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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan; Michigan State University Extension Program, East Lansing, Michigan; and Division of Immunization, Michigan Department of Community Health, Lansing, Michigan.
Address reprint requests to: Bernard Gonik, MD, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, 6071 W. Outer Drive, Detroit, MI 48235, E-mail: bgonik{at}dmc.org
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Abstract |
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Methods: Masked questionnaires requesting demographic, knowledge-based, practice, and attitudinal data were sent to 850 ACOG-registered fellows.
Results: Three hundred sixty-five physicians responded, 313 of whom were in active practice. Most were male (70%) and graduated from medical school between 1970 and 1989 (68%). The majority provided both obstetric and gynecologic services. The minority (47%) specifically identified themselves as primary care providers. Only 15% of respondents considered screening for vaccine-preventable diseases to be outside the realm of routine obstetric-gynecologic care. In practice, however, 19% did not screen their obstetric patients for any vaccine-preventable diseases, and only 10% assessed their patients for all nine vaccine-preventable diseases listed in the questionnaire. In gynecologic patients, almost 40% of physicians did not assess for any vaccine-preventable disease. A wide range in knowledge level was identified concerning vaccine-preventable diseases, immunization recommendations, and vaccine safety.
Conclusion: These data show a discrepancy between perceived responsibilities and actual practice patterns of obstetrician-gynecologists regarding vaccine-preventable diseases and the immunization of women. Limitations in current knowledge and practical concerns specific to vaccine administration contribute to this disparity.
Historically, the need to vaccinate adult patients has been underemphasized by obstetrician-gynecologists and other primary care providers,1 despite the fact that older adults are at the highest risk of complications from certain vaccine-preventable diseases. Each year 50–70,000 adults in the United States die of pneumococcus, influenza, or hepatitis B infections.2 Approximately 50% of Americans older than 50 years are not adequately immunized against diphtheria and tetanus.3 As many as 12 million reproductive-aged women world wide are susceptible to rubella virus.4 In Michigan, 73% of adults older than 65 years are not vaccinated against pneumococcus.5 Similarly, 55% of Michigan adults in this same age group were not vaccinated against influenza in 1997.6
Despite the natural fit for incorporating vaccine-related disease prevention into the daily routine of obstetrics and gynecology practices, anecdotal observations suggest that it is not being done optimally at the present time. To determine the extent of vaccination being done by obstetrician-gynecologists, members of the Michigan Section of the ACOG, with support from the Centers for Disease Control and Prevention (CDC) and the Michigan Department of Community Health, surveyed Michigan obstetricians and gynecologists regarding their knowledge, attitudes, and practice patterns with respect to vaccine-preventable diseases. The results of this survey formed the needs assessment that subsequently culminated in a statewide educational program focusing on the obstetrician-gynecologist’s role in vaccination programs.
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Materials and Methods |
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Data from returned surveys were entered into an SPSS database (SPSS Inc., Chicago, IL) for analysis. Because most of questions were binary or involved rankings, all statistics reported involved the use of nonparametric tests. 
2 tests were used to identify pattern differences, and Spearman rho correlations were used to test for relationships between practice, attitude, and knowledge. All 2 and correlations reported had a two-tailed level of significance of P < .05 or less.
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Results |
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. Thirty percent of the respondents were female. Most physicians (68%) graduated from medical school between 11 and 30 years ago, with a median of 21 years of practice. Over half (52%) of the responding physicians practiced in three southeast Michigan counties, with the remainder spread throughout the state. This distribution is similar to that of the existing practice patterns for obstetrician-gynecologists in Michigan.
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Practice pattern responses are shown in Table 2. Physicians were asked whether they currently assessed their patients for nine vaccine-preventable diseases and six associated vaccines (tetanus/diphtheria, hepatitis B, measles/mumps/rubella, influenza, varicella, and pneumococcus). If an affirmative response was given, they were asked whether they actually administered the indicated vaccine (allowing for the possibility of delaying administration until the postpartum period) or referred the patient to another health care provider. Nineteen percent of physicians did not assess their obstetric patients for any of those vaccines. Ten percent assessed their obstetric patients for all nine vaccine-preventable diseases. The highest number of obstetricians assessed for two (22%) or three (19%) vaccine-preventable diseases. In order of frequency, hepatitis B, measles/mumps/rubella, and influenza each were assessed by 50% or more of responding physicians. Almost 40% of physicians did not assess for any vaccine-preventable disease for their gynecologic patients. Eleven percent assessed for all six vaccines. The most frequently assessed were influenza, hepatitis B, and measles/mumps/rubella, but these were each assessed by fewer than 50% of all physicians.
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When asked to rank reasons for not administering an indicated vaccine in the office, 60% responded "it is not part of my usual patient care activities" as the most frequent response. The next most common answer was related to reimbursement concerns (50%), followed by a lack of availability of the vaccine (43%). Uncertainty regarding current vaccine recommendations, lack of comfort with administration, and the perceived unwillingness of patients to accept the vaccine each were ranked at approximately 30%. These responses exceed 100% because the survey allowed for multiple choices to this question. The most important reason listed, based on mean rank, was "not part of my usual activities" followed by cost/reimbursement concerns.
