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Vaccine eligibility and acceptance among ambulatory obstetric and gynecologic patients
Vaccine 29 (2011) 2024–2028
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Vaccine eligibility and acceptance among ambulatory obstetric and gynecologic patients夽,夽夽 Wendy S. Vitek a,∗ , Aletha Akers b , Leslie A. Meyn c , Galen E. Switzer d,e , Bruce Y. Lee f , Richard H. Beigi b a Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Women & Infants Hospital of Rhode Island, 90 Plain Street, Providence, RI, United States b Department of Obstetrics, Gynecology and Reproductive Sciences, Divisions of Gynecologic Specialties and Reproductive Infectious Diseases, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA, United States c Magee-Womens Research Institute, Pittsburgh, PA, United States d Departments of Medicine and Psychiatry, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States e Center for Health Equity and Promotion, VA Pittsburgh Health System, United States f Departments of Medicine and Epidemiology, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, PA, United States
a r t i c l e
i n f o
Article history: Received 10 October 2010 Received in revised form 10 January 2011 Accepted 11 January 2011 Available online 25 January 2011 Keywords: Patient acceptance of health care Vaccine Obstetrics Gynecology
a b s t r a c t Objective: To assess vaccine eligibility and factors associated with vaccine acceptance among ambulatory obstetric and gynecologic patients. Methods: An anonymous office-based survey was administered to women seeking ambulatory obstetric and gynecologic care at a large women’s hospital from December 2007 to July 2008. Information collected included: demographics, medical and vaccination history, interest in receiving vaccines and attitudes towards vaccine providers. Vaccine eligibility was based on age and/or self-reported risk factors in accord with the 2007–2008 Center for Disease Control and Prevention (CDC) adult immunization schedule. Vaccine eligibility was examined using descriptive statistics, and demographic characteristics were compared using chi-squared analysis. A multivariable logistic regression model was developed to assess factors associated with participants’ willingness to accept vaccines from their obstetrician–gynecologist. Results: A total of 1441 women completed the survey. The majority of participants (87%) would accept vaccines if recommended by their obstetrician–gynecologist. The primary factors associated with vaccine acceptance were having less than a high school education, being privately insured, currently being pregnant, reporting a history of vaccinations and previously receiving vaccinations from an obstetrician–gynecologist. A significant portion of participants were eligible for the hepatitis B, influenza and HPV vaccines (≥50% for each). The type of vaccine did not influence willingness to accept vaccines from an obstetrician–gynecologist. Conclusion: A majority of women appear eligible for, and will accept, vaccinations regardless of specific vaccine, if recommended by their obstetrician–gynecologist. These findings justify ongoing efforts to expand immunization services offered by obstetrician–gynecologists. © 2011 Elsevier Ltd. All rights reserved.
1. Introduction Vaccine-preventable diseases account for more than 50,000 deaths per year among US adults, which surpasses the mortality from breast cancer, HIV/AIDs or traffic accidents [1]. Despite the availability of safe and effective vaccines, vaccination rates among adults remain low [2]. Factors that contribute to low vaccination
夽 Financial support: 2007–2008 American Congress of Obstetricians and Gynecologists/Merck and Company Inc. Research Award on Immunization. 夽夽 Presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology, Seattle, WA, August 14–17, 2008. ∗ Corresponding author. Tel.: +1 401 452 4422; fax: +1 401 276 7845; mobile: +1 412 841 4435. E-mail addresses: [email protected], [email protected] (W.S. Vitek). 0264-410X/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.vaccine.2011.01.026
rates include lack of knowledge of vaccination need, confusion regarding vaccination history, mistrust of vaccines, and provider assumptions that adults have been vaccinated [3–5]. Adults appear more willing to accept immunizations if they understand that vaccines prevent life-threatening diseases or if a physician recommends a vaccination [1]. Women of reproductive age represent a population with unique vaccination needs. Compared to men and older women, reproductive age women are at increased risk for certain vaccinepreventable sexually transmitted infections, such as human papilloma virus (HPV) and hepatitis B. In addition, pregnancy presents special challenges. Live-virus vaccines are currently contraindicated in pregnancy due to the potential risk of pathogen transmission to the fetus. Pregnant women also experience increased morbidity and mortality from some vaccine-preventable
W.S. Vitek et al. / Vaccine 29 (2011) 2024–2028
diseases compared to non-pregnant women. Hence, women of reproductive age may gain substantial benefits from immunizations. For example, vaccinating adolescent and young women against HPV types 16 and 18 is predicted to decrease cervical cancer risk by up to 70% [6]. Ensuring immunity to rubella, varicella, hepatitis B, tetanus and pertussis prior to pregnancy can reduce or eliminate vertical and neonatal transmission of these lifethreatening diseases. Influenza vaccination is the primary method of preventing the disproportionate maternal and neonatal morbidity and mortality due to antenatal influenza infection [7]. In recognition of these benefits, many obstetrician–gynecologists (Ob–Gyns) have incorporated vaccine services into their practices [8]. Despite the increased availability of vaccinations in Ob–Gyn’s offices, a survey of obstetric and gynecologic patients found low vaccination rates for hepatitis B (36%), tetanus (45%) and influenza (23%) [9]. One step in improving vaccination rates among obstetric and gynecologic patients is the identification of factors that influence the willingness of women to accept vaccines from their Ob–Gyn. The objective of this study was to assess vaccine eligibility and factors associated with vaccine acceptance among ambulatory obstetric and gynecologic patients attending a large, tertiary care women’s hospital.
