This study aimed to understand pharmacists’ willingness to provide FITs for CRC screening through their pharmacy, potential drivers of willingness, and to explore their stipulations for willingness. The results of this study will help to inform program development and training needs for implementation of PharmFIT^™.

We conducted a national survey of community pharmacists in the US between September 2022 and January 2023. The survey included pharmacists who were members of three different online survey market research panels contracted with QualtricsXM (Provo, UT; https://www.qualtrics.com), an online survey research company. Members of panel 1 were pharmacists nation-wide who doubled opted-into the panel, and all members were verified through their official state-issued pharmacist license. Members of panel 2 were members of American Medical Association (AMA) database who identified as pharmacists, double opted-into panel membership, and whose credentials were verified by a panel management team. Finally, the members of panel 3 were pharmacists who were recruited into the panel (internal referrals, social media posts, or were from purchased lists from other panels contracted with QualtricsXM).

We recruited participants using purposive sampling methods. Eligible participants were licensed pharmacists who were practicing in community pharmacies across the US, including US territories (as pharmacy practice is governed similarly to US states), and approximately half (+/− 10%) were women. QualtricsXM contacted potential participants via email and sent email reminders to them. Respondents were compensated by Qualtrics. Non-mutually exclusive sampling quotas were applied so that half of our sample was female (+/− 10%) and a third worked in independent pharmacy practice.(15) Qualtrics pilot tested the survey with 63 pharmacists to ensure our survey’s functionality. No data from pilot respondents was retained. A total of 1,452 pharmacists accessed our survey. After excluding ineligible respondents based on our inclusion criteria and survey data quality checks (n=474), we had a final sample of 578 pharmacists who completed the survey, yielding a survey response rate of 59% (578/978) (Supplementary File Figure S1).(15) Retained respondents came from 41 states in the US, Washington D.C., and Puerto Rico.

The University of North Carolina Institutional Review Board approved this study (IRB# 18–1337).

The PharmFIT^™ National Pharmacist Survey was developed by a multidisciplinary team comprising health services researchers, physicians, pharmacists, and other research staff. It consists of 81 items adapted from past publications and newly developed items.(12,16,17) In this study, we focus on pharmacists’ willingness to provide PharmFIT^™ and their perception of the complexity of providing PharmFIT^™. The entire survey can be accessed online: [https://dataverse.unc.edu/dataverse/cpcrn-4cnc-pharmfit]

We used descriptive statistics to characterize our survey sample. We described the proportion of respondents willing to implement each step of PharmFIT^™ as well as PharmFIT^™ overall in three groups: “Strongly Disagree” or “Disagree”; “Neither Agree nor Disagree”; and “Agree” or “Strongly Agree”. To analyze perceived complexity, we calculated a mean score for the scale.(11) Higher scores indicated lower perceived complexity of PharmFIT^™ provision. We used multiple linear regression with complete case analysis (n=503; data missingness due to non-responses to survey item assessing if the pharmacy provided non-dispensing services (Supplementary File Figure S1)) to identify correlates of respondents’ perceived complexity of providing PharmFIT^™. Perceived complexity, which asks individuals to consider how difficult it would be to integration an innovation, like PharmFIT^™, into existing practice, is associated with professional and practice setting characteristics.(18) Thus, our model adjusts for professional and practice setting characteristics.

We used multiple logistic regression with complete case analysis (n=563; data missingness due to non-responses to survey item assessing respondents’ years of practice (Supplementary File Figure S1)) to identify correlates of respondents’ overall willingness to provide PharmFIT^™. For the logistic regression model, we dichotomized the overall willingness item, classifying “Strongly Disagree,” “Disagree,” and “Neither Agree Nor Disagree,” as being unwilling and “Agree,” and “Strongly Agree” as being willing to provide PharmFIT^™ as responses were not normally distributed. Willingness to provide PharmFIT asks individuals to consider how willing they would be to provide PharmFIT^™ based on both their personal characteristics (e.g., being an early adoptor or a laggard(18)) as well as their professional and practice setting; thus, we adjusted for both in this model.

We conducted all analyses using STATA 16.1 (Stata Corp, College Station, TX) and all test statistics were two-tailed with a critical alpha=.05.

The data generated in this study are available upon request from the corresponding author.

The average age of the final sample was 47 years, about half was female, and majority identified as Non-Hispanic White. The average years of practice was 21 years, about two third of respondents practiced in independent or national chain pharmacies, and most practiced full-time (Table 1).

Overall, most pharmacists (80%) were willing to provide PharmFIT^™ for their patients (Figure 1). Most were willing to discuss FIT eligibility with their patients (79%) and provide instructions on how to complete a FIT (83%). Over two-third of pharmacists were willing to remind patients about completing a FIT (68%) and discuss FIT test results with patients (68%). About half of pharmacists were willing to refer patients for a colonoscopy after a positive FIT result (50%).