The survey contained three sets of knowledge-related questions. The first concerned CDC recommendations regarding hepatitis B vaccination. Ninety-nine percent of respondents recognized CDC recommendations to give vaccine to patients in high-risk environments. However, only 69% identified the need for hepatitis B vaccination in adolescents. Conversely, 19% of physicians indicated that women over age 65 years required vaccination against hepatitis B, although this is not a current CDC recommendation. For influenza, 86% agreed with the CDC that maternal morbidity and mortality increased in the second and third trimesters. Only 69% indicated that the comorbid condition of asthma was an indication for influenza vaccination. When physicians were asked about vaccine safety in pregnancy, 73–83% agreed with the CDC that tetanus/diphtheria, influenza, and hepatitis B vaccines were safe to administer. Only 48% thought pneumococcal vaccine was safe to administer in pregnancy. Of interest, a small but identifiable minority of physicians indicated that it was acceptable to give measles/mumps/rubella (6%) and varicella (14%) vaccines during pregnancy, contrary to current recommendations. Overall, only 7% of physicians answered all 17 components of the knowledge-based questions correctly, with 57% of respondents answering 80% or more correctly; 5.5% answered fewer than seven of the questions correctly.
Two opinion questions that required a scaled response were asked in the survey. The first queried whether routine screening for vaccine-preventable diseases is outside the scope of practice for an obstetrician-gynecologist. Fifteen percent agreed or strongly agreed with this statement, compared with 23% who were neutral, and 62% who disagreed or strongly disagreed. Of the physician respondents who agreed that routine screening is outside the scope of obstetric-gynecologic practice, 36% identified themselves as primary care providers and 64% did not. When asked whether adequate data were presently available to safely administer any vaccines in pregnancy, the majority supported this statement (68%), 17% were neutral, and 15% considered the data to be inadequate.
A series of correlations were run examining physician characteristics, practice patterns, opinions, and knowledge. Female physicians were more likely to have fewer years in practice compared with male physicians (2 = 46.3, P < .001). Female obstetrician-gynecologists were also more likely to support the concept of screening for vaccine-preventable diseases as a part of routine obstetric and gynecologic care and to assess and administer indicated vaccines in their practices (r value 0.14–0.23; P < .05). Physicians with more years in practice were more likely to be male, to specialize in only obstetrics or only gynecology, less likely to consider vaccine screening as a part of routine care, and scored lower on knowledge-related questions (r value 0.22–0.31; P < .01). Physicians who assessed their patients routinely for vaccine-preventable diseases were more likely to administer vaccines, score highly on the knowledge-based questions, and consider vaccine assessment a part of their routine patient care responsibilities (r value 0.30–0.70; P < .01).
Physicians who acknowledged that they performed primary care were more likely to assess their patients for vaccine-preventable diseases (ten of 12 2s significant at P < .05) and more likely to disagree with the statement that screening is outside of obstetric-gynecologic practice (2 = 7.9, P < .05). However, there were no significant differences between physicians who practiced primary care and those who did not in their responses to the knowledge-based questions.
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Discussion |
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Our findings provide important insights into the practicing obstetrician-gynecologist’s perspective on vaccine-preventable diseases. As expected, most physician respondents provide both obstetric and gynecologic care. Of interest, only 47% of respondents to this survey identified themselves as primary care providers. It would be interesting to know how many of these physicians’ patients have alternative arrangements for obtaining primary care and how many think they are receiving such services from their obstetrician-gynecologist. This potential barrier to vaccine-related disease prevention also has significant effects on other health maintenance issues for the female population. In the context of the present study, inadequacies in vaccine screening and administration are likely reflective of this overall perspective that such duties are outside the realm of routine practice. In contradiction to their current practice patterns, however, many of these same obstetrician-gynecologists (62%) expressed the opinion that vaccine prevention should be within the scope of their responsibilities. This disparity between perception and current practice could be remedied if we define more clearly the obstetrician-gynecologist’s role in primary care through residency training.
In conjunction with these efforts, as demonstrated in this study, postgraduate educational initiatives are needed. Survey respondents who were more knowledgeable about vaccine-preventable diseases were more likely to incorporate screening and vaccine administration in their practices. Uncertainty regarding CDC vaccine recommendations, unfounded concerns regarding vaccine safety in pregnancy, and lack of comfort with vaccine administration limit physician willingness to advocate for appropriate vaccination in their patients. Some responses, which are reflective of significant knowledge deficits, are of great concern because they relate to specific vaccine contraindications (ie, live-virus vaccine use during pregnancy).
We acknowledge certain limitations to our study. Although the response rate was acceptable for this type of community survey, nonrespondents might have a different profile of knowledge, attitudes, and clinical activities. Additionally, some of the responses might be a marker for physician activities rather than actual practice. For example, although respondents answered that they screened obstetric patients for measles, mumps, and rubella, it is more likely that only rubella was studied serologically. Although physician gender differences were noted, these data were confounded by types of practices and years since medical school. Similarly, although not studied in this survey, these results might not be specific to obstetrician-gynecologists alone. Other adult primary care providers might lack knowledge and practice skills pertaining to vaccine-preventable diseases. Unlike the field of pediatrics, where vaccine administration is common practice, health care providers for adults have only recently been targeted for vaccine implementation programs.
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Footnotes |
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Received October 25, 1999. Received in revised form January 18, 2000. Accepted January 27, 2000.
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References |
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2. National Coalition for Adult Immunization. Resource guide for adult and adolescent immunization. Bethesda, Maryland: National Coalition for Adult Immunization, 3rd ed. 1998.
3. Centers for Disease Control and Prevention. Diphtheria, tetanus and pertussis: Recommendations for vaccine use and other preventive measures. MMWR Morb Mortal Wkly Rep 1991;40:1–14.[Medline]
4. Cutts FT, Robertson SE, Diaz-Ortega JL, Samuel R. Control of rubella and congenital rubella syndrome in developing countries. Bull World Health Org 1997;75:55–68.[Medline]
5. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 1997;46: 1–4.[Medline]
6. Centers for Disease Control and Prevention. Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 1998;47: 1–26.[Medline]
7. American College of Obstetricians and Gynecologists. Primary and preventive care. In: Precis V: An update in obstetrics and gynecology. Washington DC: American College of Obstetricians and Gynecologists, 1994:1–8.
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