2. Materials and methods An anonymous, self-administered, written survey investigation was conducted among women seeking obstetric or gynecologic care at Magee-Womens Hospital (MWH) of the University of Pittsburgh Medical Center (UPMC) from December 2007 to July 2008. The survey was administered to patients presenting at the outpatient general obstetric and gynecology clinics offered in the facility. Subspecialty clinics (e.g., Maternal–Fetal Medicine, Gynecologic Oncology, Urogynecology) were not included. The clinics were staffed by the academic generalist gynecology service (16 faculty providers) and the resident service (36 residents). The survey was offered to all patients presenting for care once during the study period. The response rate was determined by tracking the number of completed surveys and the number of women who sought care at these locations over the survey period. The study was approved by the University of Pittsburgh Institutional Review Board. The survey contained 54 questions and required approximately 10 min to complete. The survey was initially field-tested in the clinics for acceptability and comprehension and was found to be acceptable by patients. A copy of the survey is available upon request. Standard socio-demographic variables were assessed including age, race/ethnicity, education, income, and insurance status. Information regarding health care utilization, vaccination history and vaccine eligibility was also collected. Health care utilization was examined with three items that assessed the practice specialty for each participant’s primary care physician (PCP), whether
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participants had ever received a vaccination and whether they had received a vaccination from an obstetrician–gynecologist. Vaccine history was investigated by asking participants to indicate which of eight vaccinations they had ever received (i.e., measles/mumps/rubella, tetanus/diphtheria/pertusis (Tdap), influenza, meningococcal, human papilloma virus, varicella, hepatitis B, pneumovax). Vaccine eligibility was assessed with 13 items created based on age and risk factors in accordance with the 2007–2008 CDC adolescent and adult immunization schedule [3]. For instance, participants were considered eligible for hepatitis B vaccine if they reported occupational risk factors, high-risk sexual behaviors, intravenous drug use or sought evaluation or treatment for a sexually transmitted disease. Participants were considered eligible for the pneumococcal vaccination if they were over the age of 65 or had medical risk factors such as chronic hepatic, cardiac, pulmonary or renal disease, sickle cell anemia, splenectomy or a compromised immune system. For a complete list of eligibility criteria for included vaccinations, please refer to the CDC guidelines [10]. Willingness to accept vaccinations recommended by an Ob–Gyn was assessed with an item with three response options: willing, unwilling or undecided. Statistical analyses were performed using SPSS statistical software version release 17.0.0 (SPSS Inc., Chicago, IL). To assess vaccine eligibility the proportion of women who met eligibility criteria for each of the 8 included vaccinations based on their responses to the 13 vaccine eligibility questions was determined. To examine factors associated with a woman’s willingness to accept vaccinations recommended by their Ob–Gyn, this variable was collapsed into a dichotomous item (willing vs. unwilling/undecided). Bivariate analyses were performed using chi-square tests. In the bivariate analysis, all socio-demographic and healthcare utilization items were included. A multivariable logistic regression model was then developed to identify factors that were independently associated with participants’ willingness to accept vaccinations recommended by an Ob–Gyn. All tests of association were considered significant at the two-sided, 0.05 significance level.
3. Results During the study period, 1441 participants completed surveys, representing 25% of the patients seen in the clinics. The sociodemographics of the respondents very closely matched the overall socio-demographics of the population of women who receive care in the clinics and thus produces a representative sample of this patient population. Participants’ willingness to accept vaccinations from their Ob/Gyn and vaccine eligibility is displayed in Table 1. Large numbers of participants were eligible for hepatitis B (66%), influenza (70%) and HPV vaccine (50%) based on age, risk factors and prior vaccination history. When looking at the sample of women who were eligible for at least one vaccine, 1235 (87%) of participants reported willingness to accept immunizations if recommended by their Ob/Gyn.
Table 1 Number and proportion of participants willing to accept vaccinations from their obstetrician–gynecologist. Willingness to accept vaccinations from obstetrician–gynecologist n (%) Recommended vaccination
Entire sample, n = 1419
Vaccine eligible, n = 1235
Influenza Hepatitis B HPV Tdap Varicella Pneumococcal Meningococcal
1050 (74) 933 (66) 707 (50) 383 (27) 284 (20) 138 (10) 50 (4)
911 (87) 822 (88) 626 (89) 329 (86) 244 (86) 115 (83) 43 (86)
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W.S. Vitek et al. / Vaccine 29 (2011) 2024–2028
Table 2 Demographic analysis of participants for sample and stratified by willingness to accept vaccinations recommended by obstetrician–gynecologist. Characteristics
Samplea n = 1419
Age, years 13–17 43 (3%) 18–49 1271 (90%) 50 and older 98 (7%) Race/ethnicity White 804 (57%) African American 506 (36%) Hispanic/Latino 29 (2%) Asian 26 (2%) Multi-ethnic/other 54 (4%) Education Less than high school 108 (8%) High school/GED 448 (32%) College 709 (50%) Post graduate 145 (10%) Yearly household income <$10,000 486 (36%) $10–39,999 516 (38%) $40–79,999 182 (14%) >$80,000 159 (12%) Insurance None 177 (13%) Private 539 (38%) Medicaid/Medicare 649 (46%) Other 40 (3%) Currently pregnant Yes 562 (40%) No 768 (54%) Unsure 84 (6%) Primary care physician None 344 (24%) Obstetrician–gynecologist 193 (14%) Family practitioner 625 (44%) Internist 203 (14%) Pediatrician 21 (1%) Other 24 (2%) Have received vaccines Yes 1337 (94%) No 81 (6%) Received vaccines from obstetrician–gynecologist Yes 186 (13%) No 1232 (87%) a †
Willing to accept vaccinationsa n = 1235
Unwilling or undecided about accepting vaccinations* n = 184
38 (3%) 1108 (90%) 82 (7%)
5 (3%) 163 (89%) 19 (9%)
718 (58%) 422 (34%) 27 (2%) 24 (2%) 44 (4%)
86 (47%) 84 (46%) 2 (1%) 2 (1%) 10 (5%)
104 (8%) 377 (31%) 616 (50%) 129 (11%)
4 (2%) 71 (39%) 93 (51%) 16 (9%)
418 (36%) 447 (38%) 159 (14%) 144 (12%)
68 (39%) 69 (39%) 23 (13%) 15 (9%)
153 (13%) 487 (40%) 555 (45%) 27 (2%)
24 (13%) 52 (28%) 94 (51%) 13 (7%)
500 (41%) 671 (55%) 60 (5%)
62 (34%) 97 (53%) 24 (13%)
293 (24%) 176 (14%) 540 (44%) 179 (15%) 21 (2%) 19 (2%)
51 (28%) 17 (9%) 85 (47%) 24 (13%) 0 (0%) 5 (3%)
1176 (95%) 58 (5%)
161 (88%) 23 (12%)
181 (15%) 1053 (85%)
5 (3%) 179 (97%)
p† 0.59
0.01
0.008
0.51
<0.001
<0.001
0.11
<0.001
<0.001
Proportions do not sum to 100% where there is missing data. p-Value from Chi-square test.
