Abstract
The multiple information sources available may pose a challenge to physicians in providing accurate human papillomavirus (HPV) vaccine information to patients. The purpose of this study was to describe physicians' HPV vaccine information-seeking behaviors and assess if these behaviors differ by physician specialty and sociodemographic characteristics. In 2009, 1,008 Family Physicians (FPs), Pediatricians (Peds), and Obstetric/Gynecologists (OBGYNs) completed a survey to assess their HPV vaccine information-seeking behaviors and vaccination practices. The largest proportion obtained HPV vaccine information from professional organizations (50.0%), followed by the Advisory Council on Immunization Practices (ACIP) (36.0%), and medical conferences (33.1%). Peds and FPs were more likely to obtain vaccine information from the ACIP (p-values < 0.05). OBGYNs, non-White/Caucasian physicians and those aged 40–49 were more likely to obtain vaccine information from internet websites (p-values < 0.05). There is a need for targeted HPV vaccine communication approaches based on sociodemographic and physician specialty characteristics.
Keywords: Human papillomavirus (HPV) vaccines, information-seeking, physicians, health communication, United States
Introduction
Human papillomavirus (HPV) vaccination is an effective public health tool to prevent cervical cancer and other HPV-associated diseases.1 However, the public health impact of HPV vaccines is contingent upon widespread uptake. As physician recommendation is an important predictor of HPV vaccine uptake2–5, the medical community plays a central role in educating patients about HPV vaccination. The vast number of information sources available and the rapidly changing dynamics of vaccination guidelines6 continually challenge physicians in providing their patients with evidence-based HPV vaccine information. A critical component of promoting patient-oriented informed decision-making is that physicians are equipped with current and accurate information about vaccine guidelines, safety, and other relevant information.7 Few published studies have examined physicians' information-seeking behaviors8,9 and none have assessed physicians' HPV vaccine information-seeking behaviors. Examining physicians' HPV vaccine information sources may inform interventions to optimize HPV vaccine delivery in clinical practice. Therefore, the purpose of this study was to describe physicians' HPV vaccine information-seeking behaviors and assess if these behaviors differ by physician specialty, gender, race, and age.
Methods and Material
Study Design
Data from this study are part of a larger study that assessed HPV knowledge, attitudes, information-seeking behaviors, and vaccination practices among United States (US) physicians. In 2009, surveys were mailed to a nationally representative sample of 1,538 physicians obtained using the American Medical Association Masterfile, including 818 Family Physicians (FPs), 393 Pediatricians (Peds), and 327 Obstetricians/Gynecologists (OBGYNs). Completed surveys were received from 1,013 physicians. The overall response rate was calculated as the number of physicians completing the survey (N = 1,013) divided by the initial sample minus the undeliverables and ineligibles [1538 − (33 + 10)] which yielded a 67.8% response rate. Five surveys were received after the deadline and were not included in the analyses; therefore, the final sample used for this study was 1,008. A more detailed explanation of the study design as well as methodological justifications are described elsewhere.10 The study was approved by the University of South Florida Institutional Review Board.
Measures
HPV vaccine health information-seeking
Participants were asked “How often do you use the following sources to obtain information about the HPV vaccine:” professional organizations, Advisory Council on Immunization Practices (ACIP), state/local immunization programs, colleagues, pharmaceutical representatives, internet websites, media, medical conferences, and grand rounds/local institutional lectures. At the time of the study Gardasil was the only licensed vaccine in the US, therefore, vaccine questions only referred to Gardasil licensed for females. Physicians were asked to respond to the items on a 5-point Likert response scale (1= rarely use to 5 = always use). Because we were interested in identifying the most common sources of HPV vaccine information-seeking, the five response categories were collapsed into two, “never/rarely/sometimes” and “often/always”.
Physician practice characteristics
Physicians were asked to indicate the location of the primary practice (e.g. private practice, urgent clinic, community health center), the racial composition of their patients (e.g., non-Hispanic White, non-Hispanic Black, Asian), insurance status of patients (private, Medicaid, uninsured), daily patient load (e.g., <15, 15–19, ≥30), and the geographical location of their primary clinic (e.g., urban, rural).
