The respiratory infection caused by SARS-CoV-2 has brought the world to a standstill, followed by the World Health Organization (WHO) declaring it a pandemic [1, 2]. COVID-19-associated symptoms generally appear within 2 to 14 days of exposure, ranging from mild to severe, including chills, cough, fever, fatigue, headache, loss of taste or smell, muscle aches, sore throat, and shortness of breath [1, 3]. The COVID-19 pandemic exposed significant weaknesses in the global health care system and amplified existing social inequalities. Extended lockdowns resulted in widespread job losses, contributing to a global economic downturn [4, 5].

Throughout the pandemic, pharmacies appeared to be the easily accessible healthcare hubs, providing reliable, up-to-date, and authentic health-related information. Furthermore, to maintain social isolation and ensure social distancing, pharmacies worldwide adapted medication delivery to home and telehealth services [6, 7]. Existing literature highlighted the effective role of community pharmacists in delivering immunization services, particularly in high-income countries [8]. These pharmacists have played a vital role in curbing the pandemic through pharmaceutical care, patient counseling, and vaccination services. Surveys from Northern Ireland [9] and Puerto Rico revealed high willingness among pharmacists (80.7% and 76.1%, respectively) to administer COVID-19 vaccines, underscoring their critical public health role [10, 11].

The existing literature corroborates immunization services provided by community pharmacists at pharmacies in high-income countries [12, 13]. Community pharmacists have been an effective deterrent to containing the impact of the pandemic by providing pharmaceutical care, updated guidance, and immunization support to the public [10, 14]. In a cross-sectional study of 130 pharmacists from Northern Ireland, 80.7% were willing to administer the COVID-19 vaccination. Another study from Puerto Rico noted a 76.1% willingness of pharmacists to administer the COVID-19 vaccination [14, 15]. Thus, we acknowledge pharmacists’ role in major public health crises. A recent survey of public health leaders identified pharmacists as playing a key role in COVID-19 vaccine administration and pandemic planning [10, 16].

In Pakistan, the pandemic led to widespread unemployment and the suspension of all economic, educational, and transport activities [17]. As a resource-limited country allocating only 0.6% of its GDP to healthcare, Pakistan faces challenges such as limited infrastructure, outdated treatment facilities, and a shortage of healthcare personnel. Community pharmacy services remain underdeveloped due to regulatory gaps, pharmacist shortages, and minimal governmental support [18]. A cross-sectional survey of 393 pharmacists from two provinces revealed strong knowledge but weak attitudes and practices concerning COVID-19 [14, 18, 19].

Pharmacies are uniquely positioned to reach underserved populations. Evidence shows that pharmacy-led immunization programs are particularly effective in vaccinating older, high-risk adults who frequently rely on pharmacy services [20, 21].

In a developing country like Pakistan, the COVID-19 pandemic led to widespread unemployment, together with the suspension of all academic and transport activities, resulting in challenges such as inadequate infrastructure, unexpected therapeutic outcomes, and a shortage of healthcare professionals, including the underdevelopment and insufficient availability of community pharmacists through regulatory gaps and minimal governmental support. Although some studies indicated strong knowledge among community pharmacists, weaker attitudes and practices regarding COVID-19 were observed. A published report on the pharmacist's evolving role in the COVID-19 pandemic was heavily sourced from developed countries, citing established pharmacy-led immunization programs and advanced healthcare frameworks. However, the findings of these studies could not be effectively applied in Pakistan due to resource constraints, a weak healthcare system, and varying levels of public trust in community pharmacists. A gap arises in the judgment of how the Pakistani pharmacist played a role in shaping perceptions and practices of robust, context-specific research during the pandemic. Keeping the aforementioned objective in view, a Knowledge, Attitudes, and Practices (KAP) analysis was conducted in Pakistan regarding the COVID-19 pandemic. The current study's findings might help identify locally relevant evidence that pharmacists can use to help establish and inform national strategies for effectively managing such situations in future public health emergencies.

This study is the first of its kind to assess the Knowledge, Attitudes, and Practices (KAP) of community pharmacy staff in Pakistan regarding COVID-19 immunization. The findings reveal a growing role of pharmacy professionals in vaccine advocacy and delivery, contributing to an overall rise in vaccination rates.

A significant proportion of pharmacy staff (67.25%) demonstrated good knowledge and adherence to COVID-19 vaccination, with 70.25% accurately identifying dosage schedules. Notably, pharmacists showed higher awareness and willingness to be vaccinated compared to pharmacy technicians and dispensers. This suggests that pharmacists possess a more advanced understanding of the COVID-19 vaccine, a finding consistent with international studies. For example, a study conducted in Asia reported over 95% willingness among healthcare workers to be vaccinated [29]. Similarly, research from South and Southeast Asia showed high vaccine uptake due to pharmacists' belief in vaccine safety and the severity of the pandemic [14]. KAP studies indicated a better association among pharmacy professionals and COVID-19 vaccine knowledge practices. Positive attitudes (such as willingness to vaccinate) and practices like the use of PPE by 70% individuals correspond to and align with other studies conducted in Asian countries; however, the gap in the ADRs reporting system highlighted the need for professional training.

Comparable findings were reported in Vietnam, Lebanon, Egypt, and Pakistan, where pharmacists demonstrated strong vaccine-related knowledge, with rates ranging from 83% to over 90%. Conversely, lower awareness levels were observed in regions like Addis Ababa (53.2%) [30-33]. Overall, the purpose of vaccination was widely understood to protect individuals and their families, though some resistance stemmed from perceived lack of necessity.

More than 60% of pharmacy staff in our study were knowledgeable about vaccine brands and mechanisms of action, and had access to updated vaccine information. Pharmacists consistently outperformed other staff in vaccine-related knowledge, echoing the results of prior studies across Asia and Africa [5, 16, 34-37], which indicated high COVID-19 knowledge among pharmacists about vaccines.

When analyzing attitudes, over 60% of participants believed that COVID-19 could be fully controlled. Many expressed willingness to support community-level vaccination efforts and recognized the pharmacist’s role in preventing the spread of the virus. A large majority were in favor of empowering pharmacists to administer vaccines, provided regulatory approval was granted. These positive attitudes mirror findings from Vietnam and Egypt, where pharmacists showed strong alignment with national health strategies [6, 32]. Similarly, in another study between June and July 2020 in Egypt, pharmacists evaluated the knowledge, attitudes, and practices of the Egyptian population. Pharmacists found that about 64% of participants showed positive attitudes towards the Egyptian Ministry of Health in controlling the pandemic, which was slightly higher than in our studies [18].

In terms of practical behavior, about 70% of pharmacy staff reported using Personal Protective Equipment (PPE) such as gowns, gloves, and masks when dealing with patients. Additionally, 65% felt that pharmacies should have designated areas for vaccination and patient counseling. Around 63% supported the use of hand sanitizers post-vaccination, and 67% understood the impact of improper vaccine storage on immune responses.

Our findings also highlight that pharmacists possessed more practical knowledge on vaccine administration than other pharmacy personnel. Similar outcomes were seen in a Polish study, where pharmacists played a key role in vaccine delivery during the pandemic [38].

Regarding Adverse Drug Reactions (ADRs), 75% of participants believed that COVID-19 vaccines are generally safe, albeit with some side effects [37, 39]. Furthermore, 74% were confident in managing both minor and major adverse events, although 60% of respondents admitted that fear of side effects might deter vaccine uptake. These concerns are supported by prior findings indicating vaccine hesitancy due to fear of ADRs [19, 40]. Thus, regular training and education for pharmacy staff are essential to strengthening Pakistan’s pharmacovigilance system. Empowering pharmacy personnel with the tools and knowledge to recognize and report ADRs could lead to a more responsive and transparent vaccine safety infrastructure [40, 41].

This study further investigated the KAP of community pharmacy workers in terms of ADR reporting. In the current study, a 56.3% response rate was observed, whereas a higher response rate (82%) was observed in another study by Paul et al., 2020 [8]. A lower response rate (21.8%) was reported by other studies [10, 42]. The majority of participants had a positive view of pharmacovigilance. 61.2% of pharmacy staff thought it was important to report Adverse Drug Reactions (ADRs) because of the importance of the pharmacovigilance program. The significant respondent (77.8%) kept records of ADR and forwarded the detailed report to the ADR reporting center. Similar findings were also reported in various studies, which showcase agreement with our results [18, 39]. Education and regular training for pharmacy employees may help in pharmacovigilance program success and build a spontaneous ADR reporting system in Pakistan [43, 44]. Current Associations suggest positive aptitude, like supporting vaccination efforts; however, alternative measures like unmeasured motivation or information access may create differences. Thus, residual confounders or possible bias are possible [8, 9].

The results of the current study are restricted to twin cities in Pakistan and may not be applicable to other regions of the country; therefore, a similar study can be conducted in other regions to better understand the concept.

The scope of this study was geographically limited to community pharmacies located in the twin cities of Islamabad and Rawalpindi, Pakistan. As such, the findings may not be generalizable to other regions of the country due to potential differences in healthcare infrastructure, access, education, and professional practice standards. To gain a more comprehensive understanding of pharmacy staff's knowledge, attitudes, and practices (KAP) nationwide, similar research should be conducted in other provinces and rural settings. Expanding the geographical scope would provide a more holistic view and support the development of region-specific policies and interventions.

The findings of the current study revealed that overall pharmacy staff have better knowledge, attitude, and practice towards COVID-19 vaccines, and this could be because pharmacy workers had a rudimentary understanding of these services with basic training. However, there was a significant difference in pharmacist knowledge and preparedness as compared to other health care workers for immunization services in the community settings. This might be due to the fact that basic concepts of immunization are incorporated in the curriculum of pharmacy, so pharmacists have basic knowledge regarding immunization. In order to improve knowledge of other pharmacy staff, a number of changes are required, including updating the pharmacy curriculum taught, implementing international standards for pharmacy practice, training, and fully integrating pharmacy staff into the healthcare system. Furthermore, health care staff should dispel patients' concerns about COVID-19 vaccines. If any untoward adverse event occurs, the report must be submitted to the ADR reporting center. The results of the present study showed that improved knowledge will lead to better implementation of immunization services.