Vaccines are essential for the health of adult women to protect individuals and and the community at large. The Centers for Disease Control and Prevention (CDC) recommends all women over age 18 receive vaccinations for influenza, tetanus, diphtheria, and acellular pertussis (Tdap), measles, mumps, and rubella (until age 60), varicella, herpes zoster (over the age of 60), and human papilloma virus (through age 26) [1]. Women over the age of 65 are also recommended to receive pneumococcal conjugate and polysaccharide vaccines [1].

Nationally, women have lower than ideal rates of uptake for these recommended vaccinations, such as influenza, pertussis (Tdap), and human papillomavirus vaccine (HPV) [2-4]. Nonpregnant women frequently are not receiving recommended vaccinations, despite high utilization of healthcare services [5]. Studies suggest that many women identify their gynecologists as their primary care provider (PCP) [6]. Additionally, the American College of Obstetrics and Gynecology (ACOG) has set forth guidance for gynecologists to serve as public advocates and providers of routine vaccinations both during and outside of pregnancy [7].

Despite this, research demonstrates that, as a specialty, gynecologists face significant financial and workflow barriers to providing routinely recommended vaccines [8]. Accordingly, it is important to first understand if women would be likely to accept routine vaccines from their gynecologist, as opposed to other medical providers.

The objective of this survey was to understand women’s perceptions and trust of gynecologists as providers of immunizations, and the availability and actual use of gynecologists as vaccinators among a population of gynecology patients. Therefore, the authors’ objectives were to determine 1) women’s use of their gynecologist as their primary provider of routinely recommended vaccinations, 2) their desire and comfort to receive immunizations from them, and 3) their perceptions of their gynecologist’s care in delivery of vaccines.

The population studied was a convenience sample of 518 women who sought gynecology care at one of nine private practice obstetrics and gynecology offices in Colorado (three rural, six urban). Women were eligible to participate if they completed a paper-based survey (on a different topic) previously, and indicated that they were willing to be contacted for a follow-up survey. They also were required to have provided a working email address, be proficient in written English, and not be pregnant at the time of the initial paper survey (i.e. presented for gynecology care). A web-based survey was administered via their contact email address beginning in February 2014 [9].

Eligible women were invited by email to participate in the survey and received up to eight reminder emails and one reminder phone call over a period of seven weeks if they did not complete the survey within one week of the initial e-mailing; the survey outreach was completed from February to April 2014. Women completing the survey received a five-dollar incentive. The Colorado Multiple Institutional Review Board approved all study activities, COMIRB #11-1149.

Respondents were provided with a standard definition of a gynecologist, which included a “gynecologist, nurse midwife, nurse practitioner, or physician assistant”. Participants were queried about the type of PCP they used, their opinions of the safety and efficacy of vaccines in general, and whether they had received the influnza vaccine during that season (2013), or the Tdap vaccine since 2005 [10].

The perceived availability of and patients’ comfort with receiving routine and reproductive health-related vaccines in a gynecologist’s office, opinions about gynecologists’ vaccination practices, and trust in different vaccine information sources (i.e. patients’ “regular doctor”, their “child’s doctor” (if applicable), their “family”, “friends” “websites” etc) were also assessed.

Trust was queried using a four-point Likert scale that included trusting “a lot” or “somewhat” versus trust “somewhat”, “do not trust’, or “do not use” based on the distribution of responses. Outcomes included opinions about gynecologists as immunizers and safety of vaccines in general, self-reported Influnza, and Tdap vaccination status, comfort with, and opinions about, gynecologists as vaccinators, which were assessed with four-point Likert scales. The secondary outcome was patients’ perceptions of their gynecologist as their PCP. The survey also collected demographic information including age, insurance status, education level, race, and income level. The authors also generated descriptive statistics for all survey questions.

The survey response rate was 61.7% (518/840). Overall, the average age of participants was 42, 86.4% had private insurance, 77.3% had a college level education or advanced degree, 87.8% self-described as white, and 53.1% reported a yearly household income greater than $75,000. Table 1 outlines demographic characteristics of respondents. To determine use of their gynecologist for vaccination, questions were asked regarding their recent vaccination status and where they received those vaccines; 55.7% of women received the influnza vaccine that season. Among these, 32.0% received it from a non-gynecologist medical provider’s office, 31.4% at their workplace, and 24.6% from a retail pharmacy or grocery store. Of all respondents, 43.7% reported receiving Tdap since 2005 (41.1% had not and 15.2% did not know).

Almost half (45.9%) of the women received Tdap at a non-gynecologist medical provider’s office, 19.8% received it at their gynecologist’s office, 5.3% at a retail pharmacy or grocery store, 11.1% at their workplace, and 7.3% elsewhere. Of note, when asked about their opinion about the safety of vaccines, 37.0% of women were strongly or somewhat worried about the safety of vaccines in general.

Regarding objective one, women’s use of their gynecologist as their primary provider of routinely recommended vaccinations, the results are shown in Table 2. The table reports how participants responded when asked more specific questions about their agreement or disagreement with gynecologists providing vaccines in the office. Women responded that their gynecologist’s office was not the only place they could receive vaccines; however, the majority of patients expected their gynecologist to inquire about their vaccination status (75.1%), carry routinely recommended adult vaccines (56.5%), and be able to answer their questions about immunizations (93.9%).

