Vaccinations are essential components of preconception, prenatal, and postpartum care and of improving maternal and neonatal health for a number of infectious diseases. The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) and the American College of Obstetricians and Gynecologists (ACOG) currently recommend two immunizations for all pregnant women without contraindication, inactivated influenza and adult-type tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) [
Pregnant women and infants are at increased risk of influenza-related morbidity and mortality and adverse pregnancy outcomes [
Pertussis (whopping cough) is an acute, prolonged respiratory illness caused by the organism
Physician recommendations for and administration of vaccines have been shown to be the strongest predictors of vaccine receipt among patients [
In an effort to increase the efficacy of these immunization toolkits and ob-gyn use of toolkit materials and immunization administration, ACOG recently revised and revamped its toolkits based on feedback received from four focus groups that met at the 2013 and 2014 ACOG Annual Meeting. The purpose of this pre- and postintervention questionnaire study was to examine whether ACOG’s efforts to improve the usefulness of its immunization toolkits were successful.
A prospective, longitudinal study was conducted to assess the impact of ACOG’s efforts to increase ob-gyn use of ACOG’s immunization toolkits and vaccination administration. Between August 2012 and March 2013, the ACOG Immunization Department distributed three immunization toolkits to ACOG’s general membership. Following the distribution of the third toolkit, a preintervention questionnaire was sent out to a random sample of 1,500 ACOG members. After data collection concluded for the preintervention questionnaire, three revised toolkits (the “intervention”) were sent to ACOG’s general membership between September 2013 and September 2014. In October 2014, following the distribution of the third revised toolkit, a postintervention questionnaire was sent to 1,370 participants of the original 1,500 sample.
Revisions to the toolkits included updating the clinical information and revising the wording of some materials based on feedback from focus groups with ACOG members. ACOG also increased the promotion to members through electronic notifications such as e-mail, ACOG newsletters, and ACOG’s Immunization for Women website in addition to promotion through partner organizations. These toolkit revisions were expected to provide supplemental information to ob-gyns, who administer influenza and Tdap vaccinations, in order to improve the usefulness of the immunization toolkits.
A questionnaire on ob-gyn practices and opinions related to immunizations was developed by a team of researchers in the Immunization Department at ACOG familiar with this subject. The preintervention questionnaire contained 24 questions regarding physicians’ receipt and use of ACOG’s immunization toolkits, immunization resources needed, general immunization practice patterns, barriers to offering vaccinations, and physician use of ACOG’s Immunization for Women website. Demographic questions included gender, year of birth, and state/territory of primary practice. Some items were added to the postintervention questionnaire to gather more detailed information regarding participants’ demographic background, their patient population, and their use of ACOG’s most recently distributed immunization toolkits. New demographic questions included the participants’ number of years in practice, type of practice, primary medical specialty, practice location, primary race/ethnicity of patient population, and primary type of patient insurance. The revised postintervention questionnaire contained a total of 34 questions. Questions included yes/no, check boxes, forced choice, and Likert-scales. The questionnaire was constructed to be completed in approximately 5–10 minutes.
The ACOG Immunization Department has been distributing toolkits on vaccinations to its members since 2011 and has sent a total of seven toolkits to date. These toolkits contain resources to help educate ob-gyns and their patients on immunizations for influenza, Tdap, and human papillomavirus (HPV) and to provide physicians with tools for integrating immunizations into routine care. Each toolkit is designed based upon existing ACOG guidance primarily derived from ACOG Committee Opinions. Toolkits feature corresponding materials, including a letter from ACOG’s Vice President of Practice Activities, encouraging providers to use the resources in the toolkit; frequently asked questions (FAQs) handouts for patients; a Physician Script; coding information relevant to specific vaccines; and partner materials such as Vaccine Information Statements and sample standing orders from the CDC and Immunization Action Coalition (IAC).
