Evaluating Rural/Urban HPV Vaccine Completion Rates in Iowa After the COVID-19 Pandemic

Background: The HPV vaccine provides parents with an opportunity to significantly decrease their children's future cancer risk. Unfortunately, children face considerable barriers, including stigma and hesitancy, to completing the HPV vaccine schedule. These barriers have contributed to lower HPV vaccination completion rates in rural communities. Although general vaccine hesitancy grew during the pandemic, whether rising vaccine hesitancy further widened rural HPV vaccination gaps remains unknown. Focusing on Iowa, a state with the fastest rising incidence of HPV-associated cancer, we evaluated if county-level COVID-19 vaccination rates corresponded to county-level changes in rural-urban HPV vaccination completion trends. Methods: With data from the Iowa Department of Health and Human Services (2017-2024), we analyzed annual, county-level sex-stratified HPV vaccination completion rates. Rates were reported as a proportion of the 13-15-year-old population. In addition to evaluating overall trends, we grouped counties by rural/urban status and above/below median COVID-19 vaccination rates. We then constructed population-weighted, two-way fixed effect panel regression models testing if HPV vaccination completion rates changed after year 2020; and whether these changes varied by rurality and COVID-19 vaccination rates. Results: Overall, HPV vaccination completion rates increased 5.5%-points (CI = 4.5, 6.5) after 2020 in females and 7.1%-points (CI = 6.0, 8.1) in males. In females, there was no increase after 2020 in HPV vaccine completion in counties with below median COVID-19 vaccine rates (Urban = -0.2%-points, CI = -3.3, 3.3; Rural = 2.9, CI = -0.8, 6.7). In males, the increase after 2020 in HPV vaccine completion rates were consistent across all counties, but lowest in rural counties regardless of COVID-19 vaccine uptake (Above Median = 0.025, CI = 0.010, 0.042; Below Median = 0.027; CI = 0.011, 0.043). Conclusions: In Iowa, the dynamic post-pandemic HPV vaccination completion trends warrant interventions that address multiple factors driving unique contributors to incomplete HPV vaccination adherence.