The Veterans Health Administration (VHA) is one of the largest providers of telehealth in the United States and continues to lead the way in transforming healthcare services. VHA has been implementing its Whole Health (WH) initiative since 2018, a proactive practice empowering patients to take charge of their health and well-being. A key facilitator of the WH initiative is the WH coach who partners with Veterans to achieve their health-related goals. A gap exists in the literature regarding the understanding of WH coaches’ use of telehealth to engage rural-residing Veterans. COVID-19 unexpectedly interrupted in-person VHA delivery of care, including WH coaching which primarily relied on in-person delivery and focused less on telehealth. During the pandemic, WH coaches had to adapt and integrate different modalities to engage their Veteran patients. We examined WH coaches’ approaches to extending coaching to rural Veterans via technology, emphasizing the advantages of telehealth, existing gaps in telehealth delivery, and opportunities for telehealth as a coaching modality.n = 11; 3–4 participants per group), in-depth individual interviews (n = 9), and open-ended responses from a national web-based survey (n = 140). Focus group, in-depth interview, and open-ended survey data were collected sequentially and separately analyzed following each wave of data collection. Findings from the three analyses were then collaboratively merged, compared, reorganized, and refined by the evaluation team to create final themes.This project was implemented as part of a larger mixed methods evaluation regarding WH coaching for rural Veterans; this manuscript presents the findings from the qualitative data from the larger study. The qualitative dataset is comprised of data collected using three different qualitative methods: four focus groups  Advantages of Telehealth; (2) Telehealth Gaps for Rural Veterans, and (3) Strategies for Bridging Telehealth Gaps. Themes explicate telehealth advantages, gaps, and opportunities for rural Veteran WH coaching.Findings highlight that video telehealth alone is not sufficient for meeting the needs of rural Veterans. Digital technologies hold promise for equalizing health access gaps; however, both human factors and broadband infrastructure constraints continue to require WH coaches to use a mix of modalities in working with rural Veterans. To overcome challenges and bridge gaps, WH coaches should be ready to adopt a blended approach that integrates virtual, in-person, and lower-tech options. The Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) is one of the largest providers of telehealth in the United States . Their pThis virtual shift is especially important for rural Veterans as this population does not always have the same access to health care as their urban counterparts, despite more rural Veterans being enrolled in VHA healthcare , 9. Use Since 2018, the VHA has been transforming its approach to care through the Whole Health (WH) initiative ; a systeStudies have demonstrated the integral role health coaching plays in patients achieving behavioral changes , and datvia technology, with an emphasis on explicating advantages of telehealth, existing gaps in telehealth delivery, and opportunities for telehealth as a coaching modality.While there is a growing body of literature focusing on health coaching and its virtual delivery , 32, a gThis project was implemented as part of a larger mixed methods evaluation regarding WH coaching for rural Veterans and was conceptualized by a multidisciplinary team. It was designed as a quality improvement project. As such, its ethical review and informed consent were waived according to VA’s relevant guideline (ORD Program Guide 1200.21).We used multiple qualitative data collection techniques implemented over three waves of data collection, including focus group (FG) discussions, in-depth interviews, and open-ended survey responses from a national web-based survey, to understand WH coaches’ experiences with extending coaching to rural Veterans remotely. Each successive stage built on the previous, with the FGs providing a collective overview of how coaches perceived their ability to connect to rural Veterans at-a-distance, followed by in-depth interviews which permitted more in-depth exploration of how coaches were reaching rural Veterans, and finally the web-based survey, which allowed us to capture broader trends on barriers and facilitators to reaching rural Veterans with WH coaching.During a June 2020 WH Community of Practice (COP) virtual call, 33 WH coaches were formally invited to participate in FGs regarding their outreach to rural Veterans. Two additional WH coaches were referred for FG participation by WH leadership, and a total of 11 coaches participated in three FGs (3–5 WH coaches in each group).FG guides were prepared in dialogue with WH leadership and explored differences that coaches perceived in serving rural vs. non-rural Veterans and barriers and facilitators to coaching rural Veterans . FGs wera priori codes developed based on the FG guide. New or emerging codes were then added as we explored the data inductively. After the first cycle of coding, we reviewed all codes to identify and compile groups of codes that reflected patterns or similar meanings; these groups of codes were categorized under themes that corresponded to the evaluation objectives. These initial themes exposed the need for a more in-depth exploration into how coaches were reaching rural Veterans with WH.Audio recordings were sent to the Centralized Transcription Service Program (CTSP) for transcription. Transcribed data were analyzed with assistance of qualitative data analysis software. We used a “hybrid” approach in our coding process, beginning with a list of In-depth interviews were conducted to allow for open-ended probing and exploration in a more private one-on-one environment to follow up on our preliminary understanding of how WH coaches were reaching rural Veterans and to confirm initial FG themes and domains. We used a convenience sample to recruit FG participants for the individual interviews through e-mail invitations sent to all FG participants. Among the 11 individuals invited, 9 agreed to participate.via Zoom calls, and participants provided verbal consent to participate and be audio recorded.We used the semi-structured interview guide that was developed from preliminary understandings from FGs . This guData from in-depth interviews were also transcribed using CTSP and analyzed with assistance of qualitative data analysis software. Analysis of in-depth interviews focused on gaining greater understanding of initial themes that emerged from FGs. The focus of the analysis was to explore and understand differences in WH coaching experiences between rural and urban Veterans, and specific strategies used to engage successfully with rural Veterans. Survey questions were then developed from these themes.via the WH coaching COP distribution list.A national survey was designed to describe WH coaching within the VHA health care system. The national survey was comprised of a total of 45 closed- and open-ended questions based on items generated from previous project phases (FGs and interviews). Open-ended survey questions asked about WH coaches’ duties and experiences reaching out to and coaching rural vs. non-rural Veterans . The survia the COP distribution list. The survey allowed for individuals that did not meet eligibility criteria to exit before completion. Survey data were securely housed in the VA REDCap system . Open-ended survey data were initially analyzed using thematic analysis by three independent coders. Codes were developed both deductively from survey questions and inductively from survey data. The focus of this initial analysis included examination of differences in WH coaching between rural and urban Veterans, identification of specific strategies used to engage rural Veterans in WH, and preliminary conceptualization of alignment with our understandings from FGs and interviews.a priori questions, were identified collaboratively by the evaluation team. Equal importance was given to themes common in all three datasets, and those that were outliers in each of the datasets were retained when they provided a nuanced understanding of the phenomenon. Codes and corresponding quotations were retrieved that reflected the identified themes from the FGs, in-depth interviews, and open-ended survey responses.Following completion of the three sequential analyses, a merged analysis was conducted by reorganizing and collapsing conceptually similar themes from all three qualitative data sources. For this merged analysis and reorganization, the multidisciplinary evaluation team compared and reviewed initial themes from the three data sources, with a focus on telehealth for WH coaching with rural Veterans. Multiple rounds of discussion, comparison, and reorganization occurred before finalizing themes and subthemes. The final themes, which answered our The approaches used in this evaluation were complementary to one another, which allowed for a comprehensive understanding of the phenomenon. Analytic rigor was further enhanced by our use of two triangulation strategies. Our first strategy was data source triangulation, which involves the use of different sources of data in the analysis, and the comparison and cross-checking of the consistency of information derived from the data sources, typically “by different means within qualitative methods” , 36. OurWe had a total of 11 focus group participants (from 3 focus groups), 9 interview participants, and 140 survey participants. Participants shared experiences and perceptions of their WH practice during and after the COVID-19 pandemic, with telehealth emerging as a critical practice when working with rural Veterans. The main themes that emerged as salient to WH coaches included: (1) Advantages of Telehealth, (2) Telehealth Gaps for Rural Veterans, and (3) Strategies for Bridging Telehealth Gaps. Below is an in-depth explanation of the three themes and accompanying subthemes .WH coaches reported several advantages of using telehealth as a modality to engage Veterans and work toward their health goals. Advantages included increased Veteran participation, overcoming geographic barriers, and convenience and flexibility.via telehealth. One participant explained:Coaches noted that WH participation was increased by using telehealth to engage rural Veterans. Instead of relying primarily on in-person delivery, coaches perceived that telehealth allowed for more opportunities for WH involvement, especially following COVID-19 as efforts transitioned to being delivered [Rural Veterans] have an option [to] do the virtual group, or you have the option to come in…so I think in that context the rural individuals will have a better opportunity to participate. (Interview ID #15)via VHA’s secure telehealth platform, Veterans Video Connect (VVC), as it permitted an expansion of capacity to more than double what was available in-person. For example, they mentioned increased participation, increased number of class offerings, and increased accessibility:Another participant described their success offering classes [We offer Tai Chi] maybe like four or five times a week through VVC… [VVC] can hold up to say 30 Veterans versus we could only fit 12 people in a room…/… Currently, with the mindfulness classes on VVC, I might see six or seven Veterans on a Monday, another five or six on a Tuesday, and then I have [a class] on Thursdays…I think those numbers have gone up just ‘cause there is a lot more accessibility to them. (Interview ID #13)One coach explained telehealth helped them reach more rural Veterans with WH courses, which are paramount for learning about WH and constructing personalized health plans, instead of requiring the Veteran to visit a VA facility:…since COVID-19 hit, [we] have been doing a lot of “Intro to Whole Health” and the other courses, all through VVC [the VHA secure video telehealth platform]. And there I’ve gotten more participation rather than people coming in for the two hours [to complete the course]. (FG #3)Additionally, for some coaches, coaching virtually seemed to increase accessibility for rural Veterans living an appreciable distance from a facility, allowing