The demographic characteristics of participants are displayed in Table 2. The majority of patients were reproductive aged women between 18 and 49 years. More than half were white and a third were African American. In the bivariate analysis no differences were noted between women who were willing versus those who were unwilling or undecided to accept vaccinations based on participants’ age, yearly household income, or type of primary care physician. Compared to those who were unwilling or undecided about accepting vaccinations, women who were willing to accept them were more likely to be white (58% vs. 47%, p = 0.01); have less than a high school education (8% vs. 2%, p = 0.008); have private insurance (40% vs. 28%, p < 0.001); and be pregnant (41% vs. 34%, p < .001). Participants with more than a high school education were more likely to report having a primary care physician than participants with less then a high school education (60.6% vs. 39%, p < .001). The multivariable logistic regression model demonstrated (Table 3) that six factors were independent predictors of women’s willingness to accept vaccinations recommended by their Ob–Gyn: race, education level, insurance status, prior history of vaccination, prior history of receiving a vaccination from an obstetrician–gynecologist, and pregnancy status. Having less than a high school education and history of previously receiving vaccinations from an Ob–Gyn were the strongest predictors of willingness
to accept vaccinations recommended by their Ob–Gyn. Having a history of previously receiving vaccinations from an Ob–Gyn was a stronger predictor than simply having previously received a vaccine. Compared with white participants, African-American participants reported they were 33% less likely to accept vaccinations (p < 0.03). Having private insurance and being currently pregnant were also independently associated with willingness to accept vaccinations.
Table 3 Logistic regression model of factors associated with willingness to accept vaccinations recommended by obstetrician–gynecologist.
Race/ethnicity White African American Other Less than high school education Private insurance Currently pregnant History of vaccination History of vaccination by obstetrician–gynecologist a
Adjusted for all factors shown.
Adjusted ORa
p
Referent 0.67 (0.48–0.95) 0.72 (0.38–1.34) 4.98 (1.79–13.84) 1.70 (1.17–2.46) 1.45 (1.03–2.06) 2.10 (1.24–3.57) 5.75 (2.32–14.25)
0.03 0.30 0.002 0.005 0.04 0.006 <0.001
W.S. Vitek et al. / Vaccine 29 (2011) 2024–2028
4. Discussion The results of this study demonstrate that a significant portion of ambulatory obstetric and gynecologic patients appear to be eligible for immunization and report a willingness to accept vaccination if recommended by their Ob–Gyn, regardless of vaccine type. In this investigation, three specific factors were independently associated with vaccine acceptance; current pregnancy, lower levels of education and prior history of receiving vaccinations from an Ob–Gyn. Targeting these populations with strategies to increase vaccination uptake is likely to result in improved vaccination rates. Of note, pregnancy was independently associated with vaccine acceptance, which is an important finding given the frequent presumption of existent patient fears about immunization (and other interventions) during pregnancy. Pregnancy appears to motivate women to engage in health promoting behaviors. For example, prior research has shown that 46% of women who smoke will quit during pregnancy [11]. Vaccine acceptance during pregnancy may also result from the trust established between physicians and patients through prenatal visits [12]. Importantly, the frequency of prenatal care visits provides ample opportunities to discuss and administer vaccinations. Thus, this study reiterates the concept that pregnancy may represent a key time to target immunization efforts of non-contraindicated vaccines, as others have previously suggested [12–14]. Participants with less than a high school education were five times more likely to be willing to accept a vaccination from an Ob–Gyn. This finding may reflect lower socio-economic status as a marker for differential access to health care services. Those with higher levels of education were more likely to be privately insured and have a primary care physician to receive vaccinations from, in addition to having an Ob–Gyn. Likewise, those with lower levels of education may have fewer points of entry into the health care system and would, therefore, be willing to obtain vaccinations from their Ob–Gyn, who may serve as their sole provider. The impact of private insurance on vaccination rates is also demonstrated in a survey of adolescent and young women, which found that women with insurance coverage for the HPV vaccine were 5 times more likely to be immunized (OR 5.31 95% CI 1.61–17.79) [15]. Increased rates of societal insurance coverage for vaccinations could minimizing the access and financial barriers to immunization and improve vaccination rates among women. Prior receipt of a vaccine from an Ob/Gyn was a strong predictor of future vaccine acceptance from an Ob/Gyn. While many obstetrician–gynecologists offer the HPV and influenza vaccines, few offer the full complement of vaccines recommend by the CDC [16]. The current investigation corroborates this finding; few study participants reported having previously received several vaccinations from their Ob–Gyns. Low rates of delivery of full vaccination services is due to many factors not the least of which is incomplete reimbursement for vaccinations by third-party payers [16]. As changes in health care increase opportunities for vaccine coverage and as Ob–Gyns become more experienced in the office management of vaccine administration, strong consideration should be given to offering comprehensive vaccination services to achieve the highest rates of disease prevention in this population. For most immunizations the costs incurred by offices to procure, store, and administer immunizations is a significant providerspecific barrier to uptake of immunization provision. In many settings and for varied specific vaccines the provider reimbursement via third-party payers for vaccine services is either non-existent or inadequate to offset the true costs of vaccine provision. Frequent unrecognized and uncompensated costs include, but are not limited to: true cost of vaccine procurement, storage costs, costs of unused vaccine, time spent encouraging vaccination, personnel costs, etc. There is hope that the preventive care