A minority of pharmacists (20%, 115/578) indicated that they either disagreed or strongly disagreed for the item assessing overall willingness to provide PharmFIT^™ in their pharmacy (Table 2). Over half of these respondents indicated that they would be willing to provide this program if the FIT results be reported to the patient’s healthcare provider (60/115, 52%). Around half of respondents stipulated that if they receive adequate training to properly deliver FIT (55/115, 48%) or that the PharmFIT^™ service be well integrated in their pharmacy workflow (53/115, 46%) for them to be willing. Fewer respondents rated the other stipulations as important design characteristics to address prior to being willing to provide PharmFIT^™. Very few respondents (4/115; 4%) indicated that none of these stipulations would alter their willingness to provide PharmFIT^™. Addressing the top three stipulations among this group of responders (accounting for unique responses only; n=87) would increase overall pharmacist willingness to provide PharmFIT to over 95% (550/578).

Between 62%-80% of pharmacists indicated that PharmFIT^™ would not be complex to provide for their patients (mean=3.8; SD=.74; scale ranging from 1–5). Correlates of PharmFIT complexity are shown in Table 3. Pharmacists who have been in practice longer indicated lower complexity of providing PharmFIT^™ (β= 0.013; CI_95%: 0.01–0.02). Pharmacists who had higher levels of CRC screening knowledge indicated lower complexity of providing PharmFIT^™ (β= 0.085; CI_95%: 0.01–0.16). Finally, pharmacists who practiced in independent pharmacies indicated lower complexity of providing PharmFIT^™ compared to those practicing in national chain pharmacies (β= 0.265; CI_95%: 0.06–0.47).

Correlates of pharmacists’ willingness to provide PharmFIT^™ to their patients are reported in Table 4. As pharmacists’ appraisal of PharmFIT^™ complexity decreased, they were more likely to report being willing to provide PharmFIT^™ (OR:5.68, CI_95%: 3.96–8.15). As the number of patient care services offered the pharmacy increased, pharmacists were more willing to provide PharmFIT^™ (OR: 1.18, CI_95%: 1.01–1.39).

First, careful preparation of both data flow and care coordination between the pharmacy and PCP must be established prior to implementing PharmFIT^™ to ensure patient safety. Pharmacists responding to this survey who indicated unwillingness to provide PharmFIT^™ cited these two areas as caveats for willingness. Findings from this survey are corroborated by our previous formative research of patients, pharmacists, and PCPs cited similar implementation considerations.(11–14,19) Further, in the collaborative design of the PharmFIT^™ pilot implementation studies,(22) careful consideration was placed on the care coordination component.(23) The literature has consistently shown that coordinated care leads to better patient outcomes and lower health care costs.(24–26) And further, there is potential for coordinated care to expand patient perception of who is part of their “care team.” For example, cancer screening patient navigation, in which a dedicated person (the navigator) works one-on-one with a patient to address barriers to care, is known to improve adherence to cancer screening across multiple cancers.(27,28) Studies that have integrated the navigator into the patients’ clinical care delivery, both physically and virtually, with electronic access to patient records, have shown increased programmatic success due, in part, to patients perceiving the navigator as part of the care team.(29,30) Future iterations of PharmFIT^™ should ensure a coordinated approach to CRC screening services delivered in the pharmacy to maximize the likelihood of successful implementation.

Second, training and education for pharmacists to build an understanding of colorectal cancer and screening prior to implementing PharmFIT^™ is critical. Most of our pharmacist respondents were highly willing to implement PharmFIT^™, but among those initially unwilling, proper training in the provision of FIT kits was among the top caveats. Baseline knowledge around CRC and screening is variable, as revealed in both our qualitative(19) and quantitative(31) work. Our previous analysis revealed that just 5% of pharmacist respondents correctly answered all knowledge questions about CRC, CRC screening, and FIT, reinforcing the need for consistent, comprehensive training and education around CRC screening prior to implementing PharmFIT^™. Moreover, in qualitative interviews with patients who were eligible for CRC screening, patient trust in their healthcare provider was critical, underpinned by the provision of knowledgeable communication and counseling around this patient care service.(13) Like many other professionals, pharmacists are required to complete a certain amount of continuing education credits annually to maintain licensure. For example, in North Carolina, 15 hours are required annually.(32) Prior to implementing PharmFIT^™, it is critical that nationally-available, accredited trainings in CRC, screening, and provision of FIT specifically be developed and disseminated.