for greater participation. One participant described:Some of our Veterans live two and a half to four hours away, and to commit to just a two-hour gathering and/or a once-a-week-for-six-weeks commitment is a lot for them. So obviously, we were working on, and are still continuing to work on, providing that via VVC through either CBOCs [VHA rural community-based outpatient clinics] or allowing them to access from home. (FG #3)WH coaches reported that geographic barriers were a continuous challenge for many rural Veterans who find it difficult to reach VA facilities due to travel distance and who may not have internet:…many times, our Veterans feel like the door has just been closed in their face because [they say] ‘I can’t drive, I can’t get there, I don’t have internet’. (Interview ID #3)Participants expressed that telehealth helped some Veterans overcome geographic barriers, thereby increasing access for rural-residing Veterans. One coach explained that virtual WH has provided more options for attending programs or accessing services that rural Veterans might not have been able to because of distance from clinics, transportation challenges, or inability to attend in-person:…what I love about it is those rural Veterans now, who may not have come into the yoga or tai chi, now may have access to those…that they may not have had before. (Interview ID #15)Others mentioned that not needing to travel for WH coaching was another advantage of telehealth. For example, one participant noted that rural Veterans appreciated:[the] ability to meet virtually for coaching services instead of traveling to a facility for care. (Survey ID #18)Telehealth was thus seen as a more feasible option to reach some Veterans who might otherwise not be seen due to geographic barriers.Telehealth coaching also allowed for increased flexibility in scheduling that is not always available with in-person visits. This permitted appointments to be arranged at times convenient for the Veteran and interspersed with appointments at the VHA:…I don’t have to necessarily wait for your nutrition appointment at 3…I can call you at 8:30 in the morning and still have a coaching conversation or coaching session with you. (Interview ID #13)Additionally, telehealth allowed for Veterans to participate in WH in the comfort of their own homes, adding to its convenience. One coach reiterated that some WH sessions with patients were facilitated by the ease of remote connection:…Whether you live 10 minutes away or an hour and a half away, it’s a little bit easier just to sit at home for a 30-minute briefing. (FG #3)Moreover, some coaches reported that telehealth was highly appreciated by Veterans during the onset of COVID-19; so much so that some expressed a desire to continue meeting remotely due to the convenience of a video call, even when pandemic restrictions loosened:We do almost everything Video Connect [VVC] now, to the point where a lot of our rural Veterans [are] like—Great, now that we’ve done it, when you all get back in [after COVID], in the clinics, we’re just going to keep doing this video. (FG #2)In addition to advantages, participants described several gaps in using telehealth with rural Veterans. These gaps included rural internet access and connectivity issues, differing levels of digital literacy, and receptivity to telehealth coaching.Several participants mentioned that the lack of reliable internet and appropriate bandwidth, limited access to Wi-Fi in Veterans’ homes, and frequent connectivity issues made telehealth with rural Veterans more difficult. As one survey participant noted:Veterans Video Connect (VVC) for rural vets has been a challenge, with some not having internet access. (Survey ID #79)Participants expressed the need to ensure sufficient bandwidth and steady Wi-Fi for WH coaching classes to reduce annoyances and facilitate more enjoyable experiences. Many issues related to internet, connectivity, and bandwidth gaps resulted from broadband services not reaching remote locations, making telehealth a less viable option for some. Because of this, some coaches felt they could not adequately meet all of the needs of their rural Veterans:…\ we’re not really meeting the needs of [all] our Veterans because they don’t have internet access. At the main facility, we offer yoga, tai chi…and different complimentary therapies. However, because of access and the distance, they don’t go that far [to the facility]. Without having the internet, they’re not able to participate in those as well. (FG #1)One coach expressed how technological issues and lack of bandwidth became an impediment to getting some of their most rural Veterans to participate in video telehealth:…the very rural Veterans, they’re lucky if they have cell phone coverage out there. Video coverage—forget it. They’re not going to have it. (Interview ID #1)Participants explained that rural Veterans had differing levels of digital literacy which resulted in a gap in delivering WH coaching virtually. Some Veteran patients had difficulties logging into virtual appointments, using VVC, accessing emails with important information, and utilizing virtual resources available to them. One participant felt that limited digital literacy may have caused Veterans to be insecure about using telehealth technology:Some of them [Veterans] have been very hesitant in actually wanting to get on a video connect call. I think a lot of it was [because] they were technology challenged and they felt [a] little self-conscious about it…I think the biggest challenge was…being afraid to navigate the technology, or afraid to actually say that they don’t know how to navigate the technology. (Interview ID #15)A possible contributor to the levels of digital literacy and capabilities perceived by survey participants was the age of rural Veterans, who tend to be older and may find themselves on the other side of the digital divide in generational terms. Some expressed concern about how increased reliance on technology to deliver care created challenges for older Veterans:[There is] more reliance on web-based applications that conflicts with the abilities of [the] generally elderly rural Veteran population. (Survey ID #5)When discussing telehealth for coaching with older rural populations, participants noted that these Veterans experienced difficulties using the technology and figuring out how to navigate equipment necessary for telehealth sessions:…the majority of Veterans that I dealt with were either more frontier [rural]…or they were older and didn’t…know how to work their phone via VVC [Veteran Video Connect] or didn’t want to take the time to figure out how to work their phone for VVC…the bandwidth didn’t work right, or they couldn’t figure out their camera, or they couldn’t figure out their microphone, or they just flat out didn’t have a computer … and they just didn’t like that. (Interview ID #14)Coaches felt that rural Veterans had varying degrees of receptivity to using video telehealth as a coaching modality. In some cases, this was attributed to rural Veterans initially being less receptive to the idea of telehealth coaching. Several survey participants mentioned that some rural Veterans simply did not want to have virtual appointments or use telehealth, demonstrating less receptiveness to interact through technology:[Veterans expressed] unwillingness to use the technology. (Survey ID #32)Other coaches felt that telehealth coaching may not always be the most favorable modality for rural Veterans, comparing it to in-person coaching which might be more appealing to some:With the current pandemic, we offer more video options for Veterans. Outside of the pandemic, the video options were limited and not as desirable for the Vets. At the end of the day, nothing beats face-to-face interaction with Veterans, and rural Vets often are not interested [in telehealth]. (Survey ID #17)Other participants noted that receptivity depended on the Veteran. Although some are receptive, there are those who might never buy into remote delivery of care due to a need for the kind of connection that is perceived only to be garnered in person. One coach felt that there was a struggle for some Veterans to participate in remote coaching, whether by telephone or video call:Sometimes…we have technical difficulties…sometimes Veterans get a little bit like, ‘ugh, this doesn’t even work’…But I think that a lot of them are willing. Some are just never really gonna do it. I mean they’re like ‘no, not anything about the computer, I’m not touching it’. They wanna come in…they’re so used to seeing their providers…and they think they need that connection. (Interview ID #12)Participants emphasized strategies that could help address experienced telehealth gaps centering on technological challenges of telehealth delivery. Subthemes included increasing Veterans’ technological literacy, providing VHA-issued devices and virtual platforms, and increasing access to technical support for Veterans and coaches.Several participants explained that teaching rural Veterans about using technology could help overcome telehealth gaps they experience regarding digital literacy and facilitate telehealth coaching engagement. Some suggested offering classes to increase rural Veterans’ knowledge about accessing virtual appointments and coaching sessions and using the VVC app:Training for Vets on use of technology resources. I use a lot of phone visits to compensate for [Veteran] lack of comfort/access with VVC [Veteran Video Connect]. (Survey ID #66)In addition, a basic level of computer skills was important for WH coaching. Given that some rural Veterans may have lower levels of digital literacy and less experience using technological equipment, several survey participants recommended developing rural Veterans’ computer skills to increase their capabilities and confidence with using technology:We need some way of teaching our elder Veteran population how to utilize technology. A lot of them are rural and have never used a computer. (Survey ID #4)A couple participants also suggested going directly to the Veterans’ homes to help develop their technology skillset:For those Vets who are not computer savvy, you could find a fellow Vet in the area to go over and be a mentor for a day on technology…that would have a great impact. (Survey ID #34)Other participants mentioned equipping Veterans with tips and tricks as a strategy to help with troubleshooting connectivity issues:Slowing down my speaking and asking them about how do you hook up [to the internet]? Are you by a window? Do you have a place in your home that would face a window or the south…I was telling them to look in your neighborhood… wherever the disks [satellite dish] are that people have their DirecTV facing—maybe that’s the window you should sit in when you’re trying to connect with me. So, trying to give them some technical tips to see if that works. (Interview ID #11)Coaches emphasized the importance of bolstering Veterans’ technological problem-solving skills by both increasing their speech intelligibility and providing them with potential solutions for increasing connectivity.Providing VHA tablets with a preloaded VVC application on the home screen, and hotspots, cell service, and/or Wi-Fi capabilities was mentioned by many participants as aspects of VHA’s telehealth infrastructure that helped with coaching. These devices were especially necessary for Veterans who might have Wi-Fi but lack equipment to participate in telehealth coaching:Being able to offer tablets to Veterans who have Wi-Fi but no equipment to attend virtual classes. (Survey ID #50)One participant emphasized the value of getting tablets into the hands of rural Veterans because these devices alleviated the need to travel or coordinate transportation on the Veteran’s end while still allowing the Veteran to access coaching services:Then we look at the digital divide [consult] to get them a VA-issued iPad… [we try] to get an iPad into our patient’s hands to do video appointments…to avoid travel, to avoid those things that come up for transportation…(Interview ID #3)Although VHA devices were noted as important for overcoming telehealth gaps, participants expressed those devices should be more readily accessible to Veterans. Similarly, several participants suggested there needs to be a more