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focus of the recently passed health care legislation may produce more standardized and appropriate coverage for adult (and pediatric) immunization services. This, in turn, could potentially serve to overcome the financial barriers that present major challenges to the adoption of large-scale adult vaccination services by many providers. This study has several strengths. This is the first investigation that directly assesses specific vaccine eligibility for multiple vaccines among a large and diverse patient population served by a sample of Ob–Gyns. In addition, this data is timely given the recent experience of vaccinating pregnant women against H1N1 during the 2009 influenza pandemic and the focus on disease prevention efforts at the national level. These impressive eligibility and willingness data herein come at a time of increased interest in adult immunization services. Several limitations of the current investigation are also notable. his study was conducted at a single-site in an urban, academic tertiary care center in a population that was predominantly white or African American. The data may not be generalizable to patients seen in other settings or with different socio-demographic characteristics. The socio-demographic characteristics of respondents very closes matches those of the overall clinic population, suggesting that the selection bias among participants was minimal and that the 25% response rate in this report is a reliable representative sample of the overall clinic population. In order to capture sensitive information from women presenting for a care at Ob/Gyn clinics, an anonymous, self-administered, written survey was selected. While this approach optimized the quality of data collected, the response rate was relatively low, but did capture a representative sample of the clinic population. Recall bias may also have influenced the responses regarding vaccination history. We did not perform medical record reviews to verify participants’ vaccine eligibility or vaccination histories for this anonymous questionnaire. Thus, the current investigation can only approximate potential vaccine uptake by participants should these enhanced immunization services be offered. Future research is needed in these patient populations to determine the most effective methods of education of young adult women regarding their vaccination needs and operationalizing these findings in order to increase overall vaccine uptake. Many women seen by Ob–Gyns appear willing to accept recommended vaccinations for which they may be medically eligible. Ob–Gyns could play a strong role in increasing vaccine uptake and reducing morbidity and mortality from vaccine-preventable diseases. Future efforts will need to assess and address barriers to offering comprehensive vaccination services through Ob–Gyn outpatient clinical settings.
References [1] National Foundation for Infectious Diseases. American adults’ awareness about immunization. Available at: http://www.adultvaccination.com/doc/ Survey Fact sheet.pdf; [retrieved 01.03.10]. [2] Center for Disease Control. Vaccination coverage among U.S. adults, National Immunization Survey – Adult, 2007. Available at: http://www.cdc.gov/ vaccines/stats-surv/nis/downloads/nis-adult-summer-2007.pdf; [retrieved 01.03.10]. [3] Center for Disease Control. Reasons reported by Medicare beneficiaries for not receiving influenza and pneumococcal vaccinations – United States, 1996. MMWR 1999;48:556–61. [4] Gindi M, Peter O, Sexton R, Shpak M, Eisenhart A. Unreliability of reported tetanus vaccination histories. Am J Emerg Med 2005;23:120–2. [5] Schrag S, Fiore A, Gonik B, Malik T, Reff S, Singleton J, et al. Vaccination and perinatal infection prevention practices among obstetrician–gynecologist. Obstet Gynecol 2003;101(4):704–10. [6] Massad L, Einstein M, Myers E, Wheeler C, Wentzensen N, Solomon N. The impact of human papillomavirus vaccination on cervical cancer prevention efforts. Gynecol Oncol 2009;114(2):360–4. [7] American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. Influenza vaccination and treatment during preg-
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[8]
[9] [10]
[11]
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nancy, ACOG committee opinion no. 305, November 2004. Obstet Gynecol 2004;104:1125–6. Power M, Leddy Y, Anderson B, Gall S, Gonik B, Schulkin J. Obstetrician–gynecologists’ practices and perceived knowledge regarding immunization. Am J Prev Med 2009;37(3):231–4. Malone T, Gonik B, Tomlinson M. Patient vaccine awareness in an obstetric and gynecologic office setting. Prim Care Update Ob/Gyns 2002;9:195–8. Center for Disease Control. Recommended Adult Immunization Schedule – United States, October 2007 – September 2008. MMWR 2007;56(41): Q1–4. Colman GJ, Joyce T. Trends in smoking before, during and after pregnancy in ten states. Am J Prev Med 2003;24(1):29–35.
[12] Yeager D, Toy E, Baker B. Influenza vaccination in pregnancy. Am J Perinatol 1999;16(6):283–6. [13] Beigi R, Switzer GE, Meyn LA. Acceptance of a pandemic avian influenza vaccine in pregnancy. J Reprod Med 2009;54(6):341–6. [14] Gall S. The obstetrician–gynecologist as vaccinator. ACOG Clin Rev 2008;13(2):1–16. [15] Conroy K, Rosenthal SL, Zimet GD, Jin Y, Bernstein DI, Glynn S, et al. Human papillomavirus vaccine uptake, predictors of vaccination and self-reported barriers to vaccination. J Womens Health 2009;18(10):1679–86. [16] Gonik B, Jones T, Contreras D, Fasano N, Roberts C. The obstetrician– gynecologists role in vaccine-preventable diseases and immunization. Obstetr Gynecol 2000;96:81–4.