ACOG membership includes 95% of board-certified obstetrician-gynecologists in the United States. In January 2013, a random sample of 1,500 active ACOG members was selected to participate in this study. Participation was voluntary, with no compensation offered to participants. Participants were sent an electronic flyer alerting them that they would shortly receive an invitation to participate in an electronic questionnaire on ob-gyns’ immunization practices. The online survey was conducted using Real Magnet
In April 2013, a paper questionnaire was mailed to all nonresponders of the electronic survey (
In October 2014, 1,370 participants from the original sample were sent an electronic flyer alerting them that they would receive an invitation to participate in the follow-up study (otherwise known as “postintervention study”) on immunization practices among ob-gyns. One hundred thirty participants from the original sample were not included in the follow-up study because they were no longer active members of ACOG. Members who did not participate in the preintervention questionnaire were permitted to participate in the postintervention questionnaire. The online survey was conducted using Real Mail
In February 2015, a paper questionnaire was mailed to all nonresponders of the electronic survey (
Data were analyzed using a statistical software package (IBM SPSS Statistics
One hundred thirty-one participants completed the electronic survey, 272 participants returned the paper questionnaire, and 31 participants completed the shortened letter version questionnaire, resulting in a total response rate of 29.3%. Nineteen questionnaires were judged invalid (i.e., provider retired or provider was unreachable by mail); these participants were thus excluded from analysis. Responses to the letter questionnaire did not differ significantly from those of the electronic or paper surveys. Letter responses were excluded from data analysis because of the abbreviated questions found in the letter.
ACOG’s total membership in 2013 consisted of 30,015 female members (52.5%) and 27,160 male members (47.5%). Among respondents, 203 were female (59.0%) and 141 were male (41.0%). Males were significantly older than females (males, mean age = 55.19 years ± 10.29 years; females, mean age = 45.19 years ± 9.75 years;
One hundred and one participants completed the electronic survey, 186 participants returned the paper questionnaire, and 12 participants completed the shortened letter version questionnaire, resulting in a total response rate of 24.0%. Forty-seven questionnaires were judged invalid (i.e., provider retired, provider opted out, or provider was unreachable by mail); these participants were thus excluded from analysis. Responses to the letter questionnaire did not differ significantly from those of the electronic or paper surveys. Letter responses were excluded from data analysis because of the abbreviated questions found in the letter.
Among respondents, 182 were female (64.1%) and 102 were male (35.9%). Males were significantly older than females (males, mean age = 55.51 years ± 9.63 years; females, mean age = 46.18 years ± 9.05 years;
Demographic characteristics of postintervention study respondents.
Characteristics | Percentage (%) |
---|---|
Years since completion of residency | |
21–30 years | 33.6 |
11–20 years | 28.7 |
5–10 years | 16.1 |
<5 | 11.9 |
Type of practice | |
Large group (4+ partners) | 43.2 |
Solo private practice | 14.7 |
University full-time faculty & practice | 13.3 |
Small group (2-3 partners) | 10.9 |
Community hospital full-time | 7.7 |
One partner | 3.9 |
Others | 3.9 |
Community hospital part-time | 1.4 |
Military/government | 1.1 |
Primary medical specialty | |
General ob-gyn | 74.8 |
Gynecology only | 8.0 |
Maternal/fetal medicine | 7.3 |
Reproductive endocrinology/infertility | 5.6 |
Gynecologic oncology | 2.4 |
Obstetrics only | 1.4 |
Urogynecology | 0.3 |
Practice location | |
Suburban | 47.9 |
Urban, noninner city | 25.9 |
Urban, inner city | 15.0 |
Rural | 10.8 |
Military | 0.3 |
Professional self-identification | |
Both primary care physician and specialist | 47.9 |
Specialist | 46.9 |
Primary care physician | 5.2 |
Patient race | |
White, non-Hispanic | 63.7 |
Multiracial | 16.5 |
White, Hispanic | 10.2 |
African American, non-Hispanic | 3.2 |
African American, Hispanic | 2.1 |
Asian/Pacific Islander | 1.1 |
American Indian/Alaska native | 0.7 |
Patient insurance | |
Private (including HMO, IPO, military) | 70.9 |
Medicaid/Medicare | 26.3 |
Uninsured | 2.8 |
Significantly more ob-gyns from the postintervention study (84.5%) reported that they received the immunization toolkits than ob-gyns from the preintervention study (67.0%) (
Providers were asked to indicate the extent to which they planned to use the immunization toolkit resources. Participant responses from both studies are detailed in Table
The extent to which ob-gyns plan to use immunization toolkit resources.
Already use (%) | Plan to use (%) | Will not likely use (%) | Definitely will not use (%) | |||||
---|---|---|---|---|---|---|---|---|
Pre | Post | Pre | Post | Pre | Post | Pre | Post | |
Flu FAQ Tear Pad | 37.7 | 44.5 | 30.0 | 21.6 | 21.8 | 23.3 | 10.5 | 10.6 |
Tdap FAQ Tear Pad | 36.1 | 44.7 | 31.0 | 20.8 | 22.4 | 23.9 | 10.6 | 10.6 |
Vaccine Safety Tear Pad | 30.7 | 36.5 | 32.7 | 21.6 | 26.0 | 29.7 | 10.6 | 12.2 |
Immunization for Women website | 17.3 | 15.6 | 40.3 | 30.7 | 31.9 | 39.9 | 10.5 | 13.8 |
Coding Guide | 14.2 | 16.0 | 27.6 | 21.1 | 40.2 | 40.8 | 18.0 | 22.1 |
Physician Script | 12.4 | 18.4 | 21.8 | 13.2 | 46.2 | 46.2 | 19.7 | 22.2 |
FAQ, frequently asked question; Tdap, tetanus-diphtheria-acellular pertussis.