streamlined process for accessing devices:[We need] a much simpler process to obtain access to tablets for those who do not have a smartphone or computer. (Survey ID #42)Additionally, a couple participants suggested it would be beneficial to provide Veterans with WH coaching resources by offering YouTube videos of classes or developing virtual platforms where WH content was accessible:Perhaps a single website with access to all VA Integrative & Complementary health resources . We can then share with our patient population (as well as our employees). (Survey ID #44)A salient aspect of providing devices and resources to rural Veterans reported by most participants was making sure the technology was reliable and could be consistently and easily used.Participants highlighted the importance of increasing access to technical support for both Veterans and WH coaches. They emphasized the need for knowledgeable, designated teams to help with installing equipment and provide guidance for technology-related issues or when complications arise:Digital divide consults (iPads) WITH an install, not just delivery of an iPad via mail. If there were teams that did house calls, much like UNIPER [telehealth and social engagement company] installs. (Survey ID #17)One participant explained how the presence of a strong telehealth team alleviated many of the struggles they had with engaging Veterans virtually, noting the importance of having support available to help with VHA device setup:We still have some challenges, but we also have a whole telehealth team that we don’t even have to help the Veterans set up. Once they are identified as [needing] telehealth services, we send in a consult to telehealth, and they’re the ones that send out an iPad and walk them through the setup. (FG #1)Another coach felt unprepared to teach patients how to use telehealth technology and how to walk them through potential solutions. They explained that trainings to improve coaches’ readiness to troubleshoot telehealth problems would be beneficial:I feel like I could be trained more in the process of [telehealth troubleshooting]… it’s one thing to know how to do it yourself and it’s another thing to know how to teach it…‘cause I’m like ‘the three dots, click the three [dots]’ and they’re like ‘what three dots?’ So, I feel like if there was a trainer type of thing for telehealth, I would definitely think that was beneficial to be able to learn how to teach someone…I don’t know how to do the troubleshooting thing. (Interview ID #8)Many participants indicated that video telehealth calls are ideal for WH coaching. However, due to infrastructural deficits, video telehealth is not always effective or the right fit for rural Veterans. In addition to video telehealth, participants spoke of delivering WH coaching through complementary, low-tech modalities based on the Veterans’ needs and specific situation. Participating coaches stressed the importance of leveraging non-internet-reliant options as a less cumbersome adjunct to video telehealth.via telephone:One of the frequently discussed complementary modalities was telephone coaching instead of face-to-face or video telehealth. Participants reported this lower tech option was preferred by some Veterans. Some coaches noticed Veterans were more willing to try WH coaching when they could do it I noticed more positive feedback and more positive interest in Whole Health when I switched to doing telephone appointments versus face-to-face. Which I know that sounds odd, but we got a lot more willingness or openness to everything including all the education pieces about the Whole Health… more so when it’s one-on-one with me on the phone, versus when we were in a group setting doing the Intro to Whole Health. (FG #3)via video:Another coach mentioned they rely mostly on phone calls for their WH sessions, whether it be because some Veterans do not prefer VVC or because they cannot connect I’ve been doing most of my coaching through phone. I would say probably about 80% of it’s through phone. And some people…they’ll [try to] do video and then they won’t connect, and we’ll just cut right over to the phones. (Interview ID #13)Other participants explained that telephone sessions could be used to overcome connectivity issues that make using telehealth difficult, for those who lack reliable internet, compelling some Veterans to seek a phone session in place of video telehealth coaching:I will tell you, post-COVID, … there’s a push for us to do video appointments. But a lot of my rural Veterans are like—‘Yeah, just call me. I just want to do this over the phone. I’m not interested in trying to figure all of that out.’ I’ve had a couple who have said that they just don’t have great internet service, so they would rather a phone call. (FG #2)Participants also shared that telephone calls can be an easier modality for rural Veterans to access and navigate as they require less technological skills and less understanding of VVC. This allowed for rural Veterans who experienced technology-related challenges to still partake in WH coaching:Often rural veterans that I work with have more tech challenges, so we meet via phone rather than VVC. (Survey ID #12)Not only were rural Veterans interested in utilizing telephone calls for WH coaching, but some participants also expressed a preference for coaching over the phone. They explained it was more convenient and allowed for easier access to Veterans:…we had a meeting and I said ‘once COVID stops, are we still allowed to continue to add the phone calls?’ ‘cause to me it’s a lot easier just to pick up the phone and have a coaching conversation right there versus them checking in, try and find them in a hallway…with everybody there or they forget… or then I’m waiting in the hall trying to find them… as much as I love face to face, right? (Interview ID#13)Other modalities to engage rural Veterans in WH coaching mentioned by survey respondents and a FG participant included DVDs and mailouts. These were suggested as resources that could help rural Veterans overcome barriers related to internet or connectivity issues:[Something] that would help would be…having resources for those that don’t have internet connection- Tai Chi and yoga DVDs to mail out. (Survey ID #30)One FG participant mentioned that some Veterans did not have DVD players, which was a barrier they believed could be addressed:We were offering tai chi here in my clinic as a pilot. I would have four to six Veterans in my conference room, being led by the instructor from [city]…after so many weeks, [the Veterans] would get a DVD for improving their home practice. But we have noticed that a lot of them don’t even have a DVD player. And those DVDs, I think would be very helpful…I’d be willing to see if I could help with working past the barriers of technology….and getting our Veterans a DVD player, just to be able to play. (FG #1)This was something they were willing to further pursue as a way to overcome technological barriers faced by rural Veterans, demonstrating their support for this lower tech modality.Mailouts were viewed as an especially useful modality to introduce Veterans to WH, get them interested in coaching, and begin building relationships:[Getting] them even willing to be coached…Or even participate in a coaching session…it tends to be more steps to get there…not only am I mailing out…more materials. There might be some other things that I send out just to create that relationship. (Interview ID #8)Other coaches mentioned mailing WH welcome kits and information packets, as well as follow-up letters, to gauge the Veteran’s interest in continuing with WH coaching.Lastly, participants reiterated that there is a need for both virtual and face-to-face programs at VHA going forward, with in-person persisting as a relevant coaching modality. Participants explained that in-person interactions with rural Veterans was an important aspect of the WH coaching process. It allowed them to provide information about what WH entails, have authentic conversations, and address Veterans’ questions or concerns. While telehealth helped to extend coaching options, some participants reported that for some Veterans, the motivation for engaging in WH offerings was the direct interactions it provided:There’s a few [Veterans], there’s people that need in person. They need to see you. They need that…I can’t wait to get back to in person [after COVID-19], and hearing the stories in person, like I said, ‘cause you see the body language, you see the facial expressions…when part of the story is hard for them. (Interview #8)Several participants also mentioned that engaging with rural Veterans in-person was a great way to initially reach them with WH coaching. It was also a strategy for facilitating familiarity, authenticity, and trust and opened the door to the possibility of future telehealth coaching sessions:In-person meetings—allows a human connection which paves the way for virtual meetings. (Survey ID #56)Further, while video telehealth has been rewarding in permitting more rural Veterans to be seen, still some Veterans continued to prefer in-person visits. One participant expressed that coaching could take place across different modalities and had a place within the coaching repertoire, but in-person coaching was still preferred by some Veterans:I have to say the switch to video has been just as rewarding…I feel that it’s even more rewarding because I’m seeing more patients from all over…while still having the face-to-face feel [via video]…/…[but] as a health coach,…you could definitely have in-clinic days, you could have out-of-office days working remotely, and there are some [Veterans] that you have to see face-to-face, that have pushed off coaching because they don’t wanna live in a virtual world…but there is a time and place for every modality in coaching. (Interview ID #3)via telehealth increased in an unprecedented way. Telehealth, in the era of the COVID-19 pandemic, became a critical WH practice for engaging rural Veterans in WH care. Findings from this evaluation reveal that video-enabled telehealth became more mainstream in coaches’ delivery of WH. Still, almost all coaches in this evaluation reported an array of challenges while utilizing telehealth to engage with rural Veterans. To overcome these challenges and bridge telehealth gaps, WH coaches have integrated multiple modalities into their coaching practice; for example, using in-person, video telehealth, and non-internet reliant options, such as telephone, DVDs, and mail outs. Moreover, rather than employing a “one-size-fits-all” approach, our findings suggest that coaches should apply a pragmatic and blended approach of various modalities based on the Veterans’ contexts, needs, and preferences, which exemplifies a patient-driven approach to care  and in partnership with Office of Patient Centered Care & Cultural Transformation (OPCC&CT). According to VA quality improvement guidelines, ethical review, approval, and written informed consent were not required.JH-G and GC: project design and funding acquisition. JH-G, GC, CMK, KL, DV, CK, DCR, and HJ: conceptualization. JH-G, GC, and CMK: acquisition of data. JH-G, CMK, GC, KL, and DV: methodology. JH-G, DV, KL, and CK: analysis and interpretation of data. JH-G, KL, and CK: validation and drafting of initial work. JH-G, GC, and CK: resources and project administration. JH-G, DV, CMK, KL, GC, DCR, and HJ: critical appraisal and review, edits, and revisions. JH-G, DCR, and HJ: supervision. All authors contributed to the work and provided final approval of the version submitted for publication and agreed to be accountable for all aspects of the work as presented.The work was supported by the Office of Rural Health, U.S. Department of Veterans Affairs (Project ID: PROJ-03536).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.The views expressed in this article are those of the authors, and no official endorsement by the U.S. Department of Veteran Affairs or the U.S. government is intended or should be inferred. The contents of this article do not represent the views of the Veterans Health Administration Office of Rural Health, the Department of Veterans Affairs, or the United States Government. Any opinions, findings, or conclusions expressed in this material are those solely of the authors.