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Vaccine eligibility and acceptance among ambulatory obstetric and gynecologic patients夽,夽夽 Wendy S. Vitek a,∗ , Aletha Akers b , Leslie A. Meyn c , Galen E. Switzer d,e , Bruce Y. Lee f , Richard H. Beigi b a Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Women & Infants Hospital of Rhode Island, 90 Plain Street, Providence, RI, United States b Department of Obstetrics, Gynecology and Reproductive Sciences, Divisions of Gynecologic Specialties and Reproductive Infectious Diseases, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA, United States c Magee-Womens Research Institute, Pittsburgh, PA, United States d Departments of Medicine and Psychiatry, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States e Center for Health Equity and Promotion, VA Pittsburgh Health System, United States f Departments of Medicine and Epidemiology, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, PA, United States
a r t i c l e
i n f o
Article history: Received 10 October 2010 Received in revised form 10 January 2011 Accepted 11 January 2011 Available online 25 January 2011 Keywords: Patient acceptance of health care Vaccine Obstetrics Gynecology
a b s t r a c t Objective: To assess vaccine eligibility and factors associated with vaccine acceptance among ambulatory obstetric and gynecologic patients. Methods: An anonymous office-based survey was administered to women seeking ambulatory obstetric and gynecologic care at a large women’s hospital from December 2007 to July 2008. Information collected included: demographics, medical and vaccination history, interest in receiving vaccines and attitudes towards vaccine providers. Vaccine eligibility was based on age and/or self-reported risk factors in accord with the 2007–2008 Center for Disease Control and Prevention (CDC) adult immunization schedule. Vaccine eligibility was examined using descriptive statistics, and demographic characteristics were compared using chi-squared analysis. A multivariable logistic regression model was developed to assess factors associated with participants’ willingness to accept vaccines from their obstetrician–gynecologist. Results: A total of 1441 women completed the survey. The majority of participants (87%) would accept vaccines if recommended by their obstetrician–gynecologist. The primary factors associated with vaccine acceptance were having less than a high school education, being privately insured, currently being pregnant, reporting a history of vaccinations and previously receiving vaccinations from an obstetrician–gynecologist. A significant portion of participants were eligible for the hepatitis B, influenza and HPV vaccines (≥50% for each). The type of vaccine did not influence willingness to accept vaccines from an obstetrician–gynecologist. Conclusion: A majority of women appear eligible for, and will accept, vaccinations regardless of specific vaccine, if recommended by their obstetrician–gynecologist. These findings justify ongoing efforts to expand immunization services offered by obstetrician–gynecologists. © 2011 Elsevier Ltd. All rights reserved.
1. Introduction Vaccine-preventable diseases account for more than 50,000 deaths per year among US adults, which surpasses the mortality from breast cancer, HIV/AIDs or traffic accidents [1]. Despite the availability of safe and effective vaccines, vaccination rates among adults remain low [2]. Factors that contribute to low vaccination
夽 Financial support: 2007–2008 American Congress of Obstetricians and Gynecologists/Merck and Company Inc. Research Award on Immunization. 夽夽 Presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology, Seattle, WA, August 14–17, 2008. ∗ Corresponding author. Tel.: +1 401 452 4422; fax: +1 401 276 7845; mobile: +1 412 841 4435. E-mail addresses: [email protected], [email protected] (W.S. Vitek). 0264-410X/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.vaccine.2011.01.026
rates include lack of knowledge of vaccination need, confusion regarding vaccination history, mistrust of vaccines, and provider assumptions that adults have been vaccinated [3–5]. Adults appear more willing to accept immunizations if they understand that vaccines prevent life-threatening diseases or if a physician recommends a vaccination [1]. Women of reproductive age represent a population with unique vaccination needs. Compared to men and older women, reproductive age women are at increased risk for certain vaccinepreventable sexually transmitted infections, such as human papilloma virus (HPV) and hepatitis B. In addition, pregnancy presents special challenges. Live-virus vaccines are currently contraindicated in pregnancy due to the potential risk of pathogen transmission to the fetus. Pregnant women also experience increased morbidity and mortality from some vaccine-preventable
W.S. Vitek et al. / Vaccine 29 (2011) 2024–2028
diseases compared to non-pregnant women. Hence, women of reproductive age may gain substantial benefits from immunizations. For example, vaccinating adolescent and young women against HPV types 16 and 18 is predicted to decrease cervical cancer risk by up to 70% [6]. Ensuring immunity to rubella, varicella, hepatitis B, tetanus and pertussis prior to pregnancy can reduce or eliminate vertical and neonatal transmission of these lifethreatening diseases. Influenza vaccination is the primary method of preventing the disproportionate maternal and neonatal morbidity and mortality due to antenatal influenza infection [7]. In recognition of these benefits, many obstetrician–gynecologists (Ob–Gyns) have incorporated vaccine services into their practices [8]. Despite the increased availability of vaccinations in Ob–Gyn’s offices, a survey of obstetric and gynecologic patients found low vaccination rates for hepatitis B (36%), tetanus (45%) and influenza (23%) [9]. One step in improving vaccination rates among obstetric and gynecologic patients is the identification of factors that influence the willingness of women to accept vaccines from their Ob–Gyn. The objective of this study was to assess vaccine eligibility and factors associated with vaccine acceptance among ambulatory obstetric and gynecologic patients attending a large, tertiary care women’s hospital.
