- Email: [email protected]
Patient vaccine awareness in an obstetric and gynecologic office setting
FIRST PRIZE MANUSCRIPT
PATIENT VACCINE AWARENESS IN AN OBSTETRIC AND GYNECOLOGIC OFFICE SETTING Thomas M. Malone, MD, Bernard Gonik, MD, and Mark Tomlinson, MD
The objective of our study was to better understand patient vaccine awareness in different ob/gyn settings. A masked questionnaire was completed by ob/gyn resident teaching clinic patients (CLINIC; n ⴝ 228) and private community physician patients (PVT; n ⴝ 254) exploring demographic, immunization recollection, and vaccine administration preferences. 2 and Student t test were used for statistical analyses. The results demonstrated that those in CLINIC compared with PVT were younger (27.2 ⴞ 10.6 years old versus 38.0 ⴞ 12.6 years old; P < .001) and more often presented for pregnancyrelated visits (57.0% versus 21.6%; P < .001). PVT patients more commonly had documentation of childhood (34.3%) and adult (26.8%) vaccine status than those in CLINIC (25.6% and 15.5%, respectively; P < .03). Of the vaccine-preventable diseases (VPDs) surveyed, those in PVT (versus CLINIC) more often reported adequate vaccination or prior exposure to measles (68.5% versus 30.5%; P < .001) and varicella (65.7% versus 48.5%; P < .001). No differences were noted between study groups for hepatitis B, tetanus, and influenza. Those in PVT more often identified a non-ob/gyn provider for vaccine-related From the Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan and Women’s Healthcare Associates, Portland, Oregon.
Volume 9, Number 6, 2002
needs, as opposed to those in CLINIC, who more often relied on ob/gyn or health department sites for such needs. Over one third of both populations could not identify a provider for vaccine administration. Both groups strongly desired availability of vaccine services through their ob/gyn office. We conclude that PVT patients demonstrate a better awareness of vaccine status compared with those in CLINIC. However, overall both populations report poor documentation and inadequate immunity against most VPDs. A variety of practice sites are currently used for vaccination, although many patients cannot identify a place to go. The majority of patients would like to see this service available as a part of their ob/gyn care. (Prim Care Update Ob/Gyns 2002;9:195–198. © 2002 Elsevier Science Inc. All rights reserved.)
Studies suggest that immunization rates for children and adults remain below nationally established standards.1 Focusing on the adult population, surveillance data estimate that between 50,000 and 70,000 adults die each year in the United States from pneumococcus, influenza, and hepatitis B.2 Approximately 50% of Americans aged ⬎50 years are not adequately immunized against diphtheria and tetanus.3 Worldwide, as many as 12
© 2002 Elsevier Science Inc., all rights reserved. 1068-607X/02/$22.00
●
million women of childbearing age are susceptible to rubella infection.4 Each of these diseases is recognized as a vaccine-preventable disease. As the health care paradigm has changed for physicians, so has the status of the obstetrician/ gynecologist, who now functions in the dual role of primary care provider and specialist.5,6 Within obstetric and gynecologic practices, a recent survey of clinicians in the state of Michigan demonstrated a significant discrepancy between physician self-recognized vaccinepreventable disease responsibilities and practice patterns. Despite attitudes that generally supported the need for better immunization and vaccine surveillance, knowledge deficiencies and logistical concerns limited physician compliance. 7 Physician-focused postgraduate educational programming has been instituted to address these issues.8 This is in keeping with current American College of Obstetricians and Gynecologists recommendations that encourage primary care initiatives and focus on health maintenance and disease prevention.9 Of note, the Commonwealth Fund found that gynecologists administered more preventative care services to women than did either internists or family practitioners.10 To date, few data are available examining patient awareness or preferences related to vaccinepreventable diseases. This is particularly important in an obstetric/
PII S1068-607X(02)00117-8
195
MALONE ET AL Table 1. Adequacy of Immunization Based on Patient Recall for Infection or Vaccination Disease
PVT, % (n ⴝ 254)
CLINIC, % (n ⴝ 228)
P
Measles Chickenpox Tetanus, within 10 y HBV Flu, annual
68.5 65.7 47.6 36.6 22.0
30.5 48.5 43.1 36.1 23.3
⬍0.001 ⬍0.001 NS NS NS
PVT, private practice ob/gyn patients; CLINIC, resident teaching clinic ob/gyn patients; HBV, hepatitis B virus; Flu, influenza vaccine; NS, not significant.