In Japan, Japan’s Ministry of Health, Labor, and Welfare decided to suspend govermental recommendation for HPV vaccination in FY 2013. The HPV vaccination rate for those born in FY 2000 or thereafter declined dramatically. In 2021, the “suspension of recommendation” ended. The catch-up vaccinations for the unvaccinated have been offered nationwide from FY 2022 to FY 2024. We aimed to quantify the vaccination intentions and characteristics of those young women now eligible for catch-up vaccination. In February of 2022, we conducted an internet survey targeted women who were born in 1997–2004 but who had not yet been HPV vaccinated.p < 0.05, respectively). In the vaccinated generation, the proportion of the group that did not want to be vaccinated was significantly higher (p < 0.05). In the vaccine-suspended generation, the proportion of the group that wanted to be vaccinated was significantly higher (p < 0.05).We received 1,648 valid responses. 41.6% of the respondents wanted to uptake the catch-up HPV vaccination, 29.7% were undecided, and 28.7% did not want to be vaccinated. The intention to uptake catch-up HPV vaccination was associated with a good history of gynecological visits, intention to receive cervical cancer screening, sexual activity, degree of anxiety about cervical cancer, familiarity with problems associated with cervical cancer, experience with vaccination recommendations, and knowledge about cervical cancer (Our survey revealed that catch-up vaccination intentions differed depending on the vaccination environment. It is necessary for all organizations involved with HPV vaccination, such as government, medical institutions, and educational institutions, to make recommendations based on an understanding of the characteristics of the “vaccinated generation” and the “vaccine-suspended generation”. Of the more than 200 types of human papillomavirus (HPV) known to infect humans, 14 have a high risk of causing cervical cancer. Two strains, HPV16 and HPV18, are associated with 70% of all cervical cancers worldwide, and roughly 60% in Japan . HPV16 aOver recent decades in Japan, the incidence of cervical cancer among young females has been increasing, and the peak incidence has been shifting to ever younger age groups . With thHowever, in June of 2013, due to media reports of possible post-vaccination adverse symptoms, Japan’s Ministry of Health, Labor, and Welfare (MHLW) decided to temporarily suspend the national immunization program’s recommendation for routine HPV vaccination . As a reIn December of 2015, the World Health Organization (WHO) Global Advisory Committee for Vaccine Safety issued a statement on HPV vaccine safety , 10, warIn November of 2021, the MHLW’s “temporary suspension” of its active vaccination recommendation finally ended. The feared unwarranted ill effects of nearly 9 years of little to no HPV vaccinations nationwide have become the new reality.. reported the HPV infection rates among females aged 20–21 years old who were targeted for cervical cancer screening in the FY 2014–2020. They showed that infection rates increased for those born in 2000, the vaccine-suspended generation [The historical HPV vaccination rate, and thus the potential for infection, now varies greatly in Japan, depending on a girl or woman’s fiscal year (FY) of birth . Sekine neration . Furtherneration .Recognizing that there is a tremendous added risk for cervical cancer for this “poorly vaccinated gap generation”, i.e., in those women who failed to get vaccinated during the 8 years when the government withheld its recommendation for doing so, Japan is now offering to cover the costs of their “catch-up vaccination”. The MHLW announced that these catch-up vaccinations would be administered from April of 2022 to March of 2025 for those born between 1997 and 2005 . In addiA previous study reported the pattern of HPV vaccine hesitancy among the catch-up generations in Japan , but theWe conducted our cross-sectional study using internet survey in February of 2022. We targeted women born in 1997–2004  who had not yet been HPV vaccinated at the time of the survey.This internet survey was a cross-sectional study of monitor members selected from the panel of a market survey company, MACROMILL, INC., in Japan. Responders were selected based on the registered information of a group of ‘monitor members’ and their responses to a prescreening survey. Before our main HPV survey, 20,000 Japanese females, born in FY1997–2004 were invited by a web link which provided information about the study and pre-screened. The prescreening survey asked the respondents about their history of HPV vaccination. We collected data for area of residence, sex, age, household income, employment status, marital status, and the presence of children of the respondents. We conducted the prescreening survey from 15 to 16 February 2022. In this study, we used birth FY as allocation factors and selected respondents so that it would be equal to the residential area composition of the general population.After the prescreening survey was conducted, we conducted the main survey, which asked about the following: what are your intentions to get the HPV catch-up vaccination, what are your reasons for this intention, are you living with mother, and what is your history of cervical cancer screening, intention to receive cervical cancer screening, history of gynecological visits, sexual activity, anxiety about cervical cancer, has someone close to you ever had cervical cancer, has your mother or family recommended HPV vaccination, what is your awareness of cervical cancer screening, and what is your knowledge about cervical cancer? We asked about her COVID vaccination status, and if not yet vaccinated, her intention to get the COVID vaccine. We also asked the inoculation status of the COVID-19 vaccine that attracted as much attention as the HPV vaccine in comparison. The collection of answers was stopped on the day the number of respondents per each birth FY became 206, with 1648 answers finally. We conducted the main survey from 17 to 20 February 2022.Participants were able to open the survey only after receiving the study information and after actively consenting to study participation. In Japan, the rate for compulsory education is as high as 99% . The IntThe questionnaire for the Internet survey was based on the interviews we conducted prior to our internet survey. The interview survey examined the barriers to catch-up vaccination among eight females of age for catch-up vaccination. The intention to catch-up HPV vaccination was asked as follows: “Would you like to be inoculated with the HPV vaccine on catch-up vaccination opportunities?” The respondents answered from the options of “want to be vaccinated”, “somewhat want to be vaccinated”, “unable to determine”, “do not want to be vaccinated so much”, and “do not want to be vaccinated”. In the analysis, the respondents were categorized into two groups: those who wanted to be vaccinated and those who were somewhat wanting to be vaccinated were categorized as the “want to be vaccinated” group, and those who were unable to determine, did not want to be vaccinated so much, and did not want to be vaccinated were categorized as “do not want to be vaccinated” group. The reasons for the intention to get the catch-up HPV vaccination were answered from the following options: very applicable, somewhat applicable, neither applicable nor not applicable, not applicable so much, and not applicable at all. In the analysis, the respondents were categorized into two groups: those who answered, “very applicable” or “somewhat applicable” were categorized as “applicable as a reason” group, and those who answered “neither applicable nor not applicable” or “not applicable so much” or “not applicable at all” were categorized as “not applicable as a reason” group.HPV vaccination rates for girls in Japan significantly vary depending on year of birth. We defined two “generations of HPV vaccination” environments eligible for delayed catch-up vaccinations. The “vaccinated generation” was composed of women born in 1997–1999; the “vaccine-suspended generation” was made up of those born in 2000–2007 who initially came of HPV vaccination-eligibility age during the 9 years of recommendation suspension.Statistical analysis was performed by the Chi-square test and by residual analysis. The statistical level of significance was set to be less than 5% bilaterally.p < 0.05, for both). More than 90% of women born in 1999 or after were unmarried, and especially those born in or after 2001 (p < 0.05). For those born in and after 2002 (20 or younger at the time of the survey), the proportion of those without children was significantly higher than those born before 2002 (p < 0.05). Household income was significantly higher among those born in 1997, with 29.6% having an annual household income of less than 4 million yen, 24.8% having an annual household income of between 4 and 8 million, and 28.6% having an annual household income of less than 4 million among those born in 1998 . For work status, more than 60% of the respondents born in 1999 or later were students. The percentage of students was significantly higher for those born in 2001 and later than those born before 2001 (p < 0.05). The more recent the FY in which they were born, the higher the proportion of them still living with their mothers was.The backgrounds of our survey participants are shown in Table p < 0.05). Regarding the intention to receive cervical cancer screening, in the group who wanted to be vaccinated, those who answered, “I intend to receive cervical cancer screening within the next two years” and “I would like to receive cervical cancer screening someday” were significantly higher than for the other two groups  . The group that did not want to be vaccinated had a significantly higher percentage of those having no intention to receive cervical cancer screening, 37.3% (p < 0.05). The proportion of respondents who reported having had sexual intercourse was significantly higher in the group that wanted to be vaccinated, 43.6% (p < 0.005).In regards to the HPV catch-up vaccination, 41.6% of the respondents wanted to receive it, 29.7% were undecided, and 28.7% did not want to be vaccinated (Table p < 0.05). In the group that did not want to be HPV vaccinated, the percentage of respondents who answered that they were not at all anxious, or were not very anxious, was 36.0%, significantly higher than for the other two groups (p < 0.05). Regarding the question, “Has someone close to you had cervical cancer?”, significantly more respondents in the group who do not want to be vaccinated answered “No” than in the other two groups .The percentage of respondents who reported having a higher level of anxiety about cervical cancer (fairly or somewhat worried) was 78.3% in the group who