Abstract
Corresponding Author(s)
Rachel. Hunter, DHSc, PA-C, OMS-I, 8701 Old Troy Pike, Huber Heights, OH 45424.
E-mail address: rahunter@provmedgroup.com.
Read the article
Immunization is among the most successful and cost- effective public health interventions.1 The Centers for Dis- ease Control and Prevention (CDC) state that immunization programs have led to the eradication of smallpox as well as the elimination of measles and poliomyelitis in many re- gions of the world.2 Substantial reductions in morbidity and mortality attributed to diphtheria, tetanus, and pertussis have been proven.1 In 2003, the World Health Organization estimates that 2 million child deaths were prevented by vaccinations alone.1
Although routine adolescent immunizations have been recommended since 1996, an estimated 35 million adoles- cents (i.e., persons 11-21 years of age, as defined by the American Medical Association and the American Academy of Pediatrics) lack one or more recommended vaccinations.3 Despite the availability of a safe and effective vaccine against measles, globally 614,000 measles-related deaths were estimated to have occurred in 2002.4 Measles was a leading cause of childhood death in 2002 throughout the world. To achieve a high level of population immunity, it is necessary that control programs sustain at least 90% cover- age with the first dose of measles vaccine.4 Research sup- ports that many immunizations fall short of immunity be- cause the second vaccine opportunity, or booster, is often missed.4 These added vaccination opportunities often are required during the adolescent years. Adolescent immuni- zation rates continue to remain low, despite the success of pediatric vaccination programs.
Research shows that provider attitude and lack of rec- ommendation are strong predictors of vaccination.5 In a CDC study, provider attitude appeared to be the most sig- nificant variable influencing vaccination.6 Interpersonal and clinical issues are the primary barriers of human papilloma- virus vaccination in the United States.7 Additional barriers to vaccination included lack of reimbursement, patients’ out-of-pocket expense, and high up-front cost of vaccines. Human papillomavirus is the most common sexually transmitted disease in the United States and the predominant cause of cervical cancer and genital warts.7 Cardarelli re- ports that only 10% of females 18 to 26 years of age have received at least one dose of this vaccine. Influenza is another example of a vaccine-preventable disease.
The CDC reports that only 25% of eligible adolescents have received three doses of HPV vaccine and that 40.6% of adolescents have received just one dose of HPV vaccine in Ohio.
In addition, the survey showed that 67.7% and 50.2% of teens have received one dose of tetanus toxoid-diphtheria vaccine (Td) or tetanus toxoid, reduced diphtheria toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) since the age of 10 in Ohio.
As a result of decreased vaccination rates across the United States, research is necessary on this health promo- tion issue to identify specific barriers to vaccination for adolescents and adults. Research shows that provider atti- tude and lack of recommendation are strong predictors of vaccination.5 In a CDC study, provider attitude appeared to be the most significant variable influencing vaccination.6 Interpersonal and clinical issues are the primary barriers toward human papillomavirus vaccination in the United States.7
An expert panel of the Infectious Diseases Society of America has prepared updated, evidence-based guidelines for the immunization of infants, children, adolescents, and adults.8 The now universal recommendations include hep- atitis A vaccine to be administered to all children 6 months through 18 years. The adolescent schedule includes a sec- ond dose of varicella and has been expanded to accommo- date many of the newer recommendations.
It has been found that there is a positive relationship between reimbursement rates for immunizations and immu- nization rates.9 According to Hainer, the high cost of vac- cines and inadequate reimbursement can limit the ability of some practices to offer them. Cost has been shown to be a barrier regarding availability of immunizations should they affect negatively toward the practice.
Coverage and reimbursement influences the decisions of providers participating in the immunization process. In ad- dition, there are many factors influencing the coverage of the health insurance plans. Data suggest that although health plan coverage for ACIP-recommended vaccines is high, coverage for all vaccines is not universal in all of the products being offered.10
The purpose of this study was to determine whether the influence of environmental, economic, and insurance barri- ers affect the immunization process for adolescent patients. The study attempted to determine whether physician knowledge was positively associated with the implementation of vaccinations to adolescent patients in primary care prac- tices. This study involved the use of mixed methods through the gathering of data via a survey that included both qual- itative and quantitative components. Participants were re- cruited from Ohio. The target population made up a broad range of osteopathic primary care physicians. Study respon- dents were recruited from a generated list of primary care practitioners obtained through the Ohio Osteopathic Asso- ciation. The survey took less than 10 minutes to complete. A single-stage, stratified sampling design was used. An 8-week deadline was identified for return of the surveys. Data measured included frequency of response; the categor- ical variables were compared using a chi-square method of statistical analysis. Statistical significance was set at p < 0.05.