Sociodemographic characteristics
Physicians' age, race, gender, and specialty (FPs, Peds, OBGYNs) were obtained.
Statistical Analysis
Descriptive statistics summarized physicians' sociodemographic and practice characteristics. Chi-square tests were used to explore differences in HPV information-seeking by specialty (FPs, Peds, OBGYNs), gender, race, and age. Due to the small number of physicians comprising non-White/Caucasian categories, race was collapsed into two categories (White/Caucasian versus Other). Age was categorized into three groups (25–39, 40–49, and ≥50). All analyses were conducted using PASW 18.0 (Chicago, IL). Statistical tests were two-tailed, with an alpha level of 0.05.
Results
Of the 1,008 physicians, the largest proportion were FPs (49.5%), White/Caucasian (73.1%), and male (52.4%). Physicians' mean age was 47.27±8.87; age range from 25–65. See Table 1 for physicians' sociodemographic and practice characteristics.
Table 1.
Sociodemographic and Practice Characteristics of a Nationally Representative Sample of United States Physicians (N=1,008), 2009
| Characteristics | n (%) |
|---|---|
| Age Categories | |
| 25–39 | 239 (23.7) |
| 40–49 | 327 (32.4) |
| ≥ 50 | 422 (41.9) |
| Unknown | 20 (2.0) |
| Race | |
| White/Caucasian | 737 (73.1) |
| Black/African American | 45 (4.5) |
| Asian | 112 (11.2) |
| American Indian/Alaskan Native | 0 |
| Native Hawaiian/Pacific Islander | 2 (0.2) |
| Other (including multiracial) | 69 (6.9) |
| Unknown | 43 (4.3) |
| Gender | |
| Male | 528 (52.4) |
| Female | 466 (46.2) |
| Unknown | 14 (1.4) |
| Physician Specialty | |
| Family Physicians (FPs) | 499 (49.5) |
| Pediatricians (Peds) | 287 (28.5) |
| Obstetricians/Gynecologist (OBGYNs) | 222 (22.0) |
| Office Location | |
| Private Practice Office (solo or group) | 728 (72.2) |
| Ambulatory Care Clinic/Primary Care | 122 (12.1) |
| Urgent Care Clinic | 27 (2.7) |
| Community Health Center | 47 (4.7) |
| University/College Student Health Services | 6 (0.6) |
| Hospital Emergency Department | 9 (0.9) |
| Institutional Setting/Clinic | 8 (0.8) |
| Other | 48 (4.8) |
| Unknown | 13 (1.3) |
| Racial/Ethnic Distribution of Patients | |
| Non-Hispanic White | 735 (72.9) |
| Non-Hispanic Black | 55 (5.3) |
| Hispanic | 100 (9.9) |
| American Indian/Alaskan Native | 3 (0.3) |
| Asian | 12 (1.2) |
| Native Hawaiian/Pacific Islander | 1 (0.1) |
| Other (including multiracial) | 87 (8.7) |
| Unknown | 17 (1.7) |
| Patient Primary Payment Method | |
| Private Insurance | 527 (52.3) |
| Medicaid/Children's Health Insurance Program | 118 (11.7) |
| Uninsured/Self-Pay | 11 (1.1) |
| Medicare | 42 (4.2) |
| Other | 30 (3.0) |
| Daily Patient Load | |
| < 15 | 88 (8.7) |
| 15–19 | 170 (16.9) |
| 20–29 | 500 (49.6) |
| ≥ 30 | 232 (23.0) |
| Unknown | 18 (1.8) |
| Geographical Location of Clinic Practice | |
| Urban | 289 (28.7) |
| Suburban | 506 (50.2) |
| Rural | 182 (18.1) |
| Other | 7 (0.7) |
| Unknown | 18 (1.8) |
Patient primary payment method is presented as percentages of greater than 50%.