gynecologic setting, where officebased protocols are unlikely to exist for routine usage. Lack of patient awareness is hypothesized to be an additional barrier to adequacy of vaccination within the clinical setting. In many instances, adults are unaware of the need for immunizations, particularly ones that are predicated on medical, occupational, or lifestyle risks.11 In this study, we examine, by masked questionnaires, obstetrician/ gynecologist patient knowledge and attitudes concerning vaccine practices. Additionally, we compare these responses in two different practice settings, being private offices versus resident-teaching clinic environments.
teaching offices in the Detroit metropolitan area were used. Patients were offered participation while awaiting their scheduled visit. The questionnaires were self-administered and returned to the front office staff without editing or review. The 12-item survey contained yes–no and multiple choice questions exploring demographic, immunization recollection, and vaccine administration preferences. A copy of the questionnaire is available upon request. Data were entered into a computerized database. 2 for categorical variables and Student t test for continuous variables were used for statistical analyses, with P ⬍ .05 considered statistically significant.
Results
Methods Blinded questionnaires were given to nonselected patients attending routine obstetric and gynecologic visits at designated practice sites during the summer of 2000. Nine private-practice and two resident-
The study population consisted of 228 respondents from the resident teaching clinics and 254 respondents from the private-practice settings. Because no differences were noted between the two residentteaching clinics and between indi-
Table 2. Patient Self-Reported Health Care Provider Site for Vaccine Administration
Fm Prac/Int Med (%) Ob/Gyn (%) Health Dept (%) Other (%) None (%) Interest in using Ob/Gyn (%)
PVT, % (n ⴝ 254)
CLINIC, % (n ⴝ 228)
P
42.1 8.7 4.7 7.1 37.4 78.8
28.1 19.9 9.5 5.0 37.6 84.0
⬍0.001 ⬍0.001 ⬍0.001 NS NS NS
PVT, private practice ob/gyn patients; CLINIC, resident teaching clinic ob/gyn patients; Fm Prac/Int Med, family practice/internal medicine; NS, not significant.
196
vidual private-practice offices, these data were combined into two study populations for statistical comparisons. Data were not available as to the total number of office visits at each site; therefore, an overall response rate cannot be determined. Generally, patients willingly completed the questionnaires without reported complaints or concerns. Significant differences were identified between the two study groups. The resident-teaching clinic patients were on average younger (27.2 ⫾ 10.6 years of age versus 38.0 ⫾ 12.6 years of age; P ⬍ .001) and presented to the office more often for obstetric indications (57.0% versus 21.6%; P ⬍ .001) compared with the private-practice patients, respectively. Although the private patient group significantly more often reported having written documentation of childhood vaccinations compared with the resident-teaching clinic patients (34.3% versus 25.6%, respectively; P ⬍ 0.03), this constituted the minority of subjects overall. Even fewer patients in both groups reported having any adult vaccination documentation, although again this was more common for private patients compared with clinic respondents (26.8% versus 15.5%, respectively; P ⬍ .006). On the basis of subject recall, most patients had inadequate immunity to common vaccinepreventable diseases, either by prior exposure or vaccination (Table 1). Measles and chickenpox vaccination or infection were the most commonly reported immunization histories for both study populations. The private patients, compared with clinic subjects, more often reported these specific viral exposures. Few patients in either study group reported past vaccination for or infection with hepatitis B virus, tetanus booster administration in the last 10 years, or annual influenza vaccination (Table 1). Table 2 demonstrates current rePrim Care Update Ob/Gyns
FIRST PRIZE MANUSCRIPT
ported sites for vaccine administration by respondents. Significant differences were noted between subject groups. Compared with clinic patients, private patients more often used nonobstetrician/ gynecologist primary care offices for vaccine needs and less often used their obstetrician/gynecologist or local health department. More important, over one third of subjects in both groups could not identify a site for their current vaccine administration needs. When asked, the overwhelming majority of patients surveyed expressed a strong desire to use their obstetrician/gynecologist office for such services if the services were made available (Table 2).
