Pharmacist-Led Flu Vaccination Services in Romanian Community Pharmacies: Barriers, Perceptions, and Implementation Challenges

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript entitled
“Pharmacist-Led Vaccination Services in Romanian Community Pharmacies: Barriers, Perceptions, and Implementation Challenges”

General comments and summary

This is a well-conducted and timely mixed-methods study addressing an important and policy-relevant topic: the implementation readiness of pharmacist-led vaccination services in Romanian community pharmacies that do not yet provide such services. The focus on non-implementing pharmacies represents a clear and valuable contribution, as most existing studies concentrate on early adopters or already active vaccination providers.

The manuscript is generally well written, methodologically sound, and supported by a comprehensive dataset. The combination of quantitative survey data with qualitative thematic analysis is a strength and allows for a nuanced understanding of both structural and attitudinal barriers. The results are rich and informative, and while the volume of findings is substantial, it appears justified given the exploratory and descriptive aims of the study.

I believe the manuscript is suitable for publication after minor revisions, primarily aimed at improving methodological transparency and strengthening the balance and contextualization of the discussion.

Major comments

1. Clarification of recruitment strategy and sampling pathways

While the overall study design is appropriate, the description of participant recruitment would benefit from greater specificity. In particular, it remains somewhat unclear:

• What is meant exactly by “local branches of the College of Pharmacists,” pharmacy associations, and pharmacy chains? Is the Colle the “board of pharmacy” or university?
• How were these entities approached (centralized national contact vs. regional/local branches)?
• Were invitations distributed uniformly across regions and pharmacy types, or did some channels contribute more heavily than others?
• To what extent were chain pharmacies recruited via corporate structures versus individual pharmacists responding independently?

Providing additional detail on these points would improve transparency and allow readers to better assess potential selection effects. Even if precise response rates cannot be calculated due to the snowball approach, a clearer narrative description of recruitment pathways would strengthen the methodological section.

2. Interpretation of patient trust and perceived preference for physicians

The finding that pharmacists perceive patients to prefer vaccination by family doctors is highly relevant and clearly presented. However, the discussion would benefit from a more explicit acknowledgment that international evidence on patient trust in pharmacists is heterogeneous, and in some settings contradicts these perceptions.

For example, a study from Germany (and other European countries) report high patient satisfaction, perceived safety, and trust in pharmacist-administered vaccinations, including among populations that would otherwise not seek vaccination. This contrast suggests that the observed Romanian perceptions may reflect contextual, cultural, or systemic factors rather than a universal lack of patient trust in pharmacists. At least, it should be mentioned, that these results differ from other countries, which can be due to the overall reputation and standing of the pharmacies in Romania (?).

Explicitly acknowledging these opposing findings would strengthen the discussion and avoid an overly one-directional interpretation. It would also support the authors’ argument that current perceptions may be self-limiting and modifiable through experience, policy support, and public exposure.

Suggested revision:
In the Discussion, add a short paragraph contrasting the Romanian findings with international evidence (e.g., Germany), emphasizing that pharmacist trustworthiness appears context-dependent and evolves with service normalization.

Minor comments

3. Questionnaire transparency

Although the questionnaire is described in sufficient detail, readers would benefit from access to the full instrument.

Suggestion:
Consider providing the questionnaire as a supplementary file or, at minimum, clarifying which sections or items were adapted from prior work versus newly developed. Shorten the description in this case.

4. Statistical interpretation

The statistical analyses are appropriate and well executed. However, given the large number of comparisons, a short acknowledgment of the exploratory nature of the analyses would be helpful.

Suggestion:
Add a brief sentence in the Statistical Analysis section (Methods) or Limitations noting that findings should be interpreted in an exploratory context.

Conclusion of the review

Overall, this is a strong and relevant manuscript that makes a meaningful contribution to the literature on pharmacist-led vaccination and implementation science. The data are rich, the mixed-methods approach is appropriate, and the focus on non-implementing pharmacies fills an important gap.

The suggested revisions primarily concern clarification and contextualization rather than substantive changes to the results. I am confident that addressing these points will further strengthen the manuscript and enhance its impact for both researchers and policymakers.

Author Response

We would like to thank the reviewer for the thoughtful and constructive comments, which have greatly improved the quality of our manuscript. We carefully considered each suggestion and have revised the manuscript accordingly. Below, we provide a detailed, point-by-point response. All reviewer comments are followed by our responses in blue italics and a description of the changes made in the revised version of the manuscript.

 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript focuses on the potential for pharmacist vaccination services in Romania. This manuscript could be improved by addressing the following issues:

Title: The survey only focused on flu vaccination. Flu should be added to the title "Pharmacist-led flu vaccination services..."

Introduction line 75: Need a citation for the vaccination in pharmacies is associated with high levels of patient satisfaction.... sentence.

Introduction line 100: Need a citation for the studies show ... sentence

Introduction line 109: Need a citation for the first sentence of this paragraph.

Introduction line 109: What does it mean that pharmacists have the capacity to promote vaccination? Do you mean training and education or do you mean time/availability?

Introduction: Overall, this introduction does not motivate the research project. Why study Romanian pharmacists specifically? This intro section needs to have a paragraph added about the practice of pharmacy in Romania. It's hard to follow the results without an understanding of this and it's unclear why the project is needed without this in the background. 

Methods 2.2 Statistical analysis: This is not all statistical analysis. I recommend you rename this section Analytic methods.

What are "pharmacy organizations"?

Were any adjustments made for multiple statistical comparisons?

Why is there an entire paragraph on the regional geographic distribution of the pharmacies? This might matter, but without any context regarding how Romania funds/manages pharmacy care, it makes no sense to the reader.

Results line 276: what is the p value for? 

Results line 3924-296: this sentence is not needed

Results Theme 4 line 435-437: this is not a result. It belongs in the Discussion.

Overall, in the themes there are a lot of claims that are not backed up by data. Much of this belongs in a Discussion.

 

 

Author Response

We would like to thank the reviewer for the thoughtful and constructive comments, which have greatly improved the quality of our manuscript. We carefully considered each suggestion and have revised the manuscript accordingly. Below, we provide a detailed, point-by-point response. All reviewer comments are followed by our responses in blue italics and a description of the changes made in the revised version of the manuscript.

 

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have done a great job responding to the review feedback and the manuscript is much improved. There are just a few issues that should be addressed:

1. Line 119 - I think a dash is needed in the reference numbering so that it reads 12-22
2. Line 126 - this sentence needs to be slightly re-written. I suggest something like "Previous research examined early adopters and found high patient satisfaction. However, the vast majority of pharmacies (>93%) do not yet offer vaccination services due to concerns about renumeration." (25)
3. Line 128 - need to make clear that the 'non-vaccinating majority' are the pharmacists, not patients. Just needs a slight re-write.

Author Response

Comment 1: Line 119 - I think a dash is needed in the reference numbering so that it reads 12-22

Thank you for noting this. The reference range has been corrected to read 22 (a typo after Track changes).

Comment 2: Line 126 - this sentence needs to be slightly re-written.

We thank the reviewer for this helpful suggestion. The sentence has been revised as recommended to clarify the distinction between early adopters and the majority of pharmacies that do not yet offer vaccination services, and to explicitly attribute this to concerns regarding remuneration.

Comment 3: Need to make clear that the ‘non-vaccinating majority’ are the pharmacists, not patients.

We agree with the reviewer and have revised the wording to explicitly state that the non-vaccinating majority refers to pharmacists, thereby removing any potential ambiguity.