2. Materials and methods An anonymous, self-administered, written survey investigation was conducted among women seeking obstetric or gynecologic care at Magee-Womens Hospital (MWH) of the University of Pittsburgh Medical Center (UPMC) from December 2007 to July 2008. The survey was administered to patients presenting at the outpatient general obstetric and gynecology clinics offered in the facility. Subspecialty clinics (e.g., Maternal–Fetal Medicine, Gynecologic Oncology, Urogynecology) were not included. The clinics were staffed by the academic generalist gynecology service (16 faculty providers) and the resident service (36 residents). The survey was offered to all patients presenting for care once during the study period. The response rate was determined by tracking the number of completed surveys and the number of women who sought care at these locations over the survey period. The study was approved by the University of Pittsburgh Institutional Review Board. The survey contained 54 questions and required approximately 10 min to complete. The survey was initially field-tested in the clinics for acceptability and comprehension and was found to be acceptable by patients. A copy of the survey is available upon request. Standard socio-demographic variables were assessed including age, race/ethnicity, education, income, and insurance status. Information regarding health care utilization, vaccination history and vaccine eligibility was also collected. Health care utilization was examined with three items that assessed the practice specialty for each participant’s primary care physician (PCP), whether
2025
participants had ever received a vaccination and whether they had received a vaccination from an obstetrician–gynecologist. Vaccine history was investigated by asking participants to indicate which of eight vaccinations they had ever received (i.e., measles/mumps/rubella, tetanus/diphtheria/pertusis (Tdap), influenza, meningococcal, human papilloma virus, varicella, hepatitis B, pneumovax). Vaccine eligibility was assessed with 13 items created based on age and risk factors in accordance with the 2007–2008 CDC adolescent and adult immunization schedule [3]. For instance, participants were considered eligible for hepatitis B vaccine if they reported occupational risk factors, high-risk sexual behaviors, intravenous drug use or sought evaluation or treatment for a sexually transmitted disease. Participants were considered eligible for the pneumococcal vaccination if they were over the age of 65 or had medical risk factors such as chronic hepatic, cardiac, pulmonary or renal disease, sickle cell anemia, splenectomy or a compromised immune system. For a complete list of eligibility criteria for included vaccinations, please refer to the CDC guidelines [10]. Willingness to accept vaccinations recommended by an Ob–Gyn was assessed with an item with three response options: willing, unwilling or undecided. Statistical analyses were performed using SPSS statistical software version release 17.0.0 (SPSS Inc., Chicago, IL). To assess vaccine eligibility the proportion of women who met eligibility criteria for each of the 8 included vaccinations based on their responses to the 13 vaccine eligibility questions was determined. To examine factors associated with a woman’s willingness to accept vaccinations recommended by their Ob–Gyn, this variable was collapsed into a dichotomous item (willing vs. unwilling/undecided). Bivariate analyses were performed using chi-square tests. In the bivariate analysis, all socio-demographic and healthcare utilization items were included. A multivariable logistic regression model was then developed to identify factors that were independently associated with participants’ willingness to accept vaccinations recommended by an Ob–Gyn. All tests of association were considered significant at the two-sided, 0.05 significance level.
3. Results During the study period, 1441 participants completed surveys, representing 25% of the patients seen in the clinics. The sociodemographics of the respondents very closely matched the overall socio-demographics of the population of women who receive care in the clinics and thus produces a representative sample of this patient population. Participants’ willingness to accept vaccinations from their Ob/Gyn and vaccine eligibility is displayed in Table 1. Large numbers of participants were eligible for hepatitis B (66%), influenza (70%) and HPV vaccine (50%) based on age, risk factors and prior vaccination history. When looking at the sample of women who were eligible for at least one vaccine, 1235 (87%) of participants reported willingness to accept immunizations if recommended by their Ob/Gyn.
Table 1 Number and proportion of participants willing to accept vaccinations from their obstetrician–gynecologist. Willingness to accept vaccinations from obstetrician–gynecologist n (%) Recommended vaccination
Entire sample, n = 1419
Vaccine eligible, n = 1235
Influenza Hepatitis B HPV Tdap Varicella Pneumococcal Meningococcal
1050 (74) 933 (66) 707 (50) 383 (27) 284 (20) 138 (10) 50 (4)
911 (87) 822 (88) 626 (89) 329 (86) 244 (86) 115 (83) 43 (86)
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Table 2 Demographic analysis of participants for sample and stratified by willingness to accept vaccinations recommended by obstetrician–gynecologist. Characteristics
Samplea n = 1419
Age, years 13–17 43 (3%) 18–49 1271 (90%) 50 and older 98 (7%) Race/ethnicity White 804 (57%) African American 506 (36%) Hispanic/Latino 29 (2%) Asian 26 (2%) Multi-ethnic/other 54 (4%) Education Less than high school 108 (8%) High school/GED 448 (32%) College 709 (50%) Post graduate 145 (10%) Yearly household income <$10,000 486 (36%) $10–39,999 516 (38%) $40–79,999 182 (14%) >$80,000 159 (12%) Insurance None 177 (13%) Private 539 (38%) Medicaid/Medicare 649 (46%) Other 40 (3%) Currently pregnant Yes 562 (40%) No 768 (54%) Unsure 84 (6%) Primary care physician None 344 (24%) Obstetrician–gynecologist 193 (14%) Family practitioner 625 (44%) Internist 203 (14%) Pediatrician 21 (1%) Other 24 (2%) Have received vaccines Yes 1337 (94%) No 81 (6%) Received vaccines from obstetrician–gynecologist Yes 186 (13%) No 1232 (87%) a †
Willing to accept vaccinationsa n = 1235
Unwilling or undecided about accepting vaccinations* n = 184
38 (3%) 1108 (90%) 82 (7%)
5 (3%) 163 (89%) 19 (9%)
718 (58%) 422 (34%) 27 (2%) 24 (2%) 44 (4%)
86 (47%) 84 (46%) 2 (1%) 2 (1%) 10 (5%)
104 (8%) 377 (31%) 616 (50%) 129 (11%)
4 (2%) 71 (39%) 93 (51%) 16 (9%)
418 (36%) 447 (38%) 159 (14%) 144 (12%)
68 (39%) 69 (39%) 23 (13%) 15 (9%)
153 (13%) 487 (40%) 555 (45%) 27 (2%)
24 (13%) 52 (28%) 94 (51%) 13 (7%)
500 (41%) 671 (55%) 60 (5%)
62 (34%) 97 (53%) 24 (13%)
293 (24%) 176 (14%) 540 (44%) 179 (15%) 21 (2%) 19 (2%)
51 (28%) 17 (9%) 85 (47%) 24 (13%) 0 (0%) 5 (3%)
1176 (95%) 58 (5%)
161 (88%) 23 (12%)
181 (15%) 1053 (85%)
5 (3%) 179 (97%)
p† 0.59
0.01
0.008
0.51
<0.001
<0.001
0.11
<0.001
<0.001
Proportions do not sum to 100% where there is missing data. p-Value from Chi-square test.
