ABSTRACT
We designed our study to evaluate the knowledge and immunization practices among Lebanese obstetricians and gynecologists (OBGYN) for women of different age groups. Anonymous questionnaires were used to assess the knowledge and immunization practices among OBGYN. The survey was conducted at the annual meeting of the Lebanese Society of Obstetrics and Gynecology on November 13–15, 2014. Data collected included demographics, type of practice, academic background and familiarity with vaccine guidelines. Descriptive statistical methods were used to evaluate the responses. The response rate was 54.8% (114/208). Only 62.3% (71/114) recommend vaccination(s) to pregnant women with only 25.9% of those who recommend the Tdap vaccine for pregnant women giving it during the recommended third trimester. In addition, 52.6% are unaware of the CDC/ACIP immunization schedule for women in general. However, 83.0% (93/112) of respondents are willing to integrate vaccination in their practice. Our study highlights several gaps in the knowledge of Lebanese OBGYN regarding vaccination in addition to practices that are not in full accordance with common guidelines. Measures should be taken to spread proper awareness of the proper guidelines among Lebanese practitioners.
Introduction
Obstetricians and gynecologists (OBGYN) are often the primary care physicians for adolescents, adults, and elderly women.Citation1 This is the case in Lebanon, a middle income country where the OBGYN are the primary providers for a considerable percentage of adolescents and almost all adult women. It has long puzzled researchers from a public health perspective as to why vaccination is not a routine part of OBGYN practice given that they often serve as the primary care provider for women and that they care for a population (pregnant women and their fetuses) at high risk for morbidity and mortality from several vaccine preventable diseases. Providing appropriate vaccinations at the appropriate time is a cornerstone for any primary care practice. Vaccination guidelines are often updated and new vaccinations are always in development as witnessed by the emergence of the Human Papilloma Virus (HPV) vaccine and the updated Tetanus, Diphtheria, Pertussis vaccine (Tdap) recommendations.Citation2–8 In Lebanon, unfortunately, there are no clear guidelines on recommended vaccines to adolescent, adult and pregnant women. Many Lebanese OBGYN follow guidelines recommended by the Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and GynecologistsCitation2,Citation5,Citation6,Citation7 and the World Health Organization.Citation2,Citation4–9
Little information is available in the literature about the familiarity of OBGYN with the updated vaccination schedules. We designed our study to assess the knowledge and current immunization practices among Lebanese OBGYN.
Results
The response rate was 54.8% (114/ 208). Participants' characteristics are summarized in .
Table 1. Participants' characteristics.
Of the practitioners, 65 (57%) did not receive the influenza vaccine themselves. The reasons for not taking it were: not taking it before (76.9%), unavailability (6.2%), forgetting to take it (6.2%), having Flu even if the vaccine was taken (4.6%), medical problems (4.6%) and fear of side effects (1.5%).
When asked if they recommended vaccinations to pregnant women, 37.7% (n = 43) reported that they did not. This is attributed to absence of clear guidelines 51.2% (n = 22), unavailability of enough safety data (37.2%), logistic reasons (cost of storage, refrigeration, and administrative reasons, etc.) 7.0% (n = 3) and being convinced that vaccines are useless 4.6% (n = 2). For those who recommended vaccination, 57/65 (87.7%) believed that there were sufficient data to appropriately counsel pregnant women compared with 9/41 (22.2%) in those who do not recommend vaccination (p < 0.000). If the providers received vaccine themselves, they were more likely to recommend the vaccine to pregnant women (75.5% versus 52.3%; p = 0.02).
Of those who responded regarding their source of information, 49 (79.0%) selected medical journals, 24 (38.7%) the internet, 31 (50.0%) conferences, 13 (21.0%) the ministry of health and 8 (12.9%) the media.
The injectable influenza vaccine was recommended by 62 (91.2%) while 6 (8.8%) recommended the nasal influenza vaccine and 27/68 (39.7%) recommended the Tdap vaccine. Other vaccinations recommended included Hepatitis-B vaccine in 17 respondents (25%) and the HPV vaccine in five (7.4%). About 93% of practitioners (25/27) who recommend Tdap vaccine would also recommend the influenza vaccine.