wanted to be vaccinated, which was significantly higher than in the other two groups (p < 0.05). The percentage of those who answered “No” was significantly higher in the “Undecided” group (80.4%), and in the “I do not want to be vaccinated” group (86.2%), than in the “I want to be vaccinated” group . Personal levels of awareness of cervical cancer screening and knowledge about cervical cancer were better in the “I want be vaccinated” group , than in the “Undecided” group .Regarding the question, “Has your mother or your family recommended HPV vaccination?”, significantly more respondents in the group who wanted to be vaccinated answered “Yes” than in the other two groups . “HPV vaccine is recommended by the government” was not selected as a reason for intention to be vaccinated significantly more than other positive reasons (p < 0.05).The respondent’s reasons for their intention to receive or not receive the catch-up HPV vaccination are shown in Table p < 0.05, respectively). For the “Do not want to be vaccinated” group, the negative reason 1 and negative reason 2 were selected as significantly more the reasons for vaccination intention than the other reasons .For the “Unable to determine vaccination intention” group, the positive reasons 1, positive reason 3, negative reason 1, and negative reason 2 were selected as significantly more the reasons for vaccination intention than the other reasons  .In the defined “vaccinated generation”, the proportion that wanted to get the catch-up vaccination was significantly lower, and the proportion of the group that clearly did not want to be vaccinated was accordingly significantly higher . In the vaccine-suspended generation, the proportion of the group that had “Already been vaccinated for COVID at least once” or “I intend to be vaccinated for COVID in the future” was significantly higher, and the proportion of the group that responded “I do not intend to be COVID vaccinated” was significantly lower .In the “HPV vaccinated generation”, the proportion of the group that self-reported as having been “Already been vaccinated for COVID at least once” or “I intend to be vaccinated for COVID in the future” was significantly lower, and the proportion of the group that responded “I do not intend to be COVID vaccinated” was significantly higher . In the group that would refuse the catch-up HPV vaccination, the proportion that answered, “I have already been vaccinated for COVID at least once” and “I intend to be vaccinated for COVID in the future” was significantly lower, and the proportion of the group that “Do not intend to be vaccinated” was significantly higher .In the group that wanted to get the catch-up HPV vaccination, the proportion that responded “Already been vaccinated for COVID at least once” or “I intend to be vaccinated for COVID in the future” was significantly higher, and the proportion of the group that responded “I do not intend to be vaccinated for COVID” was significantly lower  were 17–25. In Japan, the current rate for female sexual intercourse experience at age 17 is about 25%. However, this rate increases significantly, to about 80%, by age 25. (JFPA) We need to encourage targeted females to start catch-up vaccinations as early as possible. It is necessary for all organizations involved with females eligible for HPV vaccination and their parents, such as government, medical institutions, and educational institutions, to make recommendations based on an understanding of the characteristics of the “vaccinated generation” and the “vaccine-suspended generation”.


The incidence of cervical cancer in Uyghur women ranks first among those in Han and other ethnic minority groups. We aimed to understand the natural history of HPV in Uyghur women.A longitudinal cohort study on the natural history of HPV infection in rural Uyghur women in China was conducted between May 2013 and May 2014. A total of 11000 women from South Xinjiang underwent HPV screening by careHPV and liquid-based cytology. Ultimately, a total of 298 women with positive HPV and normal biopsy results or CIN1 were enrolled to participate in a study including follow-up HPV testing for two years.P < 0.001 and P = 0.047, respectively).The HPV infection rate in Uyghur women was 9.15%. Among the participants, the careHPV test showed that 298 women were HPV-positive, and histology showed CIN1 or normal results for these women at baseline. Among these patients, after 24 months of initial recruitment, 92 (30.87%) patients had persistent HPV infections, and 206 (69.13%) had cleared HPV infection. Univariate analysis showed that persistent HPV infection was associated with age and shower frequency (Our results suggest that women over the age of 50 years who have been infected with HR-HPV for more than 1 year should be regularly screened and monitored for HPV. In addition, education should be strengthened to improve poor health habits in these women. High-risk human papillomavirus (HR-HPV) is an important cause of cervical cancer. Fortunately, most genital HPV infections are transient, with approximately 90% of women spontaneously clearing infections within 12–24 months of infection [According to China's cancer statistics in 2015, the incidence of cervical cancer has increased significantly in China compared with developed countries. This may reflect the inadequacy of Papanicolaou (Pap) screening and the increasing prevalence of HPV infection in mainland China .The incidence of cervical cancer in Uyghur women ranges from 459/100,000 to 590/100,000, which is the highest in China. Moreover, the age of HPV infection in Uyghur women is earlier than that among women in other parts of China [In total, 6,000 volunteers from Hotan and 5,000 volunteers from Kashgar, Xinjiang, China, where the incidence of cervical cancer is high, were enrolled in a population-based study between May 2013 and May 2014.The number of subjects is directly proportional to the population of the county. The inclusion criteria were as follows: Participants aged 20 years or older; those who had not received the HPV vaccine; those who had a complete uterus; those were not pregnant; and those who had no history of invasive cervical cancer. The research ethics committee of the Affiliated Tumor Hospital of Xinjiang Medical University approved the research program. All methods were performed in accordance with the relevant guidelines and regulations. Each participant signed an informed consent form. For participants who were illiterate, informed consent was obtained from a parent or legal guardian.TM, Qiagen Inc.). Among these patients, those with positive results (TCT ≥ ASCUS or HPV-positive) were referred for colposcopy. Following histology, patients with grade 2 cervical intraepithelial neoplasia (CIN 2) or CIN2 + were referred for further treatment.All participants completed a structured questionnaire based on potential risk factors, including age category, education level, occupation type, sexual behavior, birth history, age at first sexual intercourse, the use of contraception methods and personal hygiene. Each participant underwent a pelvic exam and two cervical swabs. Cervical specimens were collected using a broom device placed in liquid-based cytology medium . The sample collection brush was used for HPV testing  were detected in cervical specimens through careHPV test ,which is an in vitro nucleic acid hybridization assay coupled with signal amplification that uses microplate chemiluminescence for the qualitative detection of HPV [After collecting cervical cell specimens, colposcopy was performed to determine whether the women had positive HPV or Thinprep Cytology Test (TCT) results, and a direct biopsy or four-quadrant biopsy was performed. Cervical curettage was performed when necessary. Colposcopy was performed according to general guidelines.Persistent HR-HPV infection was defined as the detection of HR-HPV positivity at enrollment and follow-up (12-month and 24-month follow-ups). Clearance was defined as HR-HPV positivity at enrollment but negativity at follow-up.The data were analyzed by SPSS 25.0, and the count data are expressed by the frequency and rate. The relationship between the rate of HPV infection (persistent HPV infection) and related factors was analyzed by binary logistic regression analysis. The related factors were screened by single-factor binary logistic regression analysis, and then logistic regression models were established by the entry method and stepwise regression method to explore the related factors. The test level was α = 0.05.From May 2013 to May 2014, a total of 11,000 women aged 20–69 years in Hotan and Kashgar were recruited for cohort studies. The sociodemographic characteristics of the participants are shown in Table P = 0.000, OR = 1.802), whereas educational level was not significantly.associated with HPV infection. Nonfarmers had a higher HPV infection rate than farmers . Women who gave birth for the first time over the age of 18 years had a lower HPV infection rate than those who gave birth for the first time under the age of 18 years . Risk was not associated with the number of pregnancies, number of childbirths, age at first marriage or number of marriages. Women with a higher sex frequency had a higher rate of HPV infection . Compared to women who did not use IUDs and OCs, those who did use them showed a lower rate of HPV infection . Regarding shower frequency, the higher the shower frequency was, the lower the HPV infection rate .Of the 11,000 women surveyed, 1,006 women had HPV infection. The HPV infection rate was 9.15%. Table P < 0.05)  Table : (a) bein = 33), ASC-US (n = 144), ASC-H (n = 64), LSIL (n = 117), HSIL (n = 67), and SCC (squamous cell carcinoma of the cervix) (n = 4). Participants who had a positive result for both tests were referred for colposcopy. Ultimately, 1380 women underwent a cervical biopsy. The results were divided into normal results, CIN1, CIN2, CIN3, SCC and adenocarcinoma, with numbers of 1064, 147, 61, 79, 26 and 2, respectively. Patients with CIN2 and CIN2 + received definitive treatment. In women with HR-HPV infection, those with CIN1 or normal results (n = 805) were included in the follow-up study. Of these 805 women, 320 gave consent to participate in our study. Ultimately, 298 women (93.13%) completed the survey and were tested for HPV after 12 months and 24 months of follow-up. A total of 22 women (6.87%) were lost to follow-up . Among the 298 HPV-positive patients with CIN1 or normal cervical histology at baseline, 120 (40.26%) had persistent infection, and 178 (59.74%) had clearance of the infection after 12 months. After 24 months, 92 (30.87%) patients had persistent HPV infection, and 206 (69.13%) had cleared HPV infection. The relationships of HPV clearance and persistence after 24 months with sociodemographic and behavioral characteristics in