The demographic characteristics of participants are displayed in Table 2. The majority of patients were reproductive aged women between 18 and 49 years. More than half were white and a third were African American. In the bivariate analysis no differences were noted between women who were willing versus those who were unwilling or undecided to accept vaccinations based on participants’ age, yearly household income, or type of primary care physician. Compared to those who were unwilling or undecided about accepting vaccinations, women who were willing to accept them were more likely to be white (58% vs. 47%, p = 0.01); have less than a high school education (8% vs. 2%, p = 0.008); have private insurance (40% vs. 28%, p < 0.001); and be pregnant (41% vs. 34%, p < .001). Participants with more than a high school education were more likely to report having a primary care physician than participants with less then a high school education (60.6% vs. 39%, p < .001). The multivariable logistic regression model demonstrated (Table 3) that six factors were independent predictors of women’s willingness to accept vaccinations recommended by their Ob–Gyn: race, education level, insurance status, prior history of vaccination, prior history of receiving a vaccination from an obstetrician–gynecologist, and pregnancy status. Having less than a high school education and history of previously receiving vaccinations from an Ob–Gyn were the strongest predictors of willingness
to accept vaccinations recommended by their Ob–Gyn. Having a history of previously receiving vaccinations from an Ob–Gyn was a stronger predictor than simply having previously received a vaccine. Compared with white participants, African-American participants reported they were 33% less likely to accept vaccinations (p < 0.03). Having private insurance and being currently pregnant were also independently associated with willingness to accept vaccinations.
Table 3 Logistic regression model of factors associated with willingness to accept vaccinations recommended by obstetrician–gynecologist.
Race/ethnicity White African American Other Less than high school education Private insurance Currently pregnant History of vaccination History of vaccination by obstetrician–gynecologist a
Adjusted for all factors shown.
Adjusted ORa
p
Referent 0.67 (0.48–0.95) 0.72 (0.38–1.34) 4.98 (1.79–13.84) 1.70 (1.17–2.46) 1.45 (1.03–2.06) 2.10 (1.24–3.57) 5.75 (2.32–14.25)
0.03 0.30 0.002 0.005 0.04 0.006 <0.001
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4. Discussion The results of this study demonstrate that a significant portion of ambulatory obstetric and gynecologic patients appear to be eligible for immunization and report a willingness to accept vaccination if recommended by their Ob–Gyn, regardless of vaccine type. In this investigation, three specific factors were independently associated with vaccine acceptance; current pregnancy, lower levels of education and prior history of receiving vaccinations from an Ob–Gyn. Targeting these populations with strategies to increase vaccination uptake is likely to result in improved vaccination rates. Of note, pregnancy was independently associated with vaccine acceptance, which is an important finding given the frequent presumption of existent patient fears about immunization (and other interventions) during pregnancy. Pregnancy appears to motivate women to engage in health promoting behaviors. For example, prior research has shown that 46% of women who smoke will quit during pregnancy [11]. Vaccine acceptance during pregnancy may also result from the trust established between physicians and patients through prenatal visits [12]. Importantly, the frequency of prenatal care visits provides ample opportunities to discuss and administer vaccinations. Thus, this study reiterates the concept that pregnancy may represent a key time to target immunization efforts of non-contraindicated vaccines, as others have previously suggested [12–14]. Participants with less than a high school education were five times more likely to be willing to accept a vaccination from an Ob–Gyn. This finding may reflect lower socio-economic status as a marker for differential access to health care services. Those with higher levels of education were more likely to be privately insured and have a primary care physician to receive vaccinations from, in addition to having an Ob–Gyn. Likewise, those with lower levels of education may have fewer points of entry into the health care system and would, therefore, be willing to obtain vaccinations from their Ob–Gyn, who may serve as their sole provider. The impact of private insurance on vaccination rates is also demonstrated in a survey of adolescent and young women, which found that women with insurance coverage for the HPV vaccine were 5 times more likely to be immunized (OR 5.31 95% CI 1.61–17.79) [15]. Increased rates of societal insurance coverage for vaccinations could minimizing the access and financial barriers to immunization and improve vaccination rates among women. Prior receipt of a vaccine from an Ob/Gyn was a strong predictor of future vaccine acceptance from an Ob/Gyn. While many obstetrician–gynecologists offer the HPV and influenza vaccines, few offer the full complement of vaccines recommend by the CDC [16]. The current investigation corroborates this finding; few study participants reported having previously received several vaccinations from their Ob–Gyns. Low rates of delivery of full vaccination services is due to many factors not the least of which is incomplete reimbursement for vaccinations by third-party payers [16]. As changes in health care increase opportunities for vaccine coverage and as Ob–Gyns become more experienced in the office management of vaccine administration, strong consideration should be given to offering comprehensive vaccination services to achieve the highest rates of disease prevention in this population. For most immunizations the costs incurred by offices to procure, store, and administer immunizations is a significant providerspecific barrier to uptake of immunization provision. In many settings and for varied specific vaccines the provider reimbursement via third-party payers for vaccine services is either non-existent or inadequate to offset the true costs of vaccine provision. Frequent unrecognized and uncompensated costs include, but are not limited to: true cost of vaccine procurement, storage costs, costs of unused vaccine, time spent encouraging vaccination, personnel costs, etc. There is hope that the preventive care