The gestational age at which a specific vaccination is recommended is summarized in . The influenza vaccine was recommended during any trimester by 48 (67.6%). The Tdap vaccine was recommended in the third trimester by 7 (25.9%). 34.9% (n = 22) responded that the Tdap vaccine should be repeated if received in a previous pregnancy or pre-pregnancy.
Table 2. Gestational age at which vaccination is recommended during pregnancy.
Concerning vaccination practices for non-pregnant adolescents, 90 (78.9%) recommended vaccination to this population. The reasons for not recommending vaccination were: absence of guidelines (80%, n = 16) or insufficient safety data (20%, n = 4). The HPV vaccine was recommended by 88 (77.2%) followed by the influenza vaccine 52 (59.1%), the Hepatitis-B vaccine 41 (46.6%), and the Hepatitis-A vaccine 17 (19.3%). In fact, 88/90 (97.8%) of OBGYN who recommended a vaccine for adolescents would consider HPV vaccine. Sixty (68.4%) recommended the quadrivalent HPV vaccine (4vHPV), 14 (15.9%) recommended the bivalent HPV vaccine (2vHPV) and 14 (15.9%) had no preference. The reasons for recommending the HPV vaccine among the 87 respondents were: protection from cervical cancer (98.9%), warts (71.3%), anal cancer (50.6%), and vulvar cancer (48.3%). For the 86 OBGYN who responded to the question about HPV dosing regimen, the number of doses given were two in 2.3%, 3 in 96.5% and four in 1.2%. HPV vaccination was recommended to 9- to 26 year-olds in 44.8% (n = 39), at different age brackets in 20.7% (n = 18) and at any age in 34.5% (n = 30) (Appendix).
Regarding vaccination of adult women, 75 (72.8%) of respondents recommended vaccination during the annual checkup, if indicated. However, 53.6% (n = 60) were unaware of the CDC/ACIP immunization schedule for women in general. The majority (73.68%, n = 70) recommended the influenza vaccine and the HPV vaccine followed by the Hepatitis-B vaccine (48.4%), pneumococcal vaccine (21.1%) and Hepatitis-A vaccine (10.5%). Finally, of the 112 respondents (98.2%), 83% (n = 93) were willing to integrate vaccination into their practice.
As for the knowledge score (), 23.7% were aware that the Tdap vaccine is recommended during pregnancy and 13.2% believed that it should be administered in the third trimester. In addition, 36% believed that the influenza vaccine was not recommended for pregnant women or were not sure and 54.4% believed that it can be administered during any trimester. Statistically, the mean knowledge score was 52.5±19.9% with a knowledge score of 50% or less in 65 respondents (57%). There was no difference in the knowledge score in relation to the age, practice setting, years in practice or subspecialty (). On the other hand, there was a tendency towards higher knowledge scores among female physicians compared with their male colleagues, without reaching statistical significance.
Table 3. Participants' answers to knowledge statements about vaccination guidelines.
Table 4. Participants' knowledge score stratified by their characteristics.
Discussion
This survey highlights several gaps in the knowledge of Lebanese OBGYN regarding vaccination in women at different age groups. In addition, it identifies practices that are not in full accordance with common guidelines.
Immunization against vaccine-preventable diseases is an essential component of women's primary and preventive health care. OBGYN are primary care providers and in many practice settings including Lebanon, they are the only providers that a woman has, so traditionally they provide preventive care to women.Citation1 An annual visit usually includes screening, evaluation, counseling, and immunizations based on age and risk factors.