HPV-positive participants are described in Table P = 0.003, OR = 3.612). Women who gave birth to more than 3 children had higher rates of persistent HPV infection than those who gave birth to 3 or fewer children . Women with less frequent showers had a higher rate of HPV infection . A multivariate logistic regression between sustained HPV infection and subjects’ demographic and behavioral characteristics is shown in Table P < 0.05): (a) being aged 50 years or older (OR = 2.884) and (b) having had less frequent showers (OR = 0.579).Among the 11,000 participants, 1006 women tested positive for HPV infection. Of these women, 429 (3.9%) showed positive cytology tests, including AGC (ts n = 80 were incDue to its high morbidity and mortality, cervical cancer has become the most important health problem in Xinjiang, China. However, the phenomenon of lower rates of HPV infections and higher rates of cervical cancer is difficult to explain. Although most HPV infections are transient, persistent HPV infection is a strong predictor of cervical cancer, especially in women with persistent HR-HPV types. Therefore, we conclude that Uyghur women may have a longer duration of HR-HPV infection than women from other parts of China. In addition, this persistence of HPV may cause differences in the incidence of cervical cancer in Uyghur women compared with women in other parts of China.In this study, we found that the HR-HPV infection rate was 9.15% among Uygur women, lower than that among women in other parts of China, including rates of 19.81% in Guangdong Province , 22.8% iViral, host and environmental factors can affect the process of HPV infection. Since HPV infection is a sexually transmitted disease, sexually active women are generally susceptible to HPV, especially high-risk HPV. Herrero R reported that the age-specific prevalence of HPV exhibited a “U” shaped curve. The HPV infection rate was the highest at ages < 16 years, then it declined gradually, reaching the lowest at the age of 41–45 years. At ages > 50 years, it began to increase again . In our In addition, our results showed that early childbirth was associated with a higher rate of HPV infection. This might be related to the relatively low immune function of the reproductive tract. The cervical immune system of young women is not yet fully mature and might cause the cervix to be more vulnerable . HoweverThere is also no universally accepted definition of HPV persistence . In 2012It has been reported that viral variables such as HPV genotype, multiple HPV infections, and host and environmental factors such as age, smoking, and the number of sexual partners are associated with HPV persistence –27. HoweOur study also showed that among Uyghur women, the number of pregnancies was not associated with persistent HPV infection. In addition, women who gave birth to more than 3 children had higher rates of persistent HPV infection than those who gave birth to 3 or fewer children. However, the multivariate analysis showed that the number of childbirths was not associated with persistent HPV infection, which is consistent with reports that indicated that parity was not associated with HR HPV persistence , 30. TheIn conclusion, HR-HPV persistence plays a key role in the progression of precancerous lesions and the development of cervical cancer. Therefore, the epidemiological and biological understanding of the natural history of HPV infection is critical for guiding the implementation of cervical cancer prevention and control strategies. Considering that the HPV vaccine is not yet fully accessible in rural areas of China, early intervention for high-risk factors for HPV infection and persistent HPV infection may play a certain role in cervical cancer prevention.Furthermore, we should increase the awareness of HPV among women at high risk of infection. For women over the age of 50 years, those who have been infected with HR-HPV for more than 1 year should be screened and closely monitored. In addition, education should be strengthened to improve poor health habits among women.


HPV-Plus, that combines HPV vaccination with additional health services: nutritional assessments, vision screening, and vaccination for adolescent girls, and education for all genders. This qualitative descriptive study evaluated the acceptability of the HPV-Plus program in two districts in Tanzania. Key informants comprising of adolescent girls, parents, program planners, and program implementers in Njombe and Dar es Salaam Tanzania were interviewed to assess the program acceptability. Transcripts were analyzed using a team-based iterative thematic analysis approach, consisting of both inductive and deductive coding. The Theoretical Framework of Acceptability was used to guide analysis, with themes categorized according to theoretical constructs of intervention coherence, affective attitudes and perceptions, and perceived effectiveness. Overall acceptability of the HPV-Plus program was high among stakeholders. The most salient finding regarding factors that influenced HPV vaccine acceptability was largely related to education and knowledge levels surrounding the HPV, cervical cancer, and HPV vaccines. The educational component of the HPV-Plus program was key in increasing acceptability. Parents reported the lowest acceptability towards the program. This was found to be primarily due to perceptions of not being sufficiently engaged throughout program implementation. Increasing acceptability of HPV vaccination programs among key stakeholders is critical to facilitating vaccine uptake and meeting vaccination coverage targets. Our results demonstrate that the inclusion of a comprehensive education component within the HPV-Plus program was key in facilitating HPV vaccine acceptability amongst stakeholders.Tanzania has one of the highest cervical cancer incidence and mortality rates in sub-Saharan Africa. The Tanzanian Ministry of Health developed an integrated adolescent health program,  Cervical cancer is the fourth most prevalent cancer among women globally and is a leading cause of cancer-related mortality worldwide . Human PAmong countries in East Africa, Tanzania exhibits one of the highest cervical cancer morbidity and mortality rates, with cervical cancer ranking as the most frequently diagnosed cancer among women in Tanzania –14. CurrHPV-Plus, an integrated service delivery program that packages HPV vaccines with complementary adolescent health services. This program was implemented with technical support from Jhpiego, a Johns Hopkins University affiliate organization, with Gavi funding. The HPV-Plus program was informed by human-centered design workshops in 2018, finalized in 2019, and contains a core package of services including age-appropriate HPV education, provision of deworming tablets, nutritional assessments, and visual acuity assessments. The implementation guidance allowed for integrated services to be delivered in three settings: health facilities, schools, and community outreach; however, it was particularly tailored to school-based vaccination days.Currently, the government of Tanzania has established targets to fully immunize 2.7 million adolescent girls and achieve vaccine coverage rates of 85% by 2025 . To helpNevertheless, the prioritized population of school-age girls, coupled with the two-dose vaccination schedule delivered six-months apart, poses unique challenges in successful HPV vaccination uptake . LimitedHPV-Plus program, which was first introduced as a focused demonstration in two districts of Tanzania: Makambako (in Njombe Region) and Ubungo . These districts were selected in collaboration with MoH, PO-RALG and Jhpiego. The focused district demonstrations took place from November 2019 to March 2020; however, facilities were able to continue implementation after this period. For Makambako District, this was enabled by an extension of Gavi funding to allow implementation of HPV-Plus across Njombe Region. For Ubungo District, facilities were free to continue HPV-Plus with their own resources, as desired. The HPV-Plus program integrated the delivery of HPV vaccines with other selected adolescent health services. It comprised comprehensive health education for boys and girls aged 10–14 years, and provision of antiparasitic medicines (deworming), nutrition assessments, vision screening, and HPV vaccination for girls aged 10–14 years. We present findings from our qualitative study exploring the acceptability of the HPV-Plus program among various key stakeholders: program implementers, program planners, educators, adolescent girls, and parents. In assessing program acceptability, we aimed to understand stakeholder perspectives and attitudes toward the HPV vaccine, including knowledge and misinformation regarding HPV, cervical cancer, and HPV vaccines; as well as acceptability toward the integrated approach of HPV-Plus, and toward school-based service delivery compared to a health facility-based service provision. While a plethora of studies have been conducted assessing HPV vaccine acceptability in higher-income countries, less attention has been devoted to understanding HPV vaccine acceptability in low-income countries . TF. TFHPV-PHPV-Plus as both districts needed to increase rates of HPV vaccine uptake, whilst representing a mix of urban (Ubungo) and rural (Makambako) settings. Study participants included program planners , program implementers , adolescent girls, and the parents of adolescent girls. While the age range for HPV-Plus was 10–14 years, interviews for this study took place over one year after HPV-Plus was implemented. Thus, a large percentage of adolescent girls were above the age of 14 at the time of the interviews. We included stakeholders of varying backgrounds to elicit a comprehensive overview of acceptability towards the HPV vaccine and the integrated HPV-Plus program.The Makambako District Council (Njombe Region) and Ubungo District Council  had been selected for the focused demonstration of HPV-Plus was generated using registers that captured HPV vaccination coverage across implementation sites. With support from schoolteachers and trained providers, study staff contacted parents/guardians of eligible adolescent girls by telephone to provide information about the study and solicit permission to meet with the adolescent for an interview. Parents (i.e. mothers and fathers) and legal guardians who were approached regarding enrollment of their daughters’ in the study were also read informed consent documents to participate in a separate interview. Adolescent girls and her parent(s)/guardian(s) who agreed to participate in interviews were interviewed separately. Adolescents and their parent(s)/guardian(s) were still eligible to participate in the study even if one party in the dyad did not wish to be interviewed. Although adolescent boys participated in certain