Discussion Common vaccine-preventable diseases cause unnecessary morbidity and mortality in the adult population, particularly in those who are elderly and with comorbid conditions. Recent surveys have documented that the minority of adults in the United States are adequately vaccinated against influenza, pneumococcus, and tetanus/diphtheria.3 Similarly, at-risk individuals have been shown to be suboptimally vaccinated against hepatitis B virus.12 Although it is routine to serologically screen for rubella immunity in the obstetric population, appropriate vaccination in the postpartum period is not always accomplished.13 This is despite clear and authoritative immunization recommendations for these infectious agents by groups such as the Advisory Committee on Immunization Practices and the Centers for Disease Control and Prevention. We have previously demonstrated that a discrepancy exists between clinician-perceived responsibility for patient vaccination and actual practice patterns.7 As the primary care mantle settles on the obVolume 9, Number 6, 2002
stetrician/gynecologist in a more comfortable fashion via resident and postgraduate educational efforts, it is hoped that vaccination of adult women will become a more routine component of office-based practice. Until then, a significant portion of the responsibility to maintain adequate vaccination remains with the individual patient. Unfortunately, many women are unaware that they need specific vaccines.14 Also, there is evidence that adults are reluctant to receive immunizations because of unfounded concerns related to vaccine adverse reactions.11 In our study, we confirmed that one reason for underimmunization is a lack of patient awareness. Few patients maintain personal records or have an established place to obtain this information. This pattern appears to cross patient demographic boundaries and is not limited to the traditionally underserved urban populations typically represented in our resident-teaching clinic settings. Surprisingly, our data represent the first such information on patient vaccine-preventable disease knowledge and preferences in an ob/gyn population. We anticipated seeing a higher rate of reported history consistent with hepatitis exposure or vaccination in our clinic patients. This is because these patients were younger and therefore more likely to have been vaccinated as adolescents. Additionally, there is a greater awareness of hepatitis B risk factors (such as multiple partners and the presence of sexually transmitted diseases) in these clinics. But this higher rate of reported history did not prove to be the case. Likewise, we expected to see a much higher reporting of measles and chickenpox in both study groups given the known high prevalence of varicella in the community and the school entry requirements for measles vaccination. We used the term measles in our ques-
tionnaire, and not a more specific agent, in an attempt to capture the largest possible pool of affirmative responses. Clearly these common childhood viral exanthemas have been underreported in our study. The above findings further highlight the lack of patient awareness and need for more vigilant screening and education. Too few patients in our sample were 65 years or older, so no information is available regarding pneumococcal vaccination. This is unfortunate because this infectious agent results in more adult deaths each year than does any other vaccine-preventable disease. 15 We speculate that if these data were available, even lower levels of reporting would be seen because of the generally recognized lack of physician and patient familiarity with this vaccine in the adult population. Our data demonstrating a lack of an identifiable health care provider for vaccination needs is particularly disconcerting. More than one third of all our respondents fell into this category. This means that despite receiving ongoing primary care, patients did not connect adult vaccination to these services. Regarding the remainder of the population, as expected, more private patients had access to other non-obstetrician/ gynecologists for vaccine administration. It is likely that clinic subjects have only a narrow funded window of opportunity during pregnancy to access nonurgent health care and therefore recognize their current obstetrician/ gynecologist for vaccine care. Unfortunately, this is infrequently offered by the health care provider on a routine basis. It should be clear from our study, however, that patients would eagerly accept vaccine-related services from their obstetrician/gynecologist if this were made available. Limitations to our study need to be acknowledged. Only a limited 197
MALONE ET AL
amount of demographic information was collected at the time of the survey, so a more detailed analysis of patient characteristics as they relate to vaccine history and usage cannot be accomplished. This was in part because of the diversity of office settings used for the study, and the self-reporting nature of the survey. More important, the information gathered was based solely on patient recall. It is therefore likely that accurate vaccinepreventable disease exposures (based on objective serologic testing) would not necessarily agree with our reported findings. However, one of the points of our study was to examine patient perceptions because these guide initial decision-making processes for subsequent health care. Given the significance of the data presented, more investigations are warranted that can better define patient reasons for vaccine inadequacies and how the health care team can impact these issues.
3.
4.
5.
6.
7.
8.
References 1. Szilagyi P, Bordley C, Vann J, et al. Effect of patient reminder/recall interventions on immunization rates. JAMA 2000;284:1820 –6. 2. National Coalition for Adult Immunization. Resource guide for adult and adolescent immunization. 3rd
198
9.