Despite the belief that vaccines are usually handled by pediatricians, many vaccines are given to adolescents, pregnant, and adult females.Citation2,Citation6–8 Of the vaccines recommended during pregnancy,Citation3 a lot of emphasis is placed on the influenza vaccine and the Tdap vaccine for which the guidelines have changed frequently since 2012.Citation6 The 2009 influenza pandemic was a timely reminder of the maternal risks; a 7-fold increased risk of hospitalization compared with infected non-pregnant women.Citation10 Associated fetal risks include preterm birth, reduced birth weight and an elevated risk of death.Citation11 Advisory groups throughout the world have therefore recommended influenza vaccination for all pregnant women, with the WHO identifying them as a priority group.Citation12,Citation13 Another serious infection, pertussis remains endemic in much of the world.Citation13 Since infants are especially vulnerable in the early months of life, health authorities worldwide favor maternal immunization that provides passive immunity to the newborn and close to a 91% reduction in the risk of pertussis in the infants.Citation14,Citation15
Despite such evidence, uptake of recommended vaccines among pregnant women has been consistently less than expected.Citation16 Common reasons for not receiving vaccination include fear of adverse pregnancy outcomes, cost of vaccination, and failure of the healthcare provider to recommend vaccination.Citation16,Citation17 The healthcare providers' recommendation and offer of vaccination seems to be the most influential determining factor on whether a pregnant woman is vaccinated or not.Citation13 Given this, it is very striking to find that more than one third of OBGYN in our survey do not recommend any type of vaccination in pregnancy and out of those who recommend vaccination, 8.8% recommend the contraindicated nasal influenza vaccine in pregnancy. As for the Tdap vaccine, less than one quarter of OBGYN recommends it to pregnant women and only 26% of those give it at the appropriate gestational age. The rather low mean knowledge score among physicians in this survey that is reflective of poor or at most moderate knowledge is also alarming. In fact, only 42.1% are aware of the CDC/ACIP immunization schedule for pregnant women. The gap between awareness of the importance of a practice and actual implementation is illustrated in the fact that although 64% are aware that the influenza vaccine is recommended during pregnancy, only 54% are actually recommending it to pregnant women. Even for those who recommend it, only 76.1% are convinced that there is sufficient evidence about the benefits of vaccines. Given that vaccine guidelines are easily accessible online, it seems that more barriers must be contributing to the deficient implementation than knowledge alone. The potential for desirability bias in responses to the questions should also be taken into consideration.
Concerning vaccination practices for non-pregnant adolescents, a higher percentage of Lebanese OBGYN would recommend vaccination to this population (78.9%) compared with 62.3% for pregnant women. This could be partly explained by the availability of the HPV vaccine, the most commonly prescribed vaccine for this age group (97.8%), in the offices of some OBGYN. Another explanation is that some pregnant women are already reluctant to receive any kind of vaccination during pregnancy for the fear that it might pose a risk on their newborn.Citation18 This, coupled with the fact that a sizable proportion of the OBGYN surveyed do not themselves believe that there are enough safety data about the long term effects of vaccines on women and their fetuses, further decreases the chances that vaccines will be recommended to pregnant women although healthcare providers should play a key role in enhancing the knowledge of vaccine safety in all age groups, especially the vulnerable pregnant women. Furthermore, despite the higher implementation of proper vaccination in adolescents compared to pregnant women, when counseling women about an intervention – like the HPV vaccine – with proven efficacy in reducing the risk of serious health problems like cervical, vulvar and anal cancer, one would expect a much higher uptake especially if the health care providers are convinced of its safety and efficacy.
Adult females are prone to certain diseases that are preventable and they should receive immunizations based on their age and risk factors according the immunization schedule released by the CDC/ACIP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American College of Nurse-Midwives.Citation8 Our results show that 72.8% of respondents recommend annual vaccination to adult women.
When asked about willingness to integrate immunization into the daily practice, 83% of respondents were in agreement. Therefore, lack of interest in proper vaccination cannot explain the noted deficiencies in practice. The culprit in this group is rather the unawareness of the appropriate immunization scheduling; 52.6% of participants noted unfamiliarity with proper scheduling guidelines. The willingness to integrate vaccinations into daily practice however must be backed up by proper knowledge to ensure that the proper vaccine is administered at the appropriate scheduling interval. This of course is essential to prevent hazardous administration of contraindicated vaccinations and to ensure proper adherence to continuously updated guidelines. Moreover, a good number of participants were practitioners in university medical centers. As a result, it is essential to tackle any deficiencies in awareness in order to avoid propagating inaccurate information to the training resident physicians.