As shown in Table 2, physicians were most likely to seek HPV vaccine information from professional organizations (50.0%) followed by ACIP (36.0%). OBGYNs (61.1%) compared to Peds (58.5%) and FPs (40.3%) were significantly more likely to seek HPV vaccine information from professional organizations, (χ2 = 37.58, p < 0.01). Peds (62.0%) compared to FPs (31.8%) and OBGYNs (11.2%) were significantly more likely to seek vaccine information from ACIP, (χ2 = 144.57, p < 0.01). A complete list of differences in HPV vaccine information-seeking behaviors by physician specialty is presented in Table 2.
Table 2.
Nationally Representative Sample of United States' Physicians' HPV Vaccine Information-Seeking Behaviors by Practice Specialty, 2009
| HPV Vaccine Information Sources | Total (%) | FPs (%) | Peds (%) | OBGYNs (%) | χ | df | P |
|---|---|---|---|---|---|---|---|
| Professional Organizations | 50.0 | 40.3 | 58.5 | 61.1 | 37.58 | 2 | < 0.01* |
| Advisory Council on Immunization Practices (ACIP) | 36.0 | 31.8 | 62.0 | 11.2 | 144.57 | 2 | < 0.01* |
| Medical Conferences | 33.1 | 28.7 | 32.2 | 44.0 | 16.19 | 2 | < 0.01* |
| Colleagues | 32.4 | 26.3 | 42.5 | 33.2 | 21.41 | 2 | < 0.01* |
| State/Local Immunization Programs | 28.4 | 27.9 | 41.1 | 13.0 | 47.19 | 2 | < 0.01* |
| Pharmaceutical Representative | 23.7 | 19.7 | 23.2 | 33.5 | 15.74 | 2 | < 0.01* |
| Grand Rounds/Local Institutional Lectures | 18.1 | 11.1 | 22.9 | 27.6 | 34.03 | 2 | < 0.01* |
| Internet Websites | 15.4 | 15.4 | 11.7 | 20.2 | 6.72 | 2 | 0.04* |
| Media | 4.2 | 4.1 | 3.9 | 4.9 | 0.24 | 2 | 0.89 |
HPV is human papillomavirus.
χ2 is chi-square.
df is degree of freedom.
p is p-value for χ2 significance.
χ2 significance at p ≤ 0.05.
Notes: Percentages represent the proportion of physicians' who reported often/always seeking HPV vaccine information from the indicated information source.
Additional analyses (data not shown) demonstrated that female physicians were significantly more likely than males to get their HPV vaccine information from ACIP (39.6% vs. 28.3%), (χ2 = 5.32, p = 0.02); colleagues (37.4% vs. 28.3%), (χ2 = 8.70, p < 0.01); and medical conferences (37.7% vs. 28.9%), (χ2 = 8.23, p < 0.01). Physicians of other races compared to White/Caucasian physicians were significantly more likely to get their HPV vaccine information from internet websites (20.8% vs. 13.3%), (χ2 = 6.98, p < 0.01); media (6.7% vs. 3.4%), (χ2 = 4.82, p < 0.01); medical conferences (39.0% vs. 31.1%), (χ2 = 4.50, p = 0.03); and grand rounds/local institutional lectures (25.5% vs. 15.5%), (χ2 = 10.69, p < 0.01).
Physicians aged 25–39 (18.7%) were significantly more likely to use internet websites to obtain HPV vaccine information compared to physicians aged 40–49 (16.8%) and ≥ 50 (11.8%), (χ2 = 6.67, p = 0.03). Compared to those aged 25–39 (27.1%) and 40–49 (32.4%), physicians aged ≥ 50 years (36.6%) were significantly more likely to obtain HPV vaccine information from medical conferences, (χ2 = 6.12, p = 0.05).
