]. Similarly, the French students seemed motivated to extend their vaccination missions arguing the need to facilitate access to vaccination for patients (>90%), to increase vaccination coverage (>87%) and to strengthen pharmacist/patient relationship (>75%). Based on these observations, it is likely that in countries and territories where vaccination by pharmacists is implemented, the population’s opportunities to be vaccinated should be increased, particularly for people who are furthest from the healthcare system, hopefully resulting in a reduction of territorial inequalities in access to prevention and an increase of vaccination coverage [15, 17]. However, such impact of French pharmacists on vaccine coverage has yet to be investigated.

Vaccines’ Prescription by Pharmacists

Regarding the act of prescribing, in 2013, 67.5% of students surveyed preferred vaccination to be prescribed by physicians [14]. After a substantial change in the law, in 2023, and even though 92% of students were in favor of prescribing vaccines and 89% felt well trained in promoting and administering vaccination, only 78% of French students reported being ready to administer a vaccine following their own prescription. Moreover, some students of our study expressed a fear of practicing the acts of prescribing (n=10) vaccines. It is therefore essential to have a comprehensive, clear, up-to-date training during the pharmacy curriculum to give the students skills and confidence to offer this service after graduation, as highlighted in Australian and Canadian studies [19, 20].

Initial and Continuing Vaccination Training

We can imagine that a vaccination policy authorizing pharmacists to administrate and prescribe vaccines can only be fully effective when the initial training of pharmacy students is complete and comprehensible. Most faculties seem to have covered the basis of vaccination (e.g., immunological mechanism of action, vaccine recommendations). But there are still some very important concepts that don’t seem to be systematically covered, or at least students don’t remember them as much, such as pharmacovigilance, the handling of adverse reaction and the French vaccination network, particularly the health professionals authorized to prescribe and vaccinate (76%). These are concepts that deserve to be emphasized in the initial training of pharmacy students. It is essential to provide students with up-to-date, scientifically accurate vaccine training, as it has been shown that most health students consider lectures to be the most important source of information on vaccination [21]. It would be interesting to combine this theoretical initial training with less conventional learning methods, as suggested or tried out with pharmacy students, in order to increase their practical skills and confidence in promoting and providing vaccination in pharmacy, e.g., role-playing and communication, mixed reality, interprofessional practice, simulation classes on the technical gesture of administration [11, 20, 22-25]. This enables to give future pharmacists the tools they need to promote over-the-counter vaccination and provide this vaccination service, keeping in mind that this study showed that students’ satisfaction with their initial training was significantly associated with their willingness to promote vaccination afterwards (p<0.0001). Moreover, the present study highlights the importance of continuing training on vaccination after graduation, with 93.5% of students being eager to take part in vaccination continuing training. It had also been shown that pharmacists in practice consider vaccination continuing training as necessary to improve their theoretical and practical skills [11].

In addition, it was found that students who practiced vaccination as part of their professional experience were more confident and comfortable promoting and providing vaccination [25]. This is in line with the results of our study, where students’ work experience in vaccination was significantly associated with promoting vaccination after graduation (p<0.0001). So, the very positive attitude of French pharmacy students towards the extension of their vaccination missions and their strong motivation show their very likely commitment on vaccination in the future and could prove the relevance of developing these new missions in other countries.

Strengths and Limitations

The main strengths of this survey are the following. To the best of our knowledge, this is the first national study conducted in France to assess pharmacy students’ perceptions and attitudes about the pharmacist’s new missions in vaccination. Eighteen faculties are represented in this survey, which therefore provides a degree of territorial representativeness of all French students in their 6th year of pharmacy. Moreover, this survey was conducted between September and December 2023, i.e., right after the authorization of pharmacists to prescribe vaccines in August 2023. Therefore, questions related to vaccines’ prescription by pharmacists were concrete and up-to-date with vaccination evolutions, unlike previous studies which questioned the opinion of pharmacists and pharmacy students on the hypothetical vaccines’ prescription by pharmacists. However, this study also presents some limitations. Each year in France, about 1,500 students are enrolled in the final year of pharmacy in the community pharmacy curriculum. Therefore, with 231 respondents to our survey, the participation rate was only 15.4%. This rate is law but not surprising for such national survey. In a previous study conducted in 2013 exploring the perception of vaccination among French pharmacy students, the participation rate was at 9.8% [14]. However, our low participation rate leads to a risk of non-representativeness of our sample as a selection bias cannot be excluded and caution must be taken in the generalization of our results.

