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Grace Ryan, PhD, MPH, is a postdoctoral fellow in the Department of Population and Quantitative Health Sciences at the University of Massachusetts Chan Medical School. She completed her doctorate at the University of Iowa College of Public Health where she first worked on rural HPV vaccination research. Now a fellow at UMass, she is building a research program to address rural-urban adolescent health inequities in New England. Most recently, her work has centered on translating lessons learned from HPV vaccination to respond to COVID-19 vaccine hesitancy.

The full impact of the COVID-19 pandemic is yet to be known; however, it has become clear over the last three years that the pandemic has significantly affected health care delivery. One area where that was evident, particularly early in the pandemic, was HPV vaccination. In spring 2020, clinics ordered fewer HPV vaccine doses compared to 2019 and the number of vaccines administered was significantly lower in this time period compared to previous years. This is especially concerning in rural areas given the pre-existing urban-rural inequities not only in HPV vaccination rates, but in rates of HPV-associated cancers as well. In a nationwide survey of rural health clinics conducted between April and September 2021, researchers found that the percentage of clinics offering the HPV vaccine fell from 71% to 52%. Similar declines were observed in the percentage of clinics offering pap smears and HPV DNA testing.

Beyond the quantifiable impact of the COVID-19 pandemic on HPV vaccine delivery and HPV cancer prevention services, there has been a hidden impact as well. In many clinics there is substantial behind-the-scenes work going on to promote HPV vaccination and ensure adolescents complete the series by age 13. For example, clinics may integrate evidence-based approaches such as reminder/recall systems using electronic health records or education sessions about best practices in communicating with vaccine-hesitant parents. However, these efforts require coordination and collaboration between not only clinicians and clinic staff, but also higher-level system leadership and external partners. In Iowa, a state where over 35% of the population lives in a rural area, we conducted a study to explore less-understood barriers to HPV vaccine promotion during the COVID-19 pandemic. Between August and November 2020, our team at the University of Iowa interviewed clinic managers, three-quarters of whom worked in a rural area, about their experiences early in the COVID-19 pandemic.

Clinic managers reflected on the difficulties of providing routine care during the pandemic and reported how competing priorities had shifted attention away from HPV vaccine promotion efforts. Nearly everyone we interviewed spoke about how their existing efforts to address low HPV vaccination rates had been halted to respond to the more pressing needs of the pandemic.

"Prior to COVID happening, we were putting plans in place on how to increase immunizations, whether that’s signage in the rooms and just communicating with patients and parents about why this is beneficial for your child or for yourself. And then obviously COVID, and that kind of just threw everything quality improvement out the window, while you’re trying to focus on ‘how the heck are we going to do this?’"

Several clinic managers explained that the need to respond to COVID-19 meant that not only were resources redirected, but existing efforts were halted. For example, one manager noted that they had been part of a quality improvement workgroup that discussed efforts to improve HPV vaccination on a monthly basis, but that group had been redirected to address COVID-19 exclusively. Another said that prior to the pandemic they had patient education materials about HPV vaccination in clinic waiting rooms, but that due to COVID-19, all of that was removed. Put simply, as one clinic manager summarized, "HPV is probably not at the top of our list."

We know that even without the added stress of COVID-19, rural clinics faced challenges in implementing evidence-based interventions to address HPV vaccination.

Rural clinics may have few financial resources and little staff time or capacity to devote to implementation efforts. Additionally, the evidence for these types of interventions is often generated in urban and well-resourced clinical settings, and additional work is needed to adapt and tailor interventions to be appropriate and feasible in rural clinics. These challenges were compounded by COVID-19, leaving rural clinics with fewer resources to implement efforts to improve HPV vaccination rates. As the pandemic continues to have a significant impact on health care delivery and this behind-the-scenes implementation work, there is a need to not only refocus on rural HPV vaccine promotion but also to address larger issues of adapting and tailoring existing interventions to be successful in rural clinics.

Supporting HPV Vaccination with Rural Communities
Wide Open Spaces is a recently launched article series that addresses ways to improve HPV vaccination with rural communities. We invite guest contributors to share information on how they are working to improve HPV vaccination in rural areas. If you are interested in contributing, please email us at PreventHPV@stjude.org.