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Screening High Risk Individuals for Hepatitis B: Physician Knowledge, Attitudes, and Beliefs

Digestive Diseases and Sciences volume 56, pages 3471–3487 (2011)Cite this article

Abstract

Background

Although the overall incidence of hepatitis B virus (HBV) has declined since the introduction of universal vaccine guidelines, the incidence remains elevated in high risk groups. Recent guidelines from the Centers for Disease Control (CDC) have underscored the importance of vaccination against HBV in high risk individuals. However, the incidence of HBV in this group remains elevated, suggesting underuse of vaccinations by healthcare providers.

Aim

The purpose of this study was to measure practice patterns of HBV vaccination, and identify predictors of vaccination underuse.

Methods

We created a survey with four vignettes describing patients at high risk for contracting HBV, followed by questions regarding knowledge, attitudes, and beliefs (KAB) of HBV screening and vaccination. A random sample of 1,000 physicians, including internists, family medicine, OB/GYN, gastroenterologists, and experts in HBV epidemiology were surveyed. Regression analysis on composite guideline adherence scores identified KAB profiles that predict scores.

Results

On average, responders endorsed 71% of the CDC HBV vaccination guidelines. There were three predictors of diminished screening proclivity: (1) younger provider age (P = 0.028), (2) lower awareness that adult HBV is contracted primarily through heterosexual sex (P = 0.023), and (3) being a provider other than a gastroenterologist (P = 0.009).

Conclusions

Respondents endorsed most—but not all—CDC supported HBV screening practices. Lower adherence was predicted by specific and modifiable KAB profiles, and by younger age. Future efforts to improve adherence should target trainees, emphasize the importance of obtaining sexual histories in high risk patients, and inform that HBV is predominantly a heterosexually transmitted infection.

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Acknowledgments

Dr. Foster was supported by a Ruth L. Kirschstein-National Service Research Award (T32 DK 07180-34). This study was supported by an investigator-initiated research grant by Bristol-Meyers Squibb.

Author information

Affiliations

  1. Division of Digestive Diseases, Emory University School of Medicine, 49 Jesse Hill Jr. Dr. S.E. Rm 437, Atlanta, GA, 30303, USA

    Temitope Foster & Huiming Hon

  2. University of California, Los Angeles, Los Angeles, CA, USA

    Steven Han & Brennan Spiegel

  3. VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA

    Brennan Spiegel

  4. St. Louis University, St. Louis, MO, USA

    Fasiha Kanwal

  5. CURE Digestive Diseases Research Center, Los Angeles, CA, USA

    Brennan Spiegel

  6. UCLA/VA Center for Outcomes Research and Education (CORE), Los Angeles, CA, USA

    Brennan Spiegel

Authors
  1. Temitope Foster
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  2. Huiming Hon
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  3. Fasiha Kanwal
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  4. Steven Han
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  5. Brennan Spiegel
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Corresponding author

Correspondence to Temitope Foster.

Additional information

Disclaimer: The opinions and assertions contained herein are the sole views of the authors and are not to be construed as official or as reflecting the views of the Department of Veteran Affairs.

Appendices

Appendix 1: Survey Instrument

Appendix 2: Responses to Individual HBV KAB Questions

Practitioner Beliefs on Sexual History Taking

  1. 1.

    Importance of Sexual History for New Visit

We asked responders to rate their level of agreement that a detailed sexual history is an important part of a new or annual visit. The mean score was 4.7 ± 1.3 out of a maximum of 6 points where higher scores indicate more agreement. In bivariate analyses, we found that agreement was higher in younger providers (P = 0.0008) and women providers (women mean = 5.06 ± 1.04 vs. men mean = 4.44; P = 0.005).

  1. 2.

    Perceived Difficulty in Obtaining Sexual History

We asked responders to rate their level of agreement with the statement that a detailed sexual history is often difficult to obtain due to time constraints. The mean score was 4.2 ± 1.5. In bivariate analyses, we found that agreement was higher in non-experts vs. experts (expert = 2.75 ± 2.12; non-expert = 4.3 ± 1.4; P = 0.005).

  1. 3.