10.
ed. Bethesda, MD: National Coalition for Adult Immunization, 1998. 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. Cutts FT, Robertson SE, Diaz-Ortega IL, Samuel R. Control of rubella and congenital rubella syndrome in developing countries. Bull World Health Org 1997;75:55–68. Hendrix SL, Pierson SD, McNeeley SG. Primary and preventive care in a university obstetrics and gynecology group practice. Am J Obstet Gynecol 1995;172:1719 –22. Seltzer VL, Fishburne JI, Jonas HS. Obstetric and gynecology residencies: education in preventive and primary health care for women. Obstet Gynecol 1998;91:305–10. Gonik B, Jones T, Contreas D, Fasano N, Roberts C. The obstetrician’s-gynecologists role in vaccine-preventable disease and immunization. Obstet Gynecol 2000; 96:81–4. Gonik B, Jones T, Fasano N, Contreras D, Roberts C. Vaccine-preventable diseases (VPD): improving the obstetrician/gynecologist knowledge and immunization practice patterns. Am J Obstet Gynecol 2001;185:S162. American College of Obstetricians and Gynecologists [ACOG]. Primary and preventive care. Periodic assessments. ACOG Committee Opinion 229. Washington, DC: ACOG, 1999. Weisman CS. Women’s use of
11.
12.
13.
14.
15.
health care. In Falik MM, Collins KS, eds. Women’s health—the Commonwealth Fund Survey. Baltimore, Maryland: Johns Hopkins University Press, 1996. Nichol KL, Lofgren RP, Gapinski J. Influenza vaccination. Knowledge, attitudes, and behavior among highrisk outpatients. Arch Intern Med 1992;152:106 –10. Centers for Disease Control and Prevention. Prevention of perinatal transmission of hepatitis B virus: prenatal screening of all pregnant women for hepatitis B surface antigen. MMWR 1988;37:341–6. Bath SK, Singleton JA, Stritas RA, Stevenson JM, McDonald LL, Williams WW. Performance of US hospitals on recommended screening and immunization practices for pregnant and postpartum women. Am J Infect Control 2000;28:327– 32. Zimmerman RK, Clover RD. Adult immunizations—a practical approach for clinicians: part I. Am Fam Phys 1995;51:859 –67. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46:1–25.
Address correspondence and reprint requests to Bernard Gonik, MD, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Sinai-Grace Hospital, 6071 W. Outer Drive, Detroit, MI 48235.
Prim Care Update Ob/Gyns
PATIENT VACCINE AWARENESS IN AN OBSTETRIC AND GYNECOLOGIC OFFICE SETTING Thomas M. Malone, MD, Bernard Gonik, MD, and Mark Tomlinson, MD
The objective of our study was to better understand patient vaccine awareness in different ob/gyn settings. A masked questionnaire was completed by ob/gyn resident teaching clinic patients (CLINIC; n ⴝ 228) and private community physician patients (PVT; n ⴝ 254) exploring demographic, immunization recollection, and vaccine administration preferences. 2 and Student t test were used for statistical analyses. The results demonstrated that those in CLINIC compared with PVT were younger (27.2 ⴞ 10.6 years old versus 38.0 ⴞ 12.6 years old; P < .001) and more often presented for pregnancyrelated visits (57.0% versus 21.6%; P < .001). PVT patients more commonly had documentation of childhood (34.3%) and adult (26.8%) vaccine status than those in CLINIC (25.6% and 15.5%, respectively; P < .03). Of the vaccine-preventable diseases (VPDs) surveyed, those in PVT (versus CLINIC) more often reported adequate vaccination or prior exposure to measles (68.5% versus 30.5%; P < .001) and varicella (65.7% versus 48.5%; P < .001). No differences were noted between study groups for hepatitis B, tetanus, and influenza. Those in PVT more often identified a non-ob/gyn provider for vaccine-related From the Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan and Women’s Healthcare Associates, Portland, Oregon.
Volume 9, Number 6, 2002
needs, as opposed to those in CLINIC, who more often relied on ob/gyn or health department sites for such needs. Over one third of both populations could not identify a provider for vaccine administration. Both groups strongly desired availability of vaccine services through their ob/gyn office. We conclude that PVT patients demonstrate a better awareness of vaccine status compared with those in CLINIC. However, overall both populations report poor documentation and inadequate immunity against most VPDs. A variety of practice sites are currently used for vaccination, although many patients cannot identify a place to go. The majority of patients would like to see this service available as a part of their ob/gyn care. (Prim Care Update Ob/Gyns 2002;9:195–198. © 2002 Elsevier Science Inc. All rights reserved.)