Physicians’ frequency of toolkit use was assessed. The most frequently used (i.e., “weekly use”) toolkit items reported in pre- and postintervention studies were the Flu FAQ Tear Pad (28.9% versus 31.2%) and the Tdap FAQ Tear Pad (26.7% versus 31.0%). The least frequently used (i.e., “never use”) toolkit resources reported were the Physician Script (58.7% versus 59.2%), Coding Guide (51.3% versus 56.3%), and Immunization for Women website (45.9% versus 52.6%).
Providers were asked about their opinions regarding which immunization resources they would find most useful in future immunization toolkits. The immunization resources most frequently selected as valuable in both pre- and postintervention studies were clinical guidelines from ACOG (71.2% versus 58.0%), patient FAQs on specific vaccines (61.3% versus 67.7%), patient FAQs on vaccine safety (54.9% versus 62.6%), and clinical guidelines from the CDC (58.8% versus 53.3%) (Figure
Statistically significant differences between pre- and postintervention study providers.
Variable | Preintervention study (%) | Postintervention study (%) |
|
---|---|---|---|
Received ACOG’s immunization toolkit mailings† | 67.0 | 84.5 | <.001 |
Valuable immunization resources to include in future toolkit mailings | |||
Clinical guidelines from ACOG† | 71.2 | 58.0 | .001 |
Coding information and tips† | 30.7 | 18.0 | <.001 |
Reimbursement information and tips† | 15.2 | 9.4 | <.001 |
Barriers to offering immunizations | |||
Cost† | 45.5 | 34.8 | .006 |
Time |
25.4 | 33.0 | .036 |
Lack of access to patient records |
7.5 | 3.7 | .048 |
Lack of patient interest |
29.9 | 37.5 | .043 |
Use standing orders for immunizations |
36.5 | 46.6 | .011 |
Routinely offer Tdap to all pregnant patients† | 59.3 | 76.8 | <.001 |
Common reasons patients decline vaccinations | |||
They do not think they need vaccines† | 70.4 | 80.6 | .003 |
Percentage of patients that decline vaccinations | |||
Less than one-third† | 64.4 | 76.5 | .001 |
Receive annual influenza vaccination themselves |
90.7 | 96.1 | .024 |
Require staff to receive annual influenza vaccination |
78.1 | 86.2 | .011 |
ACOG, American College of Obstetricians and Gynecologists; Tdap, tetanus-diphtheria-acellular pertussis.
Resources ob-gyns indicated would be most valuable in ACOG’s next immunization toolkit.
Ob-gyns’ immunization practice patterns were examined. The use of standing orders for immunizations and the routine administration of Tdap vaccinations during pregnancy appear to be improving. Significantly more providers from the postintervention study (46.6%) than the preintervention study (36.5%) reported that they use standing orders for immunizations in their practices (
Approximately one-quarter of pre- and postintervention study respondents reported that they have assigned a staff member to be the vaccine coordinator of their practice (23.0% versus 26.1%) or always use a needs assessment with patients to determine what vaccinations they need at the time of their appointment (20.4% versus 27.0%). The large majority of ob-gyns from both studies reported that they offered or planned to offer influenza vaccinations to their patients for the 2012-2013 and 2014-2015 flu seasons (76.9% versus 78.9%). Among physicians who did not offer or plan to offer influenza vaccinations, 97.2% of preintervention study providers and 92.9% of postintervention study providers reported that they would recommend them to their patients or refer patients to local vaccine clinics or providers. Participants were also asked whether they receive annual influenza vaccination. Significantly more respondents from the postintervention study (96.1%) than the preintervention study (90.7%) indicated that they receive an annual flu vaccine (
Preintervention study physicians who reported that they annually receive a flu vaccine were significantly more likely to offer Tdap immunizations to all of their pregnant patients (62.5%) (
Lastly, ob-gyns were surveyed about whether they require their staff to receive immunizations for influenza, Hepatitis B, and Tdap. Postintervention study physicians (86.2%) were significantly more likely than preintervention study physicians (78.1%) to report that they required their staff to receive an annual influenza vaccine (
Ob-gyns were asked to rank their top three barriers to offering immunizations in their offices and the top two most common reasons their patients provide for declining vaccinations. While the top three most frequently reported barriers remained the same for pre- and postintervention studies (inadequate reimbursement, cost, and lack of patient interest), several significant differences were found between the two studies regarding the percentage of respondents who endorsed some of the listed barriers (Table
Barriers to offering immunizations among ob-gyns.