To answer objective two, when respondents were asked how comfortable they would be receiving influenza and Tdap at their gynecologist’s office, 66.5% reported they would be ‘very comfortable’ with Tdap and 69.7% would be ‘very comfortable’ with their gynecologist giving them the flu vaccine. Additonally, when asked about getting pneumococcal or shingles vaccines in their gynecologist’s office, 61.8% reported they would be ‘very comfortable’.

Women were asked about their perceptions of their gynecologist’s care in delivery of vaccines, which assessed our final objective. When they were asked about their comfort level with an obstetricians/gynecologists providing immunizations, 87.4% reported that if their gynecologist recommended a vaccine to them, they would get it.

Table 3 shows levels of trust respondents reported for their gynecologist, as well as other sources of vaccine information, including both medical and non-medical sources. The majority of women trusted their gynecologists (97.3%), their family practice or internal medicine physician (88.0%), and their child’s doctor if applicable (58.4%), while non-medical sources varied in how much patient’s trusted them as a source of information about the benefits and risks of vaccinations.

Participants were also asked about their most recent visit to their gynecologist and whether or not they were asked about their immunization status. Respondents reported 44.2% of them had been asked if they received the influnza vaccine, 23.1% were asked about the Tdap vaccine, and 19.9% were asked about vaccines other than Tdap/influnza. Evaluation of the secondary outcome found a majority of women reported having a place they usually go when they are sick or need advice about their health (83.6%), having a doctor or place that knows them best as a person (72.4%), and having a doctor or place that is most responsible for their healthcare (77.6%). This place or doctor was an obstetrics and gynecology office for 9.0%, 41.5%, and 31.7% of respondents, respectively.

Women largely trust and feel comfortable with their gynecologist stocking and administering all vaccines, not just reproductive health-related immunizations, in the office. This finding is consistent with prior studies that have shown that a substantial portion of women consider their obstetrician/gynecologist their PCP and do not visit another provider regularly (around 31%) [6].

The proportion of women that consider their obstetrician/gynecologist their pPCP is slightly higher in the present study (40%), suggesting that perhaps more women are moving towards seeing their gynecologist as their PCP [6]. Together, these results indicate that while gynecologists are considered specialists within the medical community, many women look to them specifically to provide preventive services, including vaccinations, and are unlikely to receive these services from other providers if their gynecologist does not provide them. Indeed, almost half of the present respondents agreed that if their gynecologist does not offer them a vaccine, including recommending it and having it available to receive in the office, it is unlikely that they would receive it elsewhere.

The present authors also found that a majority of women believed that gynecologists should be able to counsel patients on routine vaccinations, and that gynecologists are influential in their decision-making regarding the choice to receive a vaccine. This suggests that gynecologists have a responsibility to their patients to be able to counsel them about preventive care, at least including, but potentially not limited to, routine vaccinations. The authors also found that 56% of respondents believe that gynecologists should stock and administer routinely recommended adult vaccinations. Of note, prior research has shown that 91% of gynecologists stock the human papillomavirus vaccine and 66.8% stock the influenza vaccine, but less than 30% stock any other routinely recommend vaccine [8].

This raises the concern that women may not be able to get the vaccination services they may want from their gynecologist’s office. About 50% of the present study population reported adherence with Tdap and flu vaccine recommendations. During a typical flu season, nationally, around 40% of patients receive the influenza vaccine, far below the Healthy People 2020 goal suggests an optimal immunization rate of 70% [11, 12]. Therefore, this analysis suggests that this particular patient population could benefit from interventions to increase uptake of seasonal vaccination and adherence to Tdap guidelines [13].

Gynecologists’ offices may be an ideal place to increase the stocking and administration of routinely recommended adult vaccinations. The primary limitation of this study is the homogeneity of the surveyed population, which was majority white, educated, and high income, with access to private insurance. These characteristics limit the generalizability of the findings to the general population. The response rate was relatively high at 62%, although this is consistent with similar studies [14-16].

The present sample was also drawn from women seeking care within obstetrics/gynecology offices, and therefore may over-represent women who report their gynecologist as their PCP, although it is in line with other studies.

Performing this study within ob-gyn offices is also a strength of the study, as our findings may be considered more representative of those seeking care in ob-gyn offices, and thus more directly relevant to ob-gyn providers than a study among a general population of US women. Another strength of the study were the large sample size.

Not only does ACOG believe that gynecologists have an important public health role in the immunization of women, but so, it seems, do patients.

Most women trust their gynecologist to serve as their source of vaccines and vaccine education. Gynecologists should consider the cost- and risk-benefit of providing routinely recommended adult vaccines in their practices to both meet patient demand and fulfill their PCP role as part of the broad spectrum of gynecologic care. A substantial proportion of women utilize their gynecologist as their main PCP for sickness and routine care, and feel their gynecologist knows them best as a person.

The authors are very grateful to all participants for sharing their experiences and opinions, and support the work of all vaccine programs globally that promote a healthier global population.

This investigation was funded by the Centers for Disease Control and Prevention (Award # 1 U01 IP000501-01), awarded in response to RFA-IP-11-009, Effectiveness in an Intervention to Promote a Targeted Vaccination Program in the Obstetrician-Gynecologist Setting.