Studies suggest that immunization rates for children and adults remain below nationally established standards.1 Focusing on the adult population, surveillance data estimate that between 50,000 and 70,000 adults die each year in the United States from pneumococcus, influenza, and hepatitis B.2 Approximately 50% of Americans aged ⬎50 years are not adequately immunized against diphtheria and tetanus.3 Worldwide, as many as 12
© 2002 Elsevier Science Inc., all rights reserved. 1068-607X/02/$22.00
●
million women of childbearing age are susceptible to rubella infection.4 Each of these diseases is recognized as a vaccine-preventable disease. As the health care paradigm has changed for physicians, so has the status of the obstetrician/ gynecologist, who now functions in the dual role of primary care provider and specialist.5,6 Within obstetric and gynecologic practices, a recent survey of clinicians in the state of Michigan demonstrated a significant discrepancy between physician self-recognized vaccinepreventable disease responsibilities and practice patterns. Despite attitudes that generally supported the need for better immunization and vaccine surveillance, knowledge deficiencies and logistical concerns limited physician compliance. 7 Physician-focused postgraduate educational programming has been instituted to address these issues.8 This is in keeping with current American College of Obstetricians and Gynecologists recommendations that encourage primary care initiatives and focus on health maintenance and disease prevention.9 Of note, the Commonwealth Fund found that gynecologists administered more preventative care services to women than did either internists or family practitioners.10 To date, few data are available examining patient awareness or preferences related to vaccinepreventable diseases. This is particularly important in an obstetric/
PII S1068-607X(02)00117-8
195
MALONE ET AL Table 1. Adequacy of Immunization Based on Patient Recall for Infection or Vaccination Disease
PVT, % (n ⴝ 254)
CLINIC, % (n ⴝ 228)
P
Measles Chickenpox Tetanus, within 10 y HBV Flu, annual
68.5 65.7 47.6 36.6 22.0
30.5 48.5 43.1 36.1 23.3
⬍0.001 ⬍0.001 NS NS NS
PVT, private practice ob/gyn patients; CLINIC, resident teaching clinic ob/gyn patients; HBV, hepatitis B virus; Flu, influenza vaccine; NS, not significant.
gynecologic setting, where officebased protocols are unlikely to exist for routine usage. Lack of patient awareness is hypothesized to be an additional barrier to adequacy of vaccination within the clinical setting. In many instances, adults are unaware of the need for immunizations, particularly ones that are predicated on medical, occupational, or lifestyle risks.11 In this study, we examine, by masked questionnaires, obstetrician/ gynecologist patient knowledge and attitudes concerning vaccine practices. Additionally, we compare these responses in two different practice settings, being private offices versus resident-teaching clinic environments.
teaching offices in the Detroit metropolitan area were used. Patients were offered participation while awaiting their scheduled visit. The questionnaires were self-administered and returned to the front office staff without editing or review. The 12-item survey contained yes–no and multiple choice questions exploring demographic, immunization recollection, and vaccine administration preferences. A copy of the questionnaire is available upon request. Data were entered into a computerized database. 2 for categorical variables and Student t test for continuous variables were used for statistical analyses, with P ⬍ .05 considered statistically significant.
Results
Methods Blinded questionnaires were given to nonselected patients attending routine obstetric and gynecologic visits at designated practice sites during the summer of 2000. Nine private-practice and two resident-
The study population consisted of 228 respondents from the resident teaching clinics and 254 respondents from the private-practice settings. Because no differences were noted between the two residentteaching clinics and between indi-
Table 2. Patient Self-Reported Health Care Provider Site for Vaccine Administration
Fm Prac/Int Med (%) Ob/Gyn (%) Health Dept (%) Other (%) None (%) Interest in using Ob/Gyn (%)
PVT, % (n ⴝ 254)
CLINIC, % (n ⴝ 228)
P
42.1 8.7 4.7 7.1 37.4 78.8
28.1 19.9 9.5 5.0 37.6 84.0
⬍0.001 ⬍0.001 ⬍0.001 NS NS NS
PVT, private practice ob/gyn patients; CLINIC, resident teaching clinic ob/gyn patients; Fm Prac/Int Med, family practice/internal medicine; NS, not significant.