Materials and methods
Research design
This study involved the use of mixed methods through the gathering of data via a survey that included both qual- itative and quantitative components.
Study participants
Participants were recruited from Ohio. The target popu- lation comprised a broad range of primary care physicians. Study respondents were recruited from a generated list of primary care practitioners obtained through the Ohio Osteo- pathic Association, although there were a few MDs among the respondents. A total of 1052 physicians (>21 years old) were sent surveys for recruitment in this study. A total of 232 physicians completed the survey and returned it within a set 8-week deadline for this study. All respondents indi- cated their experience in the field of immunizations in the adolescent population within their survey. Respondents who indicated that they treated adolescents completed the sur- vey. The research protocol for this study was approved by the Institutional Review Board at A.T. Still University.
Survey
The survey questions were related to accepted current practices and beliefs within the health care industry within the United States regarding immunizations and physician attitudes toward vaccination. The survey questions encom- passed four categories:
Primary care office practice: Specific tools that may be used for screenings/risk assessments within their prac- tice. This would incorporate the decision-making models for provider treatment plans in the immunization pro- cess.
Table 1 Demographic characteristics of respondents
n = 226
Male 66.4%
Female 33.6%
Mean (median)
Age 47.2 (15)
Years since completion medical school 23.3 (10
Statistical analysis
Data were entered using Microsoft Excel (Redmond, WA). Recoding and analysis were performed with Statisti- cal Package for the Social Sciences for Windows Version
Practice setting
Solo
29.8%
Two-physician
16.2%
Group/HMO
41.7%
Practice location
Neighborhood health center
28.0%
Medical school
2.2%
Hospital
4.0%
Clinic
Community setting/population
28.9%
Metropolitan, .1 million
7.8%
500,000-1 million
9.5%
250,000-500,000
24.2%
50,000-250,000
39.8%
Nonmetro 2500-50,000
9.5%
Rural <2500
0.9%
Other
0.4%
15.0 (SPSS Inc., Chicago, IL). The data measured included frequency of response; the categorical variables were com- pared using a chi-square method of statistical analysis. Sta- tistical significance was set at p < 0.05.
Results and discussion
Respondent characteristics
Provider practice: Specific interventions or recommen- dations used by providers and their rationale for selecting these processes.
Perceived effectiveness: A measurement of satisfaction with their current practices.
Barriers or issues in practice: Recommendations for changes or improvement strategies in the immunization process.
One question from the survey was open-ended, requir- ing a narrative response. The survey was pretested among five immunization nurses and five immunizing providers. Respondents from the pretest helped ensure question clarity. Pretest respondents helped determine that the questions were clear and relevant, and that the context was understandable. These processes assessed the instru- ments’ face and content validity. Reliability and internal consistency were measured through computation of Cronbach’s alpha. The survey took less than 10 minutes to complete.
Procedure
A single-stage, stratified sampling design was used. An 8-week deadline was identified for the return of the surveys. Each survey was mailed with a self-addressed, stamped return envelope. Responses were transcribed by a research assistant, which reduced any bias that may have resulted from the investigator making assumptions or by misinter- pretation of responses.
The survey was sent to 1008 Ohio osteopathic primary care physician and respondents who received the mailed survey; responses were returned from 231 physicians. Five respondents were actually allopathic physicians. Sixty-three surveys were returned as undeliverable. Forty-seven respon- dents did not qualify for the study because they did not care for adolescents, so they were excluded. The overall re- sponse rate to the survey was 25.6%. Among all respon- dents, 28.0% were from neighborhood health centers and 7.8% were from metropolitan areas with populations greater than 1 million. Response rates by provider were compared across regions of the state of Ohio and no statistically significant differences were found. After excluding respon- dents who reported not immunizing adolescents or whose work did not include adolescent patients, the final study population was composed of 226 physicians. The practice settings of respondents included solo practice (29.8%), two- physician practice (16.2%), and group/HMO (41.7%). De- mographic characteristics of these immunizing private prac- tice respondents are shown in Table 1.
Table 2 Factors related to immunization decisions
n = 205
Prior compliance with appointments 20%
Male and female respondents made up 66.4% and 33.6%, respectively. The mean age of respondents was 47.2 years. The mean year since completion of medical school was 23.3 years. Demographic characteristics of physician respon- dents are shown in Table 1.