    Indications for Taking a Sexual History

We asked responders if they believed a detailed sexual history was only necessary when related to a specific complaint. The mean score was 2.14 ± 1.34 (lower scores indicated disagreement with this statement). USA graduates scored significantly lower than non-USA grads (USA grad mean = 2.05 ± 1.25 vs. non-US grad mean = 2.81 ± 1.65; P = 0.01). Those in private practice scored significantly higher (private practice mean 2.22 ± 1.35 vs. all others mean = 1.71 ± 1.22; P = 0.01).

  1. 4.

    Patient Comfort with Sexual History Taking

We asked if responders believed that obtaining a detailed sexual history generally makes patients uncomfortable. The mean score was 3.31 ± 1.48 (where a higher score indicates increased agreement). Gastroenterologists scored higher (mean 4.26 ± 1.45 vs. mean = 3.19 ± 1.44; P = 0.003). Responders based in the south also scored higher (3.66 ± 1.48 vs. 3.10 ± 1.44; P = 0.02). Women scored lower compared to men (mean = 2.94 ± 1.44 vs. 3.51 ± 1.47; P = 0.03) and USA graduates scored lower than non-US graduates (mean = 3.14 ± 1.45 vs. 4.22 ± 1.27; P = 0.01). Those in private practice scored higher (mean = 3.53 ± 1.48 vs. 2.78 ± 1.35; P = 0.005), whereas respondents in HMO practice scored lower (mean = 2.22 ± 1.09 vs. 3.39 ± 1.48; P = 0.02).

  1. 5.

    Practitioner Comfort with Sexual History Taking

We asked responders to rate how much they agreed with the statement that they feel comfortable taking a sexual history. The mean score was 4.31 ± 1.39. OB/Gyn physicians scored higher (5.02 ± 1.19 vs. 4.08 ± 1.38; P = 0.0002). Gastroenterologists scored lower (3.57 ± 1.39 vs. 4.46 ± 1.37; P = 0.01).

Practitioner Beliefs on Sexual History Taking

  1. 1.

    Establishing Sexual Activity

We asked if the responders believed it was important to establish whether patients are sexually active as part of a detailed sexual history. The mean score was 5.52 ± 0.89. Practitioners from the West scored higher (5.02 ± 0.43 vs. 5.43 ± 0.96; P = 0.01) than those in other regions and Asian practitioners scored lower (4.91 ± 1.38 vs. 5.57 ± 0.82; P = 0.01).

  1. 2.

    Establishing Number of Sexual Partners

We asked the responders whether it was important to establish the number of active and recent sexual partners as part of a detailed sexual history. The mean score was 5.0 ± 1.21. There were no predictors of this belief.

  1. 3.

    Frequency of Condom Use

We asked if it was important to establish the frequency of condom use or other barrier methods if a patient is sexually active. The mean score was 5.02 ± 1.15. Gastroenterologist scored lower (4.21 ± 1.27 vs. 5.13 ± 1.08; P = 0.0009) and internists scored higher (5.37 ± 1.09 vs. 4.90 ± 1.15; P = 0.03) when compared to other specialties. Respondents practicing in the Northeast scored lower (4.6 ± 1.19 vs. 5.10 ± 1.12; P = 0.04) compared to those in other regions and Asian practitioners scored lower (4.25 ± 1.29 vs. 5.08 ± 1.11; P = 0.02) compared to non-Asian practitioners.

  1. 4.

    History of STD

We asked if documenting any history of an STD was important to establish as part of a detailed sexual history. The mean was 5.5 ± 0.81. Practitioners in the Northeast scored lower (5.16 ± 0.90 vs. 5.58 ± 0.78; P = 0.01), as did practitioners in private practice (5.42 ± 0.88 vs. 5.73 ± 0.54; P = 0.03).

  1. 5.

    Sexual Orientation

We asked if establishing patient sexual orientation was an important component of a detailed sexual history. The mean score was 4.67 ± 1.37. Experts scored higher (5.62 ± 1.37 vs. 4.62 ± 1.37; P = 0.04).

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Foster, T., Hon, H., Kanwal, F. et al. Screening High Risk Individuals for Hepatitis B: Physician Knowledge, Attitudes, and Beliefs. Dig Dis Sci 56, 3471–3487 (2011). https://doi.org/10.1007/s10620-011-1928-z

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  • DOI: https://doi.org/10.1007/s10620-011-1928-z

Keywords

  • Hepatitis B
  • Vaccines
  • Screening
  • Guideline adherence