196
vidual private-practice offices, these data were combined into two study populations for statistical comparisons. Data were not available as to the total number of office visits at each site; therefore, an overall response rate cannot be determined. Generally, patients willingly completed the questionnaires without reported complaints or concerns. Significant differences were identified between the two study groups. The resident-teaching clinic patients were on average younger (27.2 ⫾ 10.6 years of age versus 38.0 ⫾ 12.6 years of age; P ⬍ .001) and presented to the office more often for obstetric indications (57.0% versus 21.6%; P ⬍ .001) compared with the private-practice patients, respectively. Although the private patient group significantly more often reported having written documentation of childhood vaccinations compared with the resident-teaching clinic patients (34.3% versus 25.6%, respectively; P ⬍ 0.03), this constituted the minority of subjects overall. Even fewer patients in both groups reported having any adult vaccination documentation, although again this was more common for private patients compared with clinic respondents (26.8% versus 15.5%, respectively; P ⬍ .006). On the basis of subject recall, most patients had inadequate immunity to common vaccinepreventable diseases, either by prior exposure or vaccination (Table 1). Measles and chickenpox vaccination or infection were the most commonly reported immunization histories for both study populations. The private patients, compared with clinic subjects, more often reported these specific viral exposures. Few patients in either study group reported past vaccination for or infection with hepatitis B virus, tetanus booster administration in the last 10 years, or annual influenza vaccination (Table 1). Table 2 demonstrates current rePrim Care Update Ob/Gyns
FIRST PRIZE MANUSCRIPT
ported sites for vaccine administration by respondents. Significant differences were noted between subject groups. Compared with clinic patients, private patients more often used nonobstetrician/ gynecologist primary care offices for vaccine needs and less often used their obstetrician/gynecologist or local health department. More important, over one third of subjects in both groups could not identify a site for their current vaccine administration needs. When asked, the overwhelming majority of patients surveyed expressed a strong desire to use their obstetrician/gynecologist office for such services if the services were made available (Table 2).
Discussion Common vaccine-preventable diseases cause unnecessary morbidity and mortality in the adult population, particularly in those who are elderly and with comorbid conditions. Recent surveys have documented that the minority of adults in the United States are adequately vaccinated against influenza, pneumococcus, and tetanus/diphtheria.3 Similarly, at-risk individuals have been shown to be suboptimally vaccinated against hepatitis B virus.12 Although it is routine to serologically screen for rubella immunity in the obstetric population, appropriate vaccination in the postpartum period is not always accomplished.13 This is despite clear and authoritative immunization recommendations for these infectious agents by groups such as the Advisory Committee on Immunization Practices and the Centers for Disease Control and Prevention. We have previously demonstrated that a discrepancy exists between clinician-perceived responsibility for patient vaccination and actual practice patterns.7 As the primary care mantle settles on the obVolume 9, Number 6, 2002
stetrician/gynecologist in a more comfortable fashion via resident and postgraduate educational efforts, it is hoped that vaccination of adult women will become a more routine component of office-based practice. Until then, a significant portion of the responsibility to maintain adequate vaccination remains with the individual patient. Unfortunately, many women are unaware that they need specific vaccines.14 Also, there is evidence that adults are reluctant to receive immunizations because of unfounded concerns related to vaccine adverse reactions.11 In our study, we confirmed that one reason for underimmunization is a lack of patient awareness. Few patients maintain personal records or have an established place to obtain this information. This pattern appears to cross patient demographic boundaries and is not limited to the traditionally underserved urban populations typically represented in our resident-teaching clinic settings. Surprisingly, our data represent the first such information on patient vaccine-preventable disease knowledge and preferences in an ob/gyn population. We anticipated seeing a higher rate of reported history consistent with hepatitis exposure or vaccination in our clinic patients. This is because these patients were younger and therefore more likely to have been vaccinated as adolescents. Additionally, there is a greater awareness of hepatitis B risk factors (such as multiple partners and the presence of sexually transmitted diseases) in these clinics. But this higher rate of reported history did not prove to be the case. Likewise, we expected to see a much higher reporting of measles and chickenpox in both study groups given the known high prevalence of varicella in the community and the school entry requirements for measles vaccination. We used the term measles in our ques-
