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Characteristic Number
Age, ya
18–26 1
27–39 8
40–59 7
≥60 1
Time employed at current clinic, y
1–3 6
4–6 4
≥6 8
Male 0
Female 18
Rurality of clinic
Rural 14
Urban 4
Clinic specialtyb
Pediatrics 6
General practice or family medicine 12
Gynecology 1

Table 1. Characteristics of Clinic Managers and Administrators (N = 18) and Clinics Participating in Semistructured Interviews on Adolescent HPV Vaccination During the COVID-19 Pandemic, Iowa, August–November 2020

a One participant did not report age.
b Participants could select ≥1 clinic specialty.


Theme/subtheme Representative quotes
Theme: Decreased opportunities for HPV vaccination and routine care
Structural barriers [Interviewer: Are there any complications with any of this work that have come up during COVID that’s affected your ability to do any of it?]
Participant: Probably the only thing would be that back a few months ago, we all had to cut hours because of location status. But now we’re all back pretty much up to our full-time status. Just got behind during the months of pretty much April, May, and June. (I-8)
I mean, there’s a lot of infection control, a lot more infection control focus with our masking mandate and [having patients who are virtual]. Virtual visits are available now. The virtual waiting room to have patients, you know, waiting in their car and communicating via secure text. So, a lot of technological advances were made and pushed through because of this. So, a lot of workflow got changed. (I-9)
So, we have talked as a whole if all of that needs to be looked at just because we had for the safety of patients pushed out appointments if necessary, or we try to do them virtually if possible, region-wide for everybody, not just pediatrics. And I think what came back for most of us as administration is, yeah, we recognize that yes some of our metrics could have been missed due to those time periods. (I-1)
Patient/parental fear of coming into clinic But like I said, the numbers are down. Parents are just very leery of bringing them in to the doctor’s office. They’ve increased a little bit, the last month or so. (I-4)
I mean, our patients were less likely to come in, we had a lot of very fearful families. And even still, they still don’t want to bring their children into an area where they’re going to encounter other people. (I-3)
So just parents that are more worried about coming into the office, just trying to reassure them that we’re keeping kids away from them. (I-18)
Theme: Disruption to ongoing EBI implementation work
Logistical challenges [Interviewer: And are you still seeing that QI person even over the last six months with COVID?]
Participant: No, they were furloughed, but they are back for the last two months I think, and back with a vengeance. They’re working hard to get us back where we need to be. (I-6)
[Interviewer: And in terms of your HPV vaccination work, have any new complications arisen during COVID-19? Were you able to go out to the schools to do a similar sports physical push this year, things like that?]
We were not because schools suspended in March and the orientation usually occurred end of March, early part of April . . . so school wasn’t in session at that time. So we missed that opportunity. (I-6)
Shift in priorities I think 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? (I-2)
A lot has changed prior to COVID and now just trying to ensure that we adhere to all the new guidelines and make sure that we have staff, that we protect our staff as well with PPE and all of those things that are constantly changing, as we’re entering into the search plan. I would say that’s probably [leadership’s] main focus right now. (I-15)

Table 2. Themes, Subthemes, and Representative Quotes Resulting From Semistructured Interviews on Adolescent HPV Vaccination During the COVID-19 Pandemic, Iowa, August–November 2020

Abbreviations: EBI, evidence-based intervention; HPV, human papillomavirus; I, interview; PPE, personal protective equipment; QI, quality improvement.


Challenges to Adolescent HPV Vaccination and Implementation of Evidence-Based Interventions to Promote Vaccine Uptake During the COVID-19 Pandemic: “HPV Is Probably Not at the Top of Our List”

  • Authors: Grace Ryan, PhD, MPH; Paul A. Gilbert, PhD; Sato Ashida, PhD; Mary E. Charlton, PhD; Aaron Scherer, PhD; Natoshia M. Askelsona, PhD, MPH
  • CME / ABIM MOC Released: 3/31/2022
  • Valid for credit through: 3/31/2023
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Target Audience and Goal Statement

This activity is intended for primary care physicians, pediatricians, and other physicians who treat and manage children and adolescents who need vaccinations.

The goal of this activity is to assess challenges to human papillomavirus vaccination among children and adolescents during the COVID-19 pandemic.

Upon completion of this activity, participants will:

  • Analyze the application of human papillomavirus vaccine in the US before and during the COVID-19 pandemic
  • Distinguish major challenges to human papillomavirus vaccination during the pandemic
  • Analyze patient-related variables associated with rates of human papillomavirus vaccination during the COVID-19 pandemic
  • Identify practice changes likely to continue after the COVID-19 pandemic


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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


  • Grace Ryan, PhD, MPH

    College of Public Health, University of Iowa, Iowa City, Iowa

  • Paul A. Gilbert, PhD

    College of Public Health, University of Iowa, Iowa City, Iowa

  • Sato Ashida, PhD

    College of Public Health, University of Iowa

  • Mary E. Charlton, PhD

    College of Public Health, University of Iowa, Iowa City, Iowa

  • Aaron Scherer, PhD

    Carver College of Medicine, University of Iowa, Iowa City, Iowa

  • Natoshia M. Askelsona, PhD, MPH

    College of Public Health, University of Iowa, Iowa City, Iowa

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline; Johnson & Johnson


  • Ellen Taratus

    Senior Editor
    Preventing Chronic Disease


    Disclosure: Ellen Taratus has disclosed no relevant financial relationships.

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  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

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Challenges to Adolescent HPV Vaccination and Implementation of Evidence-Based Interventions to Promote Vaccine Uptake During the COVID-19 Pandemic: “HPV Is Probably Not at the Top of Our List”

Authors: Grace Ryan, PhD, MPH; Paul A. Gilbert, PhD; Sato Ashida, PhD; Mary E. Charlton, PhD; Aaron Scherer, PhD; Natoshia M. Askelsona, PhD, MPHFaculty and Disclosures

CME / ABIM MOC Released: 3/31/2022

Valid for credit through: 3/31/2023


Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to COVID-19 vaccines may be provided in this activity to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.



The COVID-19 pandemic has prevented many adolescents from receiving their vaccines, including the human papillomavirus (HPV) vaccine, on time. However, little is known about the impact of the pandemic on implementation of clinic-level evidence-based interventions (EBIs) that help to improve HPV vaccine uptake. In this qualitative study, we explored the pandemic’s impact on EBI implementation and HPV vaccine delivery.


During August–November 2020, we interviewed clinic managers in a rural, midwestern state about their experiences implementing EBIs for HPV vaccination during the COVID-19 pandemic. We used a multipronged sampling approach with both stratified and purposive sampling to recruit participants from Vaccines for Children clinics. We then conducted a thematic analysis of transcripts.


In interviews (N = 18), 2 primary themes emerged: decreased opportunities for HPV vaccination and disruption to HPV-related implementation work. Most participants reported decreases in opportunities to vaccinate caused by structural changes in how they delivered care (eg, switched to telehealth visits) and patient fear of exposure to COVID-19. Disruptions to EBI implementation were primarily due to logistical challenges (eg, decreases in staffing) and shifting priorities.


During the pandemic, clinics struggled to provide routine care, and as a result, many adolescents missed HPV vaccinations. To ensure these adolescents do not fall behind on this vaccine series, providers and researchers will need to recommit to EBI implementation and use existing strategies to promote vaccination. In the long term, improvements are needed to make EBI implementation more resilient to ensure that progress does not come to a halt in future pandemic events.