aspects of the HPV-Plus program, adolescent girls who were eligble to receive HPV vaccines were the priority in our study as this group received the broadest range of integrated health interventions including HPV vaccines.A list of eligible schoolgirls that received HPV vaccines through HPV-Plus program, immunization services, and other integration efforts supported by the MoH. Implementation and planning personnel were required to be living in or associated with the study communities and provided informed consent. Implementation and planning staff were categorized into one of the following categories: a service provider who provided integrated HPV services; a national or regional level program manager for Expanded Program for Immunization (EPI) and integrated services; a community or school official that was directly involved in the administration or implementation of the program; a person responsible for planning, policy design, and supervision of the project; or a person that was responsible for specific areas of interest related to the program .Planning stakeholders and program implementers were recruited purposively through professional connections with Jhpiego Tanzania staff. Using stakeholder mapping activities with study staff, Jhpiego enumerated key personnel at various levels  engaged with the planning and scale-up of the HPV-Plus program and included questions to evaluate program acceptability. These questions were accompanied by questions related to program feasibility and sustainability. The study received ethical review and approval from the Johns Hopkins Bloomberg School of Public Health International Review Board  and the National Institute for Medical Research .Interview guides were developed through an extensive literature search of studies evaluating HPV vaccine program feasibility, acceptability, and sustainability in LMICs primarily within sub-Saharan Africa ,29–31. IHPV-Plus was introduced in Makambako and Ubungo Districts. Data collection was delayed due to local COVID-19 restrictions. Experienced data collectors fluent in English and Kiswahili were trained by an experienced in-country study coordinator with extensive experience in qualitative methods and interviewing techniques. Participants were able to select the interview location of their preference, and were interviewed by a trained data collector who was familiar with the communities from which participants were recruited. IDIs were conducted with program participants, which included adolescent girls and their parents, and other stakeholders such as implementation personnel and planning personnel. IDIs were conducted in English and/or Kiswahili, depending on participant preferences, and lasted 60 minutes on average. While the interviews were designed to specifically assess experiences from the focused demonstration period (November 2019 to March 2020), we accepted the reality that some participants would also report on extended implementation experiences.Interviews were conducted from June to July 2021, more than two years after Interviews were audio-recorded and transcribed verbatim, with translations edited for clarity. Interviews that were conducted in Kiswahili were translated into English by a verified translator. Transcripts were analyzed using a team-based thematic analysis approach consisting of inductive (drawn from a review of transcripts) and deductive coding (extracted from interview guide questions). A set number of transcripts were selected for thematic analysis by DG, JGR, AG, and RL, in which an initial set of codes was developed deductively from the semi-structured interview guides. Following close reading of transcripts by investigators, codes were adapted or added to inductively incorporate emerging themes not explicitly addressed in the IDI field guides. After pilot testing and revising the codebook on a set number of transcripts, the codebook was programmed in Atlas.ti 8 , facilitating the application of codes to text segments across transcripts. Codes were then categorized into broader themes guided by TFA constructs. After coding was complete, nine random transcripts were chosen for intercoder consistency. A member of the study team that had not coded any of the nine transcripts served as the second coder and coded the nine selected transcripts. Intercoder consistency was estimated at 84%. After coding all transcripts, Baltimore-based study staff  convened to identify the most salient insights emerging.HPV-Plus program, several themes emerged from the interviews. These themes included knowledge of the HPV Vaccine, perceptions of the HPV-Plus program, attitudes towards the HPV-Plus program, and the overall acceptability of the HPV-Plus program. A total of 87 participants were enrolled in the study . Over half (n = 50) of participants were located in Njombe, and 37 were located in Dar es Salaam . In evalHPV-Plus to be acceptable as a means to both prevent cervical cancer and address a broader range of adolescent health needs simultaneously. This overall acceptability was largely echoed by adolescent girls and parents. Within this high-level finding, many positive and negative details of nuance were brought out using our analytic framework, as discussed below. Additional quotes are provided in Program planners and implementers in their overall assessments found the Intervention coherence: Knowledge towards the HPV vaccineAcross all stakeholder groups, education sessions were essential in dispelling misconceptions about the vaccine, increasing HPV vaccine and cervical cancer knowledge, and providing clarity to questions and concerns that participants had. Low HPV vaccine knowledge, coupled with high levels of misinformation and myths surrounding the vaccine, were cited across stakeholder groups as both preceding the program and persisting during program implementation. Myths included the HPV vaccine causing infertility, the vaccine resulting in illness and death, and increased sexual activity and promiscuity among vaccinated adolescents. Numerous participants across stakeholder groups reported having questions about the HPV vaccine before program implementation and voiced that the education sessions were effective in clarifying questions and concerns.Others [in the community] say it can affect girls after they get married…it might affect their reproduction rates…I was angry [when hearing about the program] because of these street reports…they are injecting needles in those schools so that children do not give birth later"- Parent, Njombe“Nearly all adolescent girls who were interviewed stated that they had little to no information on HPV vaccines prior to the program. Education on cervical cancer, HPV vaccines, and dosing schedules were reported to improve students’ knowledge on the disease process of cervical cancer and the benefits of vaccination for prevention. In addition, students were provided with comprehensive sexual and reproductive health education. Group education in the school-based program was especially well-received by students and often distinguished as the element they liked most in the integrated program. This was confirmed by program implementers with several stating that providing educational sessions in a group setting encouraged students to ask questions regarding the vaccine, with numerous students requesting more information after educational sessions. Several students reported hearing about myths regarding the HPV vaccine within the larger community, with many of these students believing these myths prior to receiving education.I remember before the vaccination we didn’t understand anything, but after the vaccination, that’s when they told us this vaccine is going to be again on the tenth month, and make sure you have to finish the dose because if you inject one you have not finished.” - 15-year-old student, Njombe“HPV-Plus program stemmed from what they heard about the HPV vaccine from others in their local communities, which consisted largely of rumors and misconceptions. Parents cited low knowledge levels towards the HPV vaccine, with several parents stating that they believed certain rumors about the HPV vaccine prior to receiving accurate information. The most cited misconception among parents was that the HPV vaccine caused infertility. Several parents highlighted the need for more education within the community to dispel myths and misinformation.For many parents, HPV vaccine knowledge prior to the What shocked me was just that street education because everyone was talking about it, I was just scared that they said those who were vaccinated would not be able to give birth again, that is when I was hurt.”–Parent, Njombe“HPV-Plus program and the benefits of HPV vaccination prior to program implementation. Information and education on the HPV-Plus program was provided to program implementers weeks to months in advance before actual program implementation. Several program implementers had low prior knowledge of HPV vaccines, and voiced questions about the purpose of HPV vaccines prior to receiving such education. A number of program officers also believed myths about the HPV vaccine prior to receiving education through HPV-Plus.Program implementers received information on the I had a lot of questions…they want to reduce the population of Africa… these children are likely to mature so that at the end of the day they have less fertility and do not reproduce much, but after getting that education I understood that even I as an adult am supposed to check whether I have it [cervical cancer].”–Health teacher, Njombe“HPV-Plus program, particularly after receiving health education. Education was found to be beneficial in not only increasing knowledge, but also fostering positive attitudes towards the HPV vaccine among students. Several adolescent girls stated they were fearful of the vaccine due to the pain associated with injections. However, despite this fear, adolescent girls voiced the importance of undergoing vaccination to reduce their future risk of cervical cancer. Students noted that being surrounded by peers was helpful in overcoming initial fears of inoculation.The majority of adolescent girls described positive feelings towards HPV vaccines and the It is [HPV vaccination] for my own good so I loved it… .I liked it but I was scared…injecting is not an easy thing. I agreed to HPV vaccination because they said it helps us women and I am one of the women here.” - 15-year-old student, Dar es Salaam“Parents’ perceptions and attitudes towards the HPV vaccination program varied substantially. Positive attitudes towards the program were reported by parents as due to the receipt of trustworthy information on the HPV vaccine and the overall program. Several parents stated that they viewed the vaccine as important in improving health outcomes for their children; and were more likely to endorse positive feelings towards the program if they had known that stakeholders such as the government officials, teachers, and health care providers were involved. However, many parents stated they were skeptical of the program and held negative beliefs due to not having adequate information, and not being provided with education about the benefits of HPV vaccination prior to program implementation. There were inconsistencies in the education that was received among parents, with some parents being contacted by program officials to attend information seminars, while other parents stated they were not informed about the program. Parents who felt they did not receive adequate information did not perceive the vaccine to be beneficial and demonstrated hesitancy towards their children being vaccinated.I received it [HPV vaccination] well by one hundred percent because we did not see any child who had problems with this vaccine, they are all safe. After the seminar I educated her to go and get this vaccine…I want my baby to be healthy and not have effects that will cause problems later.”