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focus of the recently passed health care legislation may produce more standardized and appropriate coverage for adult (and pediatric) immunization services. This, in turn, could potentially serve to overcome the financial barriers that present major challenges to the adoption of large-scale adult vaccination services by many providers. This study has several strengths. This is the first investigation that directly assesses specific vaccine eligibility for multiple vaccines among a large and diverse patient population served by a sample of Ob–Gyns. In addition, this data is timely given the recent experience of vaccinating pregnant women against H1N1 during the 2009 influenza pandemic and the focus on disease prevention efforts at the national level. These impressive eligibility and willingness data herein come at a time of increased interest in adult immunization services. Several limitations of the current investigation are also notable. his study was conducted at a single-site in an urban, academic tertiary care center in a population that was predominantly white or African American. The data may not be generalizable to patients seen in other settings or with different socio-demographic characteristics. The socio-demographic characteristics of respondents very closes matches those of the overall clinic population, suggesting that the selection bias among participants was minimal and that the 25% response rate in this report is a reliable representative sample of the overall clinic population. In order to capture sensitive information from women presenting for a care at Ob/Gyn clinics, an anonymous, self-administered, written survey was selected. While this approach optimized the quality of data collected, the response rate was relatively low, but did capture a representative sample of the clinic population. Recall bias may also have influenced the responses regarding vaccination history. We did not perform medical record reviews to verify participants’ vaccine eligibility or vaccination histories for this anonymous questionnaire. Thus, the current investigation can only approximate potential vaccine uptake by participants should these enhanced immunization services be offered. Future research is needed in these patient populations to determine the most effective methods of education of young adult women regarding their vaccination needs and operationalizing these findings in order to increase overall vaccine uptake. Many women seen by Ob–Gyns appear willing to accept recommended vaccinations for which they may be medically eligible. Ob–Gyns could play a strong role in increasing vaccine uptake and reducing morbidity and mortality from vaccine-preventable diseases. Future efforts will need to assess and address barriers to offering comprehensive vaccination services through Ob–Gyn outpatient clinical settings.
References [1] National Foundation for Infectious Diseases. American adults’ awareness about immunization. Available at: http://www.adultvaccination.com/doc/ Survey Fact sheet.pdf; [retrieved 01.03.10]. [2] Center for Disease Control. Vaccination coverage among U.S. adults, National Immunization Survey – Adult, 2007. Available at: http://www.cdc.gov/ vaccines/stats-surv/nis/downloads/nis-adult-summer-2007.pdf; [retrieved 01.03.10]. [3] Center for Disease Control. Reasons reported by Medicare beneficiaries for not receiving influenza and pneumococcal vaccinations – United States, 1996. MMWR 1999;48:556–61. [4] Gindi M, Peter O, Sexton R, Shpak M, Eisenhart A. Unreliability of reported tetanus vaccination histories. Am J Emerg Med 2005;23:120–2. [5] Schrag S, Fiore A, Gonik B, Malik T, Reff S, Singleton J, et al. Vaccination and perinatal infection prevention practices among obstetrician–gynecologist. Obstet Gynecol 2003;101(4):704–10. [6] Massad L, Einstein M, Myers E, Wheeler C, Wentzensen N, Solomon N. The impact of human papillomavirus vaccination on cervical cancer prevention efforts. Gynecol Oncol 2009;114(2):360–4. [7] American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. Influenza vaccination and treatment during preg-
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[8]
[9] [10]
[11]
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nancy, ACOG committee opinion no. 305, November 2004. Obstet Gynecol 2004;104:1125–6. Power M, Leddy Y, Anderson B, Gall S, Gonik B, Schulkin J. Obstetrician–gynecologists’ practices and perceived knowledge regarding immunization. Am J Prev Med 2009;37(3):231–4. Malone T, Gonik B, Tomlinson M. Patient vaccine awareness in an obstetric and gynecologic office setting. Prim Care Update Ob/Gyns 2002;9:195–8. Center for Disease Control. Recommended Adult Immunization Schedule – United States, October 2007 – September 2008. MMWR 2007;56(41): Q1–4. Colman GJ, Joyce T. Trends in smoking before, during and after pregnancy in ten states. Am J Prev Med 2003;24(1):29–35.
[12] Yeager D, Toy E, Baker B. Influenza vaccination in pregnancy. Am J Perinatol 1999;16(6):283–6. [13] Beigi R, Switzer GE, Meyn LA. Acceptance of a pandemic avian influenza vaccine in pregnancy. J Reprod Med 2009;54(6):341–6. [14] Gall S. The obstetrician–gynecologist as vaccinator. ACOG Clin Rev 2008;13(2):1–16. [15] Conroy K, Rosenthal SL, Zimet GD, Jin Y, Bernstein DI, Glynn S, et al. Human papillomavirus vaccine uptake, predictors of vaccination and self-reported barriers to vaccination. J Womens Health 2009;18(10):1679–86. [16] Gonik B, Jones T, Contreras D, Fasano N, Roberts C. The obstetrician– gynecologists role in vaccine-preventable diseases and immunization. Obstetr Gynecol 2000;96:81–4.