Discussion
The largest proportion of physicians often/always obtained HPV vaccine information from professional organizations. This is a promising finding given that such organizations provide consensus statements that are evidence-based. Professional organizations may therefore provide an optimal venue for continued health education and communication efforts. One-third of physicians reported seeking vaccine information from ACIP and fewer sought information from state/local immunization programs. Professional organizations, ACIP, and state programs generally provide the most up-to-date and evidence-based HPV vaccine information. Continued efforts to promote widespread use of evidence-based information-seeking among physicians are essential.11 One-fourth of physicians obtained HPV vaccine information from pharmaceutical representatives. It is possible that information received from commercial sources may present an unbalanced view of the current evidence of vaccine efficacy and safety.12 A larger than expected proportion of physicians obtained vaccine information from the internet. Many health care providers lack proficiency in internet navigation13, 14 and the time needed to identify accurate sources of information15 which poses a challenge to optimizing clinical outcomes. Increasingly the media has been identified as a less than credible source of health information.16–18 It is reassuring that only a small number of physicians rely on media for vaccine information.
OBGYNs compared to FPs were more likely to obtain HPV vaccine information from the internet. This finding is inconsistent with some research indicating that FPs compared to specialists such as OBGYNs more often seek information from online soruces.14 In the current study, OBGYNs and Peds compared to FPs were more likely to seek vaccine information from professional organizations, while an earlier study found no difference in physician information-seeking from such organziations.14 Younger physicians more often obtained HPV vaccine information from the internet, while older physicians were more likely to get such information from medical conferences. Although the internet may not be an ideal source of health information gathering,13–15 it is important to recognize and adjust for the changing dynamics of information-seeking behaviors particularly among younger physicians. Female physicians compared to males were more likely to seek vaccine information from ACIP, colleagues, and medical conferences. However, there was no gender difference in vaccine information-seeking from professional organizations. These findings may have implications for both gender-neutral and gender-specific intervention approaches.
There are limitations to this study that should be considered when interpreting results. First, all data were self-reported which may have introduced recall and reporting error. Second, data on internet site usage were not obtained; therefore we were unable to assess the credibility of HPV vaccine information obtained on the internet.
Conclusion
In order to promote quality care and build trusting patient-provider relationships it is essential that patients are provided with balanced and relevant information that makes sense to them. Results presented here have important implications for public health practice, clinical care, and targeted communication approaches based on physician specialty, gender, race, and age characteristics. In efforts to improve the transfer of evidence-based knowledge from provider to patient, it is important to consider physicians characteristics in the information delivery and dissemination process. Targeted efforts to promote widespread use of evidence-based HPV vaccine information should be central to these efforts. Additionally, as electronic health information retrieval may be increasingly used by physicians, enhancing their web-based search skills will better ensure accurate and evidence-based information retrieval. Integration of emerging information technologies in the medical school curriculum may be of great importance to optimizing vaccine delivery in clinical practice. Largely, the medical community has an important role to play in ensuring that physicians are equipped with the necessary information to improve patient care in clinical practice.
Acknowledgements
This research was supported by a grant from the National Institutes of Health [R01 AI076440].