Conclusion

In conclusion, the French legislation has recently authorized pharmacists to administer and prescribe vaccines. To support pharmacists in these new missions, the initial and continuing training of pharmacy students should regularly evolve to include practical training in both administering and prescribing vaccines. It was important to ensure that these new missions generate interest and motivation among pharmacy students, so they can become driving forces of the vaccination missions in community pharmacy after their graduation. This national survey indeed showed the willingness and enthusiasm of future pharmacists to offer these new services and promote vaccination in community pharmacies, in order to contribute to the country’s public health. Multiplying the number of professional offering vaccination should increase opportunities for the population to be vaccinated and might ultimately increase vaccination coverage. However, the coordination between these various health professionals involved in vaccination and the impact of these new legislations on vaccination coverage remains to be investigated. 

Supplementary Materials

Students’ general opinions towards vaccination

1. Concerning vaccination in general, would you say you are:

• Very favorable, favorable, not very favorable, not at all favorable.

2. Have you been vaccinated against:

• Hepatitis B: yes, no, I haven’t had all the boosters, I don’t know.
• Diphtheria-tetanus-poliomyelitis (DTP): yes, no, I haven’t had all the boosters, I don’t know.
• Pertussis: yes, no, I haven’t had all my booster shots, I don’t know.
• Measles-mumps-rubella (MMR): yes, no, I haven’t had all my booster shots, I don’t know.
• COVID-19: yes, no, I haven’t had all my booster shots, I don’t know.
• Human papillomavirus (HPV): yes, no, I haven’t had all my booster shots, I don’t know.

Pharmacy students’ initial training on vaccination

3. During your curriculum, what did you learn about vaccination? (Multiple answers)

• The immunological mechanism of action,
• The different types of vaccines,
• Vaccination recommendations,
• Healthcare professional authorized to vaccinate,
• Vaccine administration training,
• Pharmacovigilance/risk benefit/possible adverse events,
• Contraindications
• Other: (Open answer)
• We did not discuss vaccination during my curriculum.

4. Would you say that you are sufficiently trained to promote and administer vaccination?

• Strongly agree, agree, disagree, strongly disagree.

5. As part of a student job or an internship, have you ever promoted vaccination and/or administered vaccines?

• Yes, No
• If yes: in which structure (vaccination center, pharmacy, etc.) (Open answer)

6. Are you willing to promote vaccination once graduated?

• Strongly agree, agree, disagree, strongly disagree, depends on the vaccine.

Students’ knowledge, perceptions, attitudes, and behaviors towards the extension of pharmacists’ vaccination missions

7. In 2023, can pharmacists administer vaccines in their pharmacies?

• Yes, only influenza vaccines and COVID-19
• Yes, 16 vaccines in all (influenza, COVID-19, DTP, pertussis, HPV, pneumococcus, Hepatitis A and B, Meningococcus A, B, C, Y and W, Rabies)
• No
• Don’t know

8. Have you ever been vaccinated by a pharmacist?

• Yes, No

9. Are you in favor of pharmacists administering vaccines?

• Very favorable, favorable, not very favorable, not at all favorable
• If not at all favorable/unfavorable, why (multiple choices): fear of conflict with other healthcare professionals, pharmacy premises unsuitable for vaccinating patients, timeconsuming activity for the pharmacist, not remunerated enough (€7.50), fear of carrying the act of administration, not in favor of vaccination in general, does not feel sufficiently well trained, other (Open answer).
• If very favorable/favorable, why (multiple choices): valorization of the profession of pharmacist, collective and individual protection, fee-for-service remuneration (€7.50), helps relieve overcrowding in doctors’ offices, increase in vaccination coverage, strengthened pharmacist/patient relationship, facilitating the vaccination process for patients, other (Open answer).