Strengths and limitations
One of the main limitations of our study is that its results might not be generalizable to all OBGYN in the country especially that the response rate was low (54.8%). Such a sample size could have introduced a type II error especially that in some sub-analyses the numbers were even lower, e.g., only 27 respondents for vaccination schedules for Tdap. Another limitation is that ur target population was comprised of a random sample of physicians attending the LSOG meeting. This may provide selection bias since physicians at the conference may have a higher level of literacy about scientific aspects of their profession in that they could be probably more used to training activities and hence be more eager to remain updated with guidelines.Despite this, more than half of those surveyed were unaware of the recent international guidelines. This may further strengthen our speculation that most physicians countrywide are unfamiliar with the updated immunization recommendations. One can argue that the ACIP guidelines were developed for the United States and therefore might not be practical or appropriate in Lebanon. However, in the absence of national guidelines, our study aimed to compare the knowledge and practice of Lebanese OBGYN to the available well-defined standards. In addition, shortage of vaccines might be a main reason for failing to recommend vaccines. However, during the study period the supply of the vaccines in the Lebanese market was not an issue. In fact, none of the OBGYN listed unavailability of the vaccines as a reason for not recommending vaccination for women of any age group. The major strength of this study on the other hand is that it takes the first steps toward expanding access to vaccines for women through elucidating current practices, OBGYN's interest in providing vaccinations, and potential barriers to this essential part of preventive medicine.
Methods/Materials
During the annual meeting of Lebanese Society of Obstetrics and Gynecology in November 2015, questionnaires were distributed to a random sample of 208 Lebanese OBGYN out of 435 who registered for the meeting. The organizers of the meeting provided the list of attendees. Using a random table according to the corresponding number of the attendee, 208 were chosen. The questionnaires were developed by two authors and were piloted for readability. A cover letter explained the purpose of the study, its anonymity and confidentiality, and the expected benefits. Questionnaires were collected at the end of each day.
The questionnaire (Appendix A) consisted of 40 questions in four sections. The first asked about demographics (gender, age, years in practice, subspecialty, and practice setting). The second solicited practice patterns of vaccination in pregnant women (type of vaccine, timing of administration, and awareness of guidelines). The third assessed vaccination practices in adolescents and adult women. The last section constituted of 10 questions that tested their knowledge on vaccination practice.
Sample size
In order to generate a sample size, we used a sample size calculator taking into account a 95% confidence level, a 0.05 significance level, a power of 80% and a 50% expected response rate. Based on these calculations, a sample size of 208 was chosen out of the 450 Lebanese OBGYN who registered for the meeting; 48.6% of 925 practicing Lebanese OBGYN.
Statistical analysis
Statistical analyses used the IBM Statistical Package for Social Sciences software (SPSS) for windows XP, version 11.0. Student's t test or ANOVA were used to analyze continuous variables.
Based on responses, a knowledge score was calculated. This reflects the percentage of correct answers the participant had among the 10 knowledge statements. For every statement, one point was given for answering correctly and no points were given for choosing the wrong answer or the “Do not know” option. The total points were added for every participant and a percentage was calculated: (number of points)/10*100; the knowledge score.
Conclusions
Despite its limitations, this survey explores the important question of OBGYN knowledge and practices regarding vaccination and provides a reliable evidence of a tremendous gap among Lebanese OBGYN when it comes to proper immunization scheduling for women of different age groups, in and out of a pregnancy setting. A critical step in closing this evidence-practice gap is to better understand how to effectively support those providers in aligning their practices with the best available evidence. This highlights the need of conducting special physician educational conferences across the country and adopting awareness campaigns in order to provide vaccination scheduling its well-deserved status at every obstetrics and gynecology clinic in the country.
Disclosure of potential conflicts of interest
No potential conflicts of interest were disclosed.