tionnaire, and not a more specific agent, in an attempt to capture the largest possible pool of affirmative responses. Clearly these common childhood viral exanthemas have been underreported in our study. The above findings further highlight the lack of patient awareness and need for more vigilant screening and education. Too few patients in our sample were 65 years or older, so no information is available regarding pneumococcal vaccination. This is unfortunate because this infectious agent results in more adult deaths each year than does any other vaccine-preventable disease. 15 We speculate that if these data were available, even lower levels of reporting would be seen because of the generally recognized lack of physician and patient familiarity with this vaccine in the adult population. Our data demonstrating a lack of an identifiable health care provider for vaccination needs is particularly disconcerting. More than one third of all our respondents fell into this category. This means that despite receiving ongoing primary care, patients did not connect adult vaccination to these services. Regarding the remainder of the population, as expected, more private patients had access to other non-obstetrician/ gynecologists for vaccine administration. It is likely that clinic subjects have only a narrow funded window of opportunity during pregnancy to access nonurgent health care and therefore recognize their current obstetrician/ gynecologist for vaccine care. Unfortunately, this is infrequently offered by the health care provider on a routine basis. It should be clear from our study, however, that patients would eagerly accept vaccine-related services from their obstetrician/gynecologist if this were made available. Limitations to our study need to be acknowledged. Only a limited 197
MALONE ET AL
amount of demographic information was collected at the time of the survey, so a more detailed analysis of patient characteristics as they relate to vaccine history and usage cannot be accomplished. This was in part because of the diversity of office settings used for the study, and the self-reporting nature of the survey. More important, the information gathered was based solely on patient recall. It is therefore likely that accurate vaccinepreventable disease exposures (based on objective serologic testing) would not necessarily agree with our reported findings. However, one of the points of our study was to examine patient perceptions because these guide initial decision-making processes for subsequent health care. Given the significance of the data presented, more investigations are warranted that can better define patient reasons for vaccine inadequacies and how the health care team can impact these issues.
3.
4.
5.
6.
7.
8.
References 1. Szilagyi P, Bordley C, Vann J, et al. Effect of patient reminder/recall interventions on immunization rates. JAMA 2000;284:1820 –6. 2. National Coalition for Adult Immunization. Resource guide for adult and adolescent immunization. 3rd
198
9.
10.
ed. Bethesda, MD: National Coalition for Adult Immunization, 1998. 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. Cutts FT, Robertson SE, Diaz-Ortega IL, Samuel R. Control of rubella and congenital rubella syndrome in developing countries. Bull World Health Org 1997;75:55–68. Hendrix SL, Pierson SD, McNeeley SG. Primary and preventive care in a university obstetrics and gynecology group practice. Am J Obstet Gynecol 1995;172:1719 –22. Seltzer VL, Fishburne JI, Jonas HS. Obstetric and gynecology residencies: education in preventive and primary health care for women. Obstet Gynecol 1998;91:305–10. Gonik B, Jones T, Contreas D, Fasano N, Roberts C. The obstetrician’s-gynecologists role in vaccine-preventable disease and immunization. Obstet Gynecol 2000; 96:81–4. Gonik B, Jones T, Fasano N, Contreras D, Roberts C. Vaccine-preventable diseases (VPD): improving the obstetrician/gynecologist knowledge and immunization practice patterns. Am J Obstet Gynecol 2001;185:S162. American College of Obstetricians and Gynecologists [ACOG]. Primary and preventive care. Periodic assessments. ACOG Committee Opinion 229. Washington, DC: ACOG, 1999. Weisman CS. Women’s use of
11.
12.
13.
14.
15.
health care. In Falik MM, Collins KS, eds. Women’s health—the Commonwealth Fund Survey. Baltimore, Maryland: Johns Hopkins University Press, 1996. Nichol KL, Lofgren RP, Gapinski J. Influenza vaccination. Knowledge, attitudes, and behavior among highrisk outpatients. Arch Intern Med 1992;152:106 –10. Centers for Disease Control and Prevention. Prevention of perinatal transmission of hepatitis B virus: prenatal screening of all pregnant women for hepatitis B surface antigen. MMWR 1988;37:341–6. Bath SK, Singleton JA, Stritas RA, Stevenson JM, McDonald LL, Williams WW. Performance of US hospitals on recommended screening and immunization practices for pregnant and postpartum women. Am J Infect Control 2000;28:327– 32. Zimmerman RK, Clover RD. Adult immunizations—a practical approach for clinicians: part I. Am Fam Phys 1995;51:859 –67. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46:1–25.
Address correspondence and reprint requests to Bernard Gonik, MD, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Sinai-Grace Hospital, 6071 W. Outer Drive, Detroit, MI 48235.
Prim Care Update Ob/Gyns