–Parent, Dar es Salaam“I think teachers were the one who called us parents, the children were given leaflets that we need you parents at the school…when we arrived they started giving us the seminar…now when we go to the school we found teachers and specialists they are saying this vaccine is to prevent cervical cancer…and we as parents always listen to specialists mostly”–Parent, Njombe“HPV-Plus program after being provided with education on the purpose and benefits of the HPV vaccine. Program planners and implementers cited having positive feelings and attitudes towards the program in knowing that HPV vaccination would be beneficial in reducing cervical cancer outcomes and disease burdens in the community. Among planners and implementers, teachers more often reported negative perceptions and attitudes towards HPV vaccines and the HPV-Plus program prior to receiving education.Similar to the other key informant groups, program planners and implementers were more likely to demonstrate positive attitudes towards the I was shocked…It’s not like I didn’t receive it [the HPV-Plus program] well, [however] I always have to ask, that is…about its effects, its benefits…these are someone’s children and we live with them for four years here. Maybe she is married only two or three years she has not given birth [because] you vaccinated her. So I wanted to satisfy myself [through looking up information], after satisfying myself I said it was okay.”—Health teacher, Njombe“HPV-Plus program, which was primarily attributed to the lack of accurate knowledge about the program. Based on their beliefs, it was not uncommon for some parents to forbid their children from getting vaccinated. Lack of awareness and engagement throughout the program implementation process was a prominent complaint among parents.Across stakeholder groups, parents exhibited the most hesitancy towards the There was no information [provided on cervical cancer]. It was just a conversation between me and my daughter, we were not called as parents to say we had a seminar.”–Parent, Njombe“Parents who did exhibit high program acceptability stated that the health benefits associated with HPV vaccination were important to them. Although the program included additional adolescent health services, most parents seemed to either lack accurate information on the complementary services or were unaware that additional health services were provided alongside HPV vaccine. Parents who were aware of the supplementary adolescent health services voiced being satisfied with the services provided.I was happy because my child told me that they were given medication and her eyes were checked, and she later received the vaccination.”–Parent, Njombe“Students reported feeling supported and empowered to participate in the program. As with parents, a key rationale for program acceptability was the benefits of the HPV vaccine in preventing cervical cancer. Several adolescent girls noted that some of their peers did not participate in the program due to parental refusal. Adolescent girls who demonstrated high acceptability towards the program also voiced encouraging and supporting their peers to participate in the program.I persuaded my friends to go and inject, I was the one who persuaded them after I was inspired.”– 15-year-old student, Dar es Salaam“HPV-Plus program effectively met HPV vaccination targets, particularly as HPV vaccination rates were low prior to program implementation. Program planners and implementers highlighted the efficacy of the HPV-Plus program filling in gaps between education and the uptake of health behaviors, with stakeholders at multiple levels effectively coordinating program implementation to ensure that coverage targets were met. It was noted that collaboration with education officers was critical in heightening acceptance and subsequent uptake of HPV vaccines. Regarding recommendations for increasing acceptability, nearly all program implementers voiced that there was a need for accurate information regarding the vaccine as levels of misinformation tended to be high among parents.Program planners and implementers had high acceptability overall of the program and voiced that the To my personal understanding of this service to me I found it to be good, because this integrated service was helping a ten- to fourteen-year-old girls. The biggest challenges we faced in high schools, especially these private schools…every time you go for a service, we did not get much cooperation from the principal and teachers. They used to think that if you have these vaccines they will be unable to give birth. So we did not get enough cooperation. I think later after providing adequate education and asking for the numbers of the parents of the children, because it is a boarding school, the problem was solved and we were able to cooperate well.”–Special education officer, Njombe“It [coverage] increased because we involved the ward education officer of the primary schools, CBGC [Community-based Group Coordinators], peer educators, district medical officers, religious leaders, mayors, teachers and the Regional Commissioner. We talked about it with all our might and it was a topic everywhere and that’s why we ascended the charts.”–Program officer, Dar es Salaam“Across districts, schools were the preferred venue for HPV vaccine services, as they were viewed as being ideal settings for targeting adolescents in large numbers. Students reported feeling supported and empowered by teachers to participate in the program. Group education in the school-based program was especially well-received by students and often distinguished as what they liked most about the program. Students enjoyed receiving the education alongside their peers and felt comforted and supported by one another, particularly in overcoming initial fears of inoculation.In the whole group, you may be educated, even if someone asks a question you can consult with your colleague here how to ask, as opposed to an individual.”– 15-year-old student, Njombe“Parents stated that school-based delivery offered convenience and reduced several logistical challenges . Parents who were employed emphasized difficulties taking time off work to take their children to health facilities to receive HPV vaccination.Near my home I have a business, so I can just let someone watch for me and go to the school that is close by… but if you are told to come to Kimara  you see the challenge… I have to close the shop until evening.”–Parent, Dar es Salaam“Program implementers and planners expressed high acceptability of school-based delivery and disclosed that school-based delivery allowed for more effective outreach, resulting in more success in meeting vaccination targets. Program implementers and planners also cited benefits in school-based delivery reducing costs and being more inclusive through engaging multiple stakeholders throughout the community. Commenting on the benefits of school-based delivery, stakeholders said that health facilities do not offer the physical space required to speak with adolescents privately about sexual and reproductive health topics including HPV vaccines.Ubungo is very large… We were very low in vaccination coverage, our coverage was very low but we questioned how can we be able to involve those young people but not only to involve young people but also to share with other departments for example education. At first there was a gap between education and health…but the campaign integrated it. We came, sat together and teachers we planned together and performed. We performed well so that also help to reach the targeted us in a way that is simple but that it is participatory.”- Ministry of Health official, Dar es Salaam“At health facilities…we have no place to talk to these young people because even if we go to school we tell them if there is anything you want to know more should come here at Sinza hospital but as you can see for yourself here on the benches it was full in there it was full so this youth cannot open up because there is no friendly environment for them to open up…first the area should be set aside for youth service for example we provide youth services in a certain room and when they come here to our center we have a special area for them”–Health care worker, Dar es Salaam“HPV-Plus to be implemented on a greater scale.A subset of parents and girls identified health facilities as more fitting sites for health care, and the potential for a broader range of non-vaccine services to be integrated. A number of respondents identified the need for health facilities to be more responsive to adolescent preferences and needs if they are to become sites for …at the hospital most people go to get different services so it will be easier for most people to get that service [HPV vaccines]…”–Parent, Njombe“I know at the health facility, I would have trust more than at schools where they just explain then you go for test…”—Parent, Njombe“HPV-Plus program was largely rooted in knowledge levels regarding the vaccine and the disease it was preventing. The majority of participants in our study reported that prior to the HPV-Plus program they had low levels of knowledge toward HPV vaccines, HPV, and cervical cancer. This is critical to highlight as knowledge gaps have been shown to contribute to major barriers to the uptake of HPV vaccines in numerous settings [HPV-Plus program particularly after receiving health education on the HPV vaccine. Positive attitudes were found to be a facilitator in HPV vaccine acceptability and uptake among adolescents. Similar findings have been reported in studies assessing HPV vaccine acceptability among beneficiaries [Improving HPV vaccine acceptability can heighten demand generation which can be critical in successfully