Barrier | Overall % of ob-gyns who agreed | ||
---|---|---|---|
Preintervention study | Postintervention study |
|
|
Inadequate reimbursement | 51.4 | 44.6 | .085 |
Cost† | 45.5 | 34.8 | .006 |
Lack of interest from patients |
29.9 | 37.5 | .043 |
Lack of time |
25.4 | 33.0 | .036 |
Lack of storage for vaccine/supplies | 24.2 | 18.0 | .059 |
Concerns about vaccine safety | 18.5 | 18.4 | .959 |
Lack of staff | 16.7 | 19.5 | .363 |
Participating in immunization registries | 10.5 | 9.0 | .514 |
Lack of access to patient records |
7.5 | 3.7 | .048 |
Several other demographic differences were observed in the postintervention study. A larger number of ob-gyns who reported practicing in suburban and rural locations indicated that cost (44.7% and 48.4%,
According to pre- and postintervention study participants, the top two most common reasons patients provide for declining vaccinations are safety concerns (84.2% versus 78.5%; (
Ob-gyn awareness and use of the ACOG Immunization for Women website and the Text4baby program were assessed. Text4baby is a free mobile educational service designed for pregnant women to promote maternal and child health through text messaging. No significant differences were found between pre- and postintervention study respondents for any of these variables. Less than one-quarter of pre- (19.0%) and post- (22.1%) intervention study providers reported that they had ever visited ACOG’s Immunization for Women website. The majority of pre- and postintervention study ob-gyns reported that they never refer staff (77.3% versus 74.1%), fellow ob-gyns (82.1% versus 80.8%), or patients (76.3% versus 68.4%) to ACOG’s Immunization for Women website. Responses to this question did not differ by physician age or gender. Similarly, most ob-gyns were unfamiliar with the Text4baby program (72.7% versus 69.5%). Younger physicians (pre (
Findings from this study indicate that ACOG’s efforts to improve their immunization resources were successful in many ways. More ob-gyns from the postintervention study reported receiving the immunization toolkits than respondents from the preintervention study. This may be attributed to the more robust promotional campaign that accompanied the second round of immunization toolkits. It is also possible that the increase of postintervention respondents resulted from some type of Hawthorne effect whereby ob-gyns were made aware of the toolkit purely by participating in the preintervention study. Additionally, a greater number of postintervention study providers reported already using all of the immunization toolkit resources (except the Immunization for Women website); however, these results were not statistically significant. The most frequently used toolkit materials reported in both studies were the Flu FAQ Tear Pad and the Tdap FAQ Tear Pad.
The percentage of physicians who reported offering Tdap vaccination to all women during pregnancy increased significantly from 59% to 77% between pre- and postintervention studies. However, these numbers are much higher than those found in the existing literature (30%), indicating that further research is warranted to clarify accurate estimates of Tdap coverage among ob-gyns [
Several barriers to offering immunizations were identified by participants. In support of previous findings [
One of the limitations to this study is the relatively low response rate. The low response rate may indicate a lack of physician interest in this topic. In order to increase the response rate, multiple mailings and a simplified questionnaire were utilized. It is also possible that characteristics of respondents are different from those of nonrespondents, although nonresponse bias analysis did not reveal statistically significant differences for comparison variables. The simplified questionnaire offered a sufficient amount of content-relevant questions that would assert that those who responded and those who did not respond held similar attitudes towards vaccination during pregnancy. Lastly, these data are based on physician recall and could not be checked through chart review or other methods.
Improving immunization coverage among pregnant women has numerous health benefits for mothers, their infants, and society. While it appears that influenza and Tdap administration rates are increasing among ob-gyns, several barriers to offering immunizations persist. It is crucial to help providers overcome these obstacles in order to ensure that these vaccinations become a routine part of obstetric health care.
The study’s contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.
The authors declare that there is no conflict of interests regarding the publication of this paper.
This study was supported by Cooperative Agreement 5U66IP000667 from the Centers for Disease Control and Prevention.