Time pressures on physicians also distract attention from prevention. Zyzanski and colleagues24 found that physicians seeing high volumes of patients, in comparison to those with low volumes, had visits that were 30% shorter, scheduled fewer patients for well-care visits, delivered fewer preventive screenings, and gave fewer immunizations.
Finally, the responsibility for adult immunization has not been definitively assigned, resulting in fewer programmatic efforts. Many groups have an interest in adult immunization; however, coordination is limited, causing immunization messages to become diffuse. As a result, many providers caring for adults do not see vaccination as their responsibility.
The cumulative effect of these factors is that, despite access to medical care, many of the adults at high risk for vaccine-preventable diseases remain unvaccinated.25
Research Questions
- Several research questions emerge from this scenario:
- What are the influenza and pneumococcal vaccination rates among persons 65 years and older of both majority and minority populations?
- What are the internal structure and office culture of various medical practices, and how do they facilitate or inhibit adult immunizations?
- What are providers’ attitudes, knowledge, and practices regarding adult immunizations?
- What are patients’ attitudes, knowledge, and beliefs regarding influenza and pneumococcal immunizations?
- What are the relationships among patient and provider knowledge, attitudes, beliefs, and practices and their impact on adult influenza and pneumococcal immunization rates?
- To answer these questions, a large multicomponent study with a variety of physician practice types and patient populations is required. Also, both quantitative and qualitative data need to be collected. In this article, we will describe the development of the methods used to answer these research questions.
Methods
Theoretical Framework and Models
To design our questionnaires, we used data from the literature, observations of the investigators, and 2 theoretical models: the Awareness to Adherence physician decision-making model and the Triandis consumer decision-making model.
The Awareness to Adherence model was developed to understand how physicians comply with new national practice guidelines for hepatitis B.26 It was chosen because it is perhaps the only theoretical model that has both been designed and tested to explain the vaccination behavior of clinicians. This model includes 4 sequential cognitive and behavioral steps: awareness, agreement, adoption, and adherence. It is similar to the Stages of Change model of precontemplation, contemplation, preparation, action, and maintenance.27 Shortly after national recommendations for hepatitis B vaccination of all infants, 98% of physicians were aware of them; 70% agreed with them; 55% adopted them; and 30% adhered to them.26 Interventions to improve compliance with any given recommendation can fail if the specific problem of either awareness, agreement, adoption, or adherence is not identified and addressed. For example, efforts at further dissemination are the most common type of intervention to increase compliance, but in the case of hepatitis B vaccinations for children, 98% of physicians were aware of the guidelines. Therefore, further attempts to increase physicians’ awareness would be unlikely to increase vaccination rates.
The Triandis model has been used to understand consumer decision making and is based on the theory of reasoned action. We chose it for several reasons. First, The Triandis model as used for influenza immunization is internally consistent (Chronbach a = .91) and has been externally validated.28 Second, it is broader than earlier models in that it accounts not only for beliefs, but also for values, social networks, habits, and physician influence on patients. Third, the Triandis model is able to predict behavior in a variety of cultural and economic situations.28-31
Although these 2 models capture behavioral and educational issues related to health practices, they miss systemwide interventions such as standing orders that have had a major impact in raising immunization rates. Thus, we sought a larger framework that was comprehensive, would allow us to incorporate behaviorally oriented models as well as system interventions, and would facilitate the development of interventions. We chose the PRECEDE-PROCEED framework, a systematic process to evaluate health problems and design intervention programs.32 PRECEDE, an acronym for the Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation, is an educational diagnosis model developed in the 1970s. PROCEED, an acronym for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development, was added to the model in 1991.32 PRECEDE-PROCEED offers specific guidelines for analysis of target populations so that the appropriateness of specific interventions can be determined.32 Although not a theory itself, PRECEDE-PROCEED provides a framework for applying theories. A key element of this framework is participation by the population in defining its problems and goals (Phase 1). In Phase 2, an epidemiologic diagnosis sets priorities for the community’s health problems so that resources can be applied to interventions that will have the most impact. Phase 3 is the behavioral and environmental diagnosis that helps planners determine risk factors for a particular problem and which of those risk factors are amenable to change. Phase 4, the educational and organizational diagnosis, enables planners to determine the predisposing, reinforcing, and enabling factors that influence the likelihood that behavioral and environmental change will occur. Those factors within an organization that have the capacity to facilitate or hinder the implementation of a program are determined in Phase 5 Figure 1. Phase 6 is the implementation phase, and Phases 7 to 9 comprise the evaluations of the process, impact, and outcome of the intervention program.