Authors' contributions
E. Hobeika was involved in conception and study design. R. Helou and S. Jabak were involved in data acquisition and entry and helped in writing the manuscript. I. Usta did the data analysis and helped in editing the paper. F. El Kak was involved in data acquisition and gave input at the stage of writing the manuscript. A. Nassar was involved in conception and study design, interpretation of data and manuscript writing. All authors have approved of the final version of the article.
Acknowledgments
The authors would like to thank the Lebanese Society of Obstetrics and Gynecology for the help and support that allowed the study to be conducted.
References
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Appendix:
The Immunization practice Questionnaire – Physician survey
Serial Number: __________________ Date of interview: ___________________
Please choose the single best answer except when asked to give more than one option.
| 1. | Gender: □ Male □ Female | ||||
| 2. | Age: □ <30 years □ 30–35 years □ 36–40 years
| ||||
| 3. | OB/GYN degree obtained in (year) ____________ from (Country): | ||||
| 4. | Practice: □ Private practice
| ||||
| 5. | Years in practice: □ <5 years □ 5–10 years □ >10 years | ||||
| 6. | Any subspecialty? □ No □ Yes | ||||
| 7. | If answer of question 6 is Yes, what subspecialty?
| ||||
| 8. | Do you practice? □ Only OBS □ Only GYN □ Both OBS & GYN | ||||
| 9. | Did you receive the seasonal influenza vaccine?
| ||||
| 10. | Why did you take the seasonal influenza vaccine this year? (You can choose more than one answer then skip to Question 12)
| ||||
| 11. | Why did you choose not to take it? (You can choose more than one answer)
| ||||
| 12. | Do you recommend vaccines to pregnant women?
If the answer of question 12 is Yes, skip to Question 14 | ||||
| 13. | Why don't you recommend vaccines for pregnant women?
If the answer question 12 is No, skip to Question 20 | ||||
| 14. | As an obstetrician, do you think you have sufficient data and information about vaccines in order to adequately counsel pregnant women?
| ||||
| 15. | Where do you get such information? (You can choose more than one answer)
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| 16. | Which vaccines do you offer for pregnant women? (You can choose more than one answer)
| ||||
| 17. | When do you give the influenza vaccine during pregnancy?
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| 18. | When do you give Tdap vaccine during pregnancy?
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| 19. | If a pregnant woman has already received Tdap before becoming pregnant or in a previous pregnancy, do you repeat Tdap during the current pregnancy?
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| 20. | Do you recommend vaccines to non-pregnant adolescents?
If the answer of question 20 is Yes, skip to Question 22 | ||||
| 21. | Why don't you recommend vaccines for adolescent women?
| ||||
| 22. | Which vaccines you recommend to adolescent women? (You can choose more than one answer)
| ||||
| 23. | If you provide HPV vaccine, which vaccine do you use?
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| 24. | Why do you recommend HPV vaccine? (You can choose more than one answer)
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| 25. | At what age you recommend HPV vaccine administration? (You can choose more than one answer)
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| 26. | How many doses of the HPV vaccines you give?
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| 27. | Do you recommend vaccines for adult women at their annual checks?
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| 28. | Which vaccines you recommend to adult women? (You can choose more than one answer)
| ||||
| 29. | Are you aware of the CDC/ACIP immunization schedule for women in general?
| ||||
| 30. | Are you willing to integrate immunization into your practice?
In the last section, please choose either yes/no/or do not know | ||||
| 31. | Do you believe the injectable influenza vaccine is recommended during pregnancy?
| ||||
| 32. | Do you believe the nasal influenza vaccine is recommended during pregnancy?
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| 33. | Do you believe that in pregnancy the influenza vaccine can be administered during any trimester?
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| 34. | Do you believe the Tdap vaccine is recommended during pregnancy?
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| 35. | The Tdap vaccine is recommended in pregnancy during the second trimester?
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| 36. | Are you aware of the CDC/ACIP immunization schedule for pregnant women?
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| 37. | The HPV vaccine should be offered between 9 and 26 years?
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| 38. | Should the HPV vaccine be offered to men?
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| 39. | The number of recommended doses for the HPV vaccine is two?
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| 40. | Are you aware of the recommended vaccinations that should be offered to adult women of different age groups?
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