Amount of child is behind | 3.4% |
How well physician knows family | 0.0% |
Presence of a chronic illness | 0.0% |
Child’s age | 0.0% |
Visit type (acute or follow-up) | 30.4% |
Specific immunization | 2.9% |
Practice policy | 14.4% |
Community standards | 0.0% |
Don’t know | 0.5% |
Other | 30% |
Table 3 Support of school-based immunization program
n = 215
Support school-based immunization program
Yes 62.8%
No 34%
What vaccines have been unavailable during the past year and why?
When are adolescents vaccinated?
The majority of respondents (84%) reported administer- ing vaccinations during well-child appointments. Some pro- viders (1.9%) indicated that they are unlikely to vaccinate during acute care appointments. A smaller number of re- spondents indicated that they are unlikely to vaccinate dur- ing follow-up care appointments (1.4%) or chronic illness follow-up appointments (0%). Six percent of responses from physicians indicated that they do not vaccinate for other reasons during their scheduled appointment because they refer their patients elsewhere for vaccination. One respondent indicated, “. . . tell them to get vaccination at the county health dept.” Another responded, “Send kids to the health department.”
What are factors in the decision-making to vaccinate during an acute care visit?
The focus on acute problems (30.4%) and the practice policy (14.4%) were the most common responses in the decision not to vaccinate during an adolescent acute care visit. Contraindication and insufficient time were cited by providers as additional reasons why they do not vaccinate during acute care visits. Physicians (1%) shared that lack of immunization records contributed to their inability to vac- cinate during these visits. A very small number of physi- cians (<1%) revealed that they feared that immunizing during this period of time might decrease their well-child visits. Additional factors affecting the decision to vaccinate are shown in Table 2.
At the time of the survey, half of the respondents (50%) indicated that vaccines had not been available to them within the past year as a result of national shortages. In regard to costs, 19.2% of physicians indicated that some vaccines were unavailable to them because of a variety of reasons (Table 2).
How supportive are providers of school-based immunization programs?
Participants stated that they would support a school- based program (62.8%). The minority of respondents (34%) revealed that they would not support a program of this nature. The majority of respondents (62.8%) stated that they would not participate in a school-based immunization pro- gram (see Table 3).
Is influenza vaccination profitable?
One-third (33%) of respondents stated that influenza vaccinations were profitable to their practice. Other respon- dents indicated that influenza vaccination produced a finan- cial loss (27%). Profitability within physician practices can be viewed in Figure 1.
What mechanisms are in place to help identify undervaccinated adolescents and is there a callback system in place for influenza vaccination?
Computer (19.8%) and systematic chart review (56%) produced the highest responses from respondents in terms of mechanisms to identify undervaccinated adolescents. Only 1% of physicians indicated that a “Tickler file” played little part as a mechanism of delivery of vaccination. Mech- anisms of detecting undervaccinated adolescents can be seen in Figure 2.
Figure 1 Influenza immunization profitability within practice.
Other
Mechanisms in Place to Idenfy Under-vaccinated Adolescents
Don't Know
Systematic Chart Review
"Tickler File"
Computer
None
0 5 10 15 20 25 30 35 40
Percentage of Physicians
Figure 2 Mechanisms in office to identify undervaccinated adolescents.
Should consent be required for vaccination?
The majority of respondents stated that one consent should be required to cover all vaccinations (40%). How- ever, other physicians (30%) indicated that consents should not be required separately in an immunization series. An equal number of physicians (30%) felt that a consent form should be signed for each vaccination.
Why do providers not give all recommended vaccines during the same encounter?
A majority of physicians (83.8%) indicated that they give all recommended vaccines during the same encounter (Fig- ure 3). Other respondents (26.1%) stated that parental ob- jection prevented all vaccines from being administered dur- ing the same encounter. Physician responses about why vaccinations are not given during the same encounter can be seen in Figure 4.
Where should adolescent-recommended vaccination occur?
Nearly half of the respondents (46.6%) felt that the physician’s office should be the location where vaccination
46.8
50.5
3
60
Percentage of Physicians
50
40
30
20
10
50
46
16.4
11.4
7.6
3.8
3.8
3.8
3.8
2.5
Percentage of Physicians
45
40
35
30
25
20
15
10
5
0
Figure 4 Reasons that vaccinations are not administered at the same encounter.
should occur. Physicians unanimously concurred that im- munizations should not be administered in pharmacies or hospitals. Physician responses about where adolescent im- munizations should be administered are listed in Figure 5. Respondents (62.8%) revealed that they would only par- ticipate indirectly under an off-site supervision agreement with a school-based immunization program. Physicians sug- gested that an on-site supervision agreement is something that they are not interested in participating in at this time. Twenty percent stated that civic involvement might per- suade them to participate in such a program. This was followed by 12.3% of respondents citing financial recom- pense as a reason to participate in a school-based immuni- zation program. Few respondents (1%) noted that they would participate in a school-based immunization program if it was required or if they were persuaded. Finally, 27.7% of respondents indicated that there was nothing that could
persuade them to participate in a program of this nature.