10. Are you in favor of pharmacists prescribing vaccines?

• Very favorable, favorable, not very favorable, not at all favorable
• If not at all favorable/unfavorable, why (multiple choices): fear of conflict with other healthcare professionals, requires taking additional prescription training (17.5h), time-consuming activity for the pharmacist, not remunerated enough (€9.50), fear of the act of prescription, not in favor of vaccination in general, other (Open answer).
• If very favorable/favorable, why (multiple choices): valorization of the profession of pharmacist, collective and individual protection, fee-for-service remuneration (€9.50), helps relieve overcrowding in doctors’ offices, increase in vaccination coverage, strengthened pharmacist/patient relationship, facilitating the vaccination process for patients, other (Open answer).

11. Would you agree to administer a vaccine to patients in a pharmacy?

• On a doctor’s prescription: Strongly agree, agree, disagree, strongly disagree, it depends on the vaccine.
• On a nurse’s prescription: Strongly agree, agree, disagree, strongly disagree, depends on the vaccine.
• On your own prescription: Strongly agree, agree, disagree, strongly disagree, depends on the vaccine.

12. Would you advise your loved ones to be vaccinated by a pharmacist?

• Yes, no, depends on the person, depends on the vaccine.

13. Do you think that vaccination in pharmacies (prescription and administration) would facilitate the vaccination process for patients?

• Strongly agree, agree, disagree, strongly disagree.

14. Do you think that vaccination in pharmacies (prescription and administration) would help to reduce territorial inequalities and inequalities in access to healthcare for people who are furthest from the healthcare system?

• Strongly agree, agree, disagree, strongly disagree.

15. Do you think that vaccination in pharmacies (prescription and administration) would increase vaccination coverage in targeted populations?

• Totally agree, agree, disagree, totally disagree.

16. As part of your continuous professional development, would you be willing to attend training and/or e-learning courses on vaccination and its promotion during your professional practice? 

• Yes, No, Don’t know

17. In general, what do you think of the extension of pharmacists’ vaccination missions?

• Very favorable, favorable, not very favorable, not at all favorable

Characteristics of the respondents

18. You are:

• A male
• A female
• Other
• I prefer not to specify.

19. How old are you? (Open answer, only numbers are accepted)

20. What is your faculty of origin?

• Angers
• Clermont-Ferrand
• Dijon
• Grenoble
• Lille
• Limoge
• Lyon
• Marseille
• Montpellier
• Nancy
• Nantes
• Paris Cité
• Poitiers
• Reims
• Rennes
• Strasbourg
• Toulouse
• Tours

Supplementary Material S1: Questionnaire for French students in their final year of pharmacy in the community curriculum.

Table S2: Characteristics of students, their gender, age, and faculty of origin.

Acknowledgments:

We would like to thank Pr. Raphael Duval, Dean of the Nancy Faculty of Pharmacy, for his support in sharing our survey with his fellow Deans of all the faculties of pharmacy in France. We would also like to extend our gratitude to all the other Deans and Professors who sent our survey to their students. Finally, we would like to thank all the pharmacy students who completed the questionnaire.

Author Contributions

Conceptualization, M.D., M.S., N.T.; Methodology, M.D., M.S., N.T.; Software, M.D.; Validation, M.S., F.D., N.T.; Formal Analysis, M.D.; Investigation, M.D.; Writing – Original draft, M.D.; Writing – Review & Editing, M.S., F.D., N.T.; Supervision, M.S., F.D., N.T.

Conflicts of interest: The authors declare no conflict of interest.

Funding: This research received no external funding.

Ethical statement: The survey was completely anonymous at all stages, and as this research was not interventional, ethical approval was not required according to the French legislation.

Data availability statement: Data are available upon request to the corresponding author.

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