Introduction
Facing the threat of antimicrobial resistance, efforts to expand the footprint of antimicrobial stewardship (AS) are urgently needed. Antimicrobial agents are commonly prescribed in the outpatient setting. 1 Community pharmacists, with their expanding scope of practice (including prescribing and deprescribing), and skills in patient education, are uniquely positioned to support appropriate antibiotic use. There are over 28,000 community pharmacists in Canada, a setting in which there is variable but increasing authority for pharmacists to prescribe, administer and monitor medications and immunizations. Reference Raiche, Pammett and Dattani2 Given their position as trusted and highly accessible healthcare professionals, Reference Isenor, Renaud and Mathews3 this places a large and increasing number of pharmacists in a strong position to support AS.
Several studies have evaluated opportunities for AS in community pharmacy settings, Reference Bishop, Yacoob, Knobloch and Safdar4–Reference Lee and Bradley6 however, formal implementation of these strategies in community pharmacies remains uncommon.
A better understanding of the barriers and facilitators to AS in the community pharmacy context may help identify strategies to support feasible, impactful and sustainable interventions. Our objective was to identify the determinants to implementation of AS in community pharmacies in the Canadian context.
Methods
Survey design
In this cross-sectional study, we designed two surveys, one for the public and another for community pharmacists and other healthcare providers (HCP) (see Supplemental Material for survey questions and additional methodological details). Survey questions aimed to identify barriers and facilitators to community pharmacists’ involvement in AS were based on the Theoretical Domains Framework Reference Michie, Johnston and Abraham7 and the Consolidated Framework for Implementation Research. Reference Damschroder, Reardon, Widerquist and Lowery8 The supplementary material illustrates the mapping of each statement to a framework. Responses were in 5-point Likert scale.
Survey dissemination
The survey was open from January 17 to 26 and February 5 to March 23, 2025 and disseminated to community pharmacy networks, patient partners, nurse practitioners, and primary care organizations to their email and social media contacts across Canada. Participants were offered a $10 coffee gift card in recognition for their time.
Analysis
Descriptive statistics were provided to indicate the extent to which study participants agreed (agree or strongly agree) with each statement. R version 4.4.0 was used for visualization.
Ethics
Informed consent was obtained from survey respondents before participation. The study has been approved by the University of Toronto Research Ethics Board (application ID 47105).
Results
Of 148 respondents that started the survey, 144 completed the survey during the study period. Forty-eight were members of the public, 64 community pharmacists, and 32 were HCP, amongst them 18 (56.2%) were physicians and 10 (31.3%) were nurse practitioners. Supplementary Table 1 includes respondent characteristics.
Public perspectives
Most members of the public agreed that AS is important for patient safety (N = 44, 92%) and that pharmacists’ involvement in AS will lead to safer patient care (N = 41, 85%). Most supported the idea of their pharmacist providing information about antibiotics (N = 40, 83%). However, many did not agree that involving pharmacists in AS will save them money (N = 18, 38%), cut healthcare costs (N = 19, 40%) or save time (N = 22, 46%) (Figure 1a).
(a) Public perspectives, (b) healthcare providers perspectives, and (c) community pharmacy implementation factors. AS, antimicrobial stewardship.
Figure 1. Long description
Three bar graphs depict public perspectives, healthcare provider perspectives, and community pharmacy implementation factors on antimicrobial stewardship. The first graph, labeled ‘a. Public Perspectives,’ shows responses from the public on various statements about involving pharmacists in antimicrobial stewardship. The x-axis represents the percentage of responses, while the y-axis lists statements such as ‘Involving pharmacists in antibiotic stewardship will help save money’ and ‘AS is important for patient safety.’ The responses are color-coded: red for strongly disagree, orange for disagree, yellow for neither agree nor disagree, light green for agree, and dark green for strongly agree. The second graph, labeled ‘b. Healthcare Provider Perspectives,’ is divided into two sections: Community Pharmacy and Other Healthcare Providers (HCP). It shows responses from healthcare providers on statements like ‘Non-pharmacist prescribers are supportive’ and ‘Pharmacist involvement in AS will reduce costs.’ The x-axis represents the percentage of respondents, and the y-axis lists the statements. The responses are color-coded similarly to the first graph. The third graph, labeled ‘c. Community Pharmacy Implementation Factors,’ shows responses from community pharmacies on factors such as ‘For the pharmacists, there is financial incentive’ and ‘AS activities can be integrated into my pharmacy’s workflow.’ The x-axis represents the percentage of responses, and the y-axis lists the factors. The responses are color-coded as in the previous graphs..