Implementation champions, defined as people within an organization who have both interest in a particular intervention as well as knowledge and drive to make it happen, will be critical for successful implementation of PharmFIT^™.(33) For widespread adoption, it’s crucial that certain programmatic stipulations are met, as our data demonstrate that many pharmacists may not support the program otherwise. A champion can help address these stipulations and remove barriers. Identifying potential champions, however, can be challenging and the lack of a champion, or the lack of an effective champion, can be impactful on the success of the intervention.(34,35) While much of the research into implementation champions has been in more traditional healthcare delivery settings(36,37), our findings support some takeaways. Pharmacists with more years in practice and greater knowledge of CRC and screening find PharmFIT^™ to be “less complex” to implement; these senior pharmacists, who are likely to be in or closer to leadership in their organizations, may be more successful champions for PharmFIT^™ implementation. Organizations considering implementing PharmFIT^™ should focus on the identification of a strong champion and should consider more senior pharmacists with some leadership or connection to leadership to serve in this role.

Our findings highlight two additional considerations around implementation setting. The first is in the role of primary care in PharmFIT^™. In this survey study, the most reported stipulation for willingness to implement PharmFIT^™ was that results would be appropriately reported to the PCP. In our previous formative research, we found that all key partners in PharmFIT^™, patients, pharmacists, and PCPs, all reported a desire for a clear, defined, and agreed upon role in implementation.(11,13,14,19) This is consistent with a broad literature showing that patients who have more access to primary care complete CRC screening at higher rates.(38–40) To achieve the goal of increasing access to CRC screening, real-world implementation of PharmFIT^™ should include consideration for a PCP safety-net, i.e., a PCP or primary care practice in close proximity to a pharmacy implementing PharmFIT^™ that is willing and able to take in patients participating in the program who do not have established primary care.

The second implementation setting consideration is in the type of community pharmacy (e.g., chain, independent). All pharmacists, regardless of practice setting, are highly trained medical professionals with the capability to counsel patients on a wide variety of health services.(5) However, practice setting, that is chain versus independent pharmacy, can impact capacity to implement new patient care workflows. What chain pharmacies have over independently owned pharmacies in available resources they may lack in terms of capacity to test out novel interventions.(41) Pharmacists in independent pharmacies tend to have more flexibility in terms of testing out new patient care services, like PharmFIT^™, and may be more comfortable with non-medication dispensing services.(42) We observed this in our study with pharmacist respondents practicing in independent pharmacies viewing PharmFIT^™ as less complex than respondents in chain pharmacies. Likely, establishing an evidence-base for PharmFIT^™ and for the potential return on investment in this intervention will need to be accomplished in smaller independent pharmacies before the chain pharmacies would be willing to adopt it.

In the broader context of cancer screening implementation, our findings here, paired with those of our related work(11,13,14,19), suggest that shifting this and other similar cancer prevention and control (CPC) activities to pharmacies may be an important venue to improve access to cancer screening services. Pharmacies have many advantages over primary care in this context. First, they are more evenly geographically distributed; over 90% of Americans live within 5 miles of a pharmacy(1) and visit their pharmacy 2–3 times as often as their primary care provider.(1) Second, most pharmacies do not require appointments and have more convenient hours than physician offices. And third, although pharmacist encounters have historically focused on medication dispensing, they are perceived as trusted members of the health care team and, in recent years, have substantially expanded their scope of practice to include many preventive services.(1,43) FIT is particularly well-suited for pharmacy implementation as it can be distributed without physician prescription. Other promising services include a PharmFIT^™-adjacent program to distribute the newly FDA approved Teal Health HPV self-collection test or a pharmacist-led educational and referral program to promote other procedure-based cancer screening tests (e.g., prostate cancer screening or lung cancer screening).

Strengths and limitations of the larger survey have been outlined elsewhere.(31) Relevant to this analysis, a notable strength is that this survey is the first to assess, in a national sample of community pharmacists, willingness to implement a CRC screening intervention. Additionally, the findings are strengthened by the fact that our survey was developed by a multidisciplinary team representing several of the key partners (pharmacists, PCPs) and other stakeholders (health services researchers).

Limitations relevant to this analysis include the potential lack of representation of certain subgroups of pharmacists. As previously noted,(31) we did not receive responses from pharmacists in all 50 states, meaning that our results may not be nationally representative. However, respondents do represent all regions of the United States. Additionally, the characteristics of our sample are very similar to that of the pharmacist workforce. Thus, the responses and our conclusions are likely to be similar to that of the larger pharmacist workforce.(44)

This study demonstrates that pharmacists are willing to implement CRC screening as an expanded pharmacy service. These findings, including the caveats of proper training and care coordination, are supported by our other formative work and pilot implementation(11–14,19,22,23), and supplement other literature supporting the potential for expanded pharmacy services on access to care.(2,3) With appropriate pharmacist training and care coordination planning, testing PharmFIT^™ in a larger randomized controlled trial is now warranted to estimate its potential impact on CRC screening access and uptake.