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
References
- 1.Centers for Disease Control and Prevention FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP) MMWR Morb Mortal Wkly Rep. 2010 May 28;59(20):626–629. [PubMed] [Google Scholar]
- 2.Do H, Seng P, Talbot J, Acorda E, Coronado GD, Taylor VM. HPV vaccine knowledge and beliefs among Cambodian American parents and community leaders. Asian Pac J Cancer Prev. 2009 Jul–Sep;10(3):339–344. [PMC free article] [PubMed] [Google Scholar]
- 3.Caskey R, Lindau ST, Alexander GC. Knowledge and early adoption of the HPV vaccine among girls and young women: results of a national survey. J Adolesc Health. 2009 Nov;45(5):453–462. doi: 10.1016/j.jadohealth.2009.04.021. [DOI] [PubMed] [Google Scholar]
- 4.Conroy K, Rosenthal SL, Zimet GD, et al. Human papillomavirus vaccine uptake, predictors of vaccination, and self-reported barriers to vaccination. J Womens Health (Larchmt) 2009 Oct;18(10):1679–1686. doi: 10.1089/jwh.2008.1329. [DOI] [PubMed] [Google Scholar]
- 5.Gamble HL, Klosky JL, Parra GR, Randolph ME. Factors influencing familial decision-making regarding human papillomavirus vaccination. J Pediatr Psychol. 2010 Aug;35(7):704–715. doi: 10.1093/jpepsy/jsp108. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Hillenbrand KM. What is going on with vaccines: keeping up with the childhood immunization schedule. J Public Health Manag Pract. 2007 Nov–Dec;13(6):544–552. doi: 10.1097/01.PHH.0000296128.54767.d7. [DOI] [PubMed] [Google Scholar]
- 7.Pickering LK, Baker CJ, Freed GL, et al. Immunization programs for infants, children, adolescents, and adults: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2009 Sep 15;49(6):817–840. doi: 10.1086/605430. [DOI] [PubMed] [Google Scholar]
- 8.Al-Habashneh R, Barghout N, Humbert L, Khader Y, Alwaeli H. Diabetes and oral health: doctors' knowledge, perception and practices. J Eval Clin Pract. 2010 Jul 21; doi: 10.1111/j.1365-2753.2009.01245.x. [DOI] [PubMed] [Google Scholar]
- 9.Younger P. Internet-based information-seeking behaviour amongst doctors and nurses: a short review of the literature. Health Info Libr J. 2010 Mar;27(1):2–10. doi: 10.1111/j.1471-1842.2010.00883.x. [DOI] [PubMed] [Google Scholar]
- 10.Vadaparampil ST, Kahn JA, Salmon D, et al. Prevalence of HPV Vaccine Recommendation for Females among a National Sample of U.S. Primary Care Physicians. Lancet Infectious Disease. under-review. [Google Scholar]
- 11.Davies KS. Physicians and their use of information: a survey comparison between the United States, Canada, and the United Kingdom. J Med Libr Assoc. 2011 Jan;99(1):88–91. doi: 10.3163/1536-5050.99.1.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Ziegler MG, Lew P, Singer BC. The accuracy of drug information from pharmaceutical sales representatives. JAMA. 1995 Apr 26;273(16):1296–1298. [PubMed] [Google Scholar]
- 13.Lappa E. Undertaking an information-needs analysis of the emergency-care physician to inform the role of the clinical librarian: a Greek perspective. Health Info Libr J. 2005 Jun;22(2):124–132. doi: 10.1111/j.1471-1842.2005.00563.x. [DOI] [PubMed] [Google Scholar]
- 14.Bennett NL, Casebeer LL, Kristofco R, Collins BC. Family physicians' information seeking behaviors: a survey comparison with other specialties. BMC Med Inform Decis Mak. 2005;5:9. doi: 10.1186/1472-6947-5-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Verhoeven F, Steehouder MF, Hendrix RM, van Gemert-Pijnen JE. Factors affecting health care workers' adoption of a website with infection control guidelines. Int J Med Inform. 2009 Oct;78(10):663–678. doi: 10.1016/j.ijmedinf.2009.06.001. [DOI] [PubMed] [Google Scholar]
- 16.Wilson A, Bonevski B, Jones A, Henry D. Media reporting of health interventions: signs of improvement, but major problems persist. PLoS One. 2009;4(3):e4831. doi: 10.1371/journal.pone.0004831. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.MacKenzie R, Chapman S, Barratt A, Holding S. “The news is [not] all good”: misrepresentations and inaccuracies in Australian news media reports on prostate cancer screening. Med J Aust. 2007 Nov 5;187(9):507–510. doi: 10.5694/j.1326-5377.2007.tb01391.x. [DOI] [PubMed] [Google Scholar]
- 18.Hochman M, Hochman S, Bor D, McCormick D. News media coverage of medication research: reporting pharmaceutical company funding and use of generic medication names. JAMA. 2008 Oct 1;300(13):1544–1550. doi: 10.1001/jama.300.13.1544. [DOI] [PubMed] [Google Scholar]