Other healthcare provider perspectives
Most non-pharmacist HCPs agreed that AS is an important part of their own job (N = 31, 97%). Most were aware of AS principles (N = 31, 97%), confident in implementing these principles (N = 30, 94%), and reported providing education on appropriate antibiotic use (N = 30, 94%). Only a minority of HCP agreed that community pharmacist-led AS is supported by policy makers (N = 13, 41%), that pharmacist involvement in AS will save time (N = 15, 47%) or money (N = 20, 62%) (Figure 1b).
Community pharmacist perspectives
In contrast, most pharmacists agreed that their involvement in AS will reduce healthcare costs (N = 59, 92%). They were in alignment with other HCPs’ position in that they provide education to patients about AS (N = 58, 91%), that AS is an important part of their job and (N = 55, 86%) and that they are aware of AS principles (N = 55, 86%). However, only a minority perceived that non-pharmacist prescribers supported pharmacists’ involvement in stewardship (N = 12, 19%). Similar to other HCPs, only a minority of pharmacists agreed that there is policy maker support for such initiatives (N = 25, 39%) (Figure 1c).
Community pharmacy implementation factors
Although formal implementation of at least one AS practice change was lacking according to community pharmacy respondents (N = 18, 28%), more than half of respondents agreed that AS activities could be implemented in their workflow (N = 37, 58%) and that they have sufficient access to the information they need to provide AS (N = 34, 53%). A minority of pharmacists agreed that there were financial incentives for the pharmacist (N = 8, 12%) or pharmacy (N = 10, 16%) to perform AS interventions.
When pharmacists were asked to rank factors that would facilitate AS in community pharmacy, pharmacy corporation support, public desire for higher quality services, and pharmacy advocacy organizations as champions were identified as the three most important potential facilitators (Supplementary Figure 1).
Discussion
This survey of community pharmacists, other HCPs and the public identified key factors affecting the success of AS implementation in Canadian community pharmacies. Commonly cited barriers pertain largely to the social, environmental, and economic context of the community pharmacy setting, including perceived lack of support from non-pharmacist HCPs and the lack of financial sustainability to adopt a greater role in AS. Support and buy-in from pharmacy corporations, policy makers, patients, and pharmacy advocacy organizations were often cited as important gaps. Facilitators included the perceived importance of AS amongst most respondents, the positioning of pharmacists as educators on appropriate medication use, and the potential for healthcare cost savings.
These findings largely align with a systematic review of barriers and facilitators to AS in community pharmacy across 40 studies. Reference Vigneswaran, Langford and Brown9 Key factors in this study included the need for remuneration to support business continuity, interprofessional collaboration, access to patient medical information and antibiotic prescribing guidelines. Our findings contextualized the key determinants and identified some conflicting perspectives among respondents. For example, although pharmacists tended to believe AS will bring cost-saving to the healthcare system (92% agree), members of the public (40% agree) did not indicate the same level of agreement. Although the primary goal of AS is not cost savings, evaluating and highlighting the potential benefits of resource stewardship may incentivize decision-makers and the public.
Strengths of this work include the use of behavior change frameworks to inform survey questions, and representation from not only pharmacists but others who may influence their practice, including the public and other HCP. A limitation to this study is the potential for selection bias in that participants may not represent the range of opinions of the broader community (eg, well-informed or already engaged members of the public and HCPs may be more likely to respond). Given the open survey, it was not possible to determine a denominator and calculate a response rate, nor compare respondents with non-respondents. Furthermore, the survey captured limited qualitative data and lacked details about each barrier and facilitator. To gather more in-depth qualitative data, we aim to identify determinants across a range of individuals using semi-structured interviews.
The survey highlights the current state of AS implementation in community pharmacy, which is nascent. Alhtough community pharmacists acknowledge that AS is an important part of their job and they are well-positioned to provide advice on appropriate antibiotic use, formal implementation is lacking. With the increasing involvement of community pharmacists in medication management, there may be an opportunity to leverage this expanding role to embed AS interventions into pharmacy practice. Reference Wu, Khalid and Langford10 Our survey suggests several strategies may support this implementation including engaging leaders to increase buy-in, linking stewardship to cost-saving opportunities as an incentive for funding for AS initiatives in the community, and enhanced interoperability to equip community pharmacists with clinically relevant information, such as the documented indication for antimicrobial therapy.
Conclusion
This survey of pharmacists, other HCPs, and the public identified key social, environmental, and economic contextual factors related to AS implementation in Canadian community pharmacies. Addressing these determinants may help to advance AS and improve antibiotic use in the community.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/ash.2026.10410.
Financial support
This work was funded by the New Initiative and Innovation Award—Network for Improving Health Systems from the University of Toronto, Leslie Dan Faculty of Pharmacy and the Dalla Lana School of Public Health.
Competing interests
None.
Artificial Intelligence
ChatGPT (GPT-5) was used to support the generation and troubleshooting of code for statistical analysis. The authors reviewed and edited the content as needed and take full responsibility for the final content of the manuscript.
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