0
Yes No Unsure
Figure 3 Participation in school-based immunization program. Figure 5 Recommended location for adolescent vaccination.
Figure 6 Preferred method of receiving immunization information.
What is the preferred method of receiving immunization information?
First Class mail (27.7%) and fax at the office (13.4%) were the most common physician responses. For a complete list of survey results, see Figure 6.
What methods would help improve vaccination within the state?
Respondents suggested various solutions to improve vaccination within the state. Some respondents indicated that improving communication from either chart record to provider and/or to parent would improve rates of vaccination. Respondents stated that physicians’ commu- nicating with pharmaceutical companies to learn of newer vaccines was a mechanism to improve immuniza- tions within the state. Cost of the vaccines was cited by 3.8% as a barrier within the state. Reimbursement was cited by 3.8% of 226 respondents as an additional factor affecting administration rates of vaccines in their state. Finally, the most frequently reported recommendation to improve vaccination within the state was improved avail- ability of the vaccines to adolescents.
What is the overall physician satisfaction with current immunization practices?
All respondents stated that they were satisfied with their current immunization practices. Twenty percent of physi- cians indicated that they were very satisfied with their current practices. Providers suggested ways to improve pro- vider satisfaction indirectly through increasing reimburse- ment rates to physicians. Physician satisfaction rates can be seen in Figure 7.
Conclusions
The survey results revealed that respondents were most likely to give immunizations on a well check-up or a chronic illness follow-up appointment, which causes de- lays for the patient that comes in for an acute illness and is not current with immunizations. Focus on the acute problem was the most common reason why physicians did not vaccinate during the acute care visit. Physicians would vaccinate during an acute visit depending on how far the child was behind. It was encouraging to see that if children were behind, physicians may be more likely to give the immunizations to catch the child up. A majority of the respondents agreed that consents should be re- quired for immunizations and only one consent should be required for all vaccinations. Most physicians reported that they do not have a call-back system for flu immuni- zations and that flu immunizations were minimally prof- itable or produced a loss. Manufacturing problems were the main reason that providers reported that some vac- cines were unavailable during the last season.
Figure 7 Overall physician satisfaction with their current im- munization practices.
The physicians reported that parental objections were one of the primary reasons they did not give all the recommended vaccines at the same time. “Parents’ re- quest that immunizations be separated over a course of visits versus of receiving them all in one visit” was a common theme among physician open responses. This can lead to further delay in immunizations when fol- low-up appointments are missed. The physician office and the health department—not in the hospital or phar- macy—were the two settings where the majority of phy- sicians felt vaccinations should occur. This was interest- ing because there is an increasing push to immunize in the latter two locations. School-based immunization pro- grams were supported by a majority of physicians, al- though most would not participate in the program. Most physicians were satisfied with the current immunization system and stated that increased availability would im- prove the program.
The participants in the study were mainly Ohio osteo- pathic family physicians with limited participation from MDs; this is considered a limitation in the study because the study may not be generalizable to all geographic locations within the United States. Objectifying predic- tors of success has led to studies that attempt to identify the barriers that influence rates of vaccine administration. Therefore, continued research in this area can help in- crease access to immunizations on a global scale. Repli- cation of this study throughout the country could enhance physician awareness of immunization patient outcomes, which could encourage providers to be involved with vaccinations within their communities.
Research showed in 2009 that there were increases in the percentages of adolescents between ages 13 and 17 receiv- ing vaccines that were routinely recommended. However, further research is needed to explore variables that contrib- ute to decreased immunization rates within the country. Clinical providers actively involved with adolescent vacci- nation within their communities could be of great benefit and may further aid the development of program activities that would prevent disease progression.
Immunization is among the most successful and cost- effective public health intervention.1 In 2003, the World Health Organization estimated that 2 million child deaths
were prevented by vaccinations alone.1 Although routine adolescent immunizations have been recommended since 1996, an estimated 35 million adolescents (i.e., persons 11-21 years of age, as defined by the American Medical Association and the American Academy of Pediatrics) lack one or more recommended vaccination.3
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