Pharmacies have been recommended as alternative sites for the delivery of immunization services, especially to medically underserved adults and children in inner cities and rural areas. Currently, 35 of 50 states in the USA have legalized the administration of vaccines by pharmacists on the basis of certain training requirements and specific protocols. Since the role of pharmacists is expected to expand, it is important to assess the factors that would enable them to improve the delivery of immunization services and the acceptance of these services by communities. It is particularly important for pharmacists to have knowledge of community circumstances and be able to respond to community needs. This case study of a pharmacy immunization programme (PIP) in rural West Virginia assessed how well pharmacists were aware of community circumstances and which community factors affected the utilization of pharmacy-delivered immunizations. Our findings suggest that although pharmacists played important roles as facilitators, hosts and motivators in PIP, they overestimated the trust placed in them by community members. The convenient locations of pharmacies and the convenient times when they offered immunization services were found to be the determining factors of mothers' decisions to take their children to these places for their vaccinations. The study concludes that as the use of pharmacies as sources of immunization is expected to continue to expand, pharmacists should take these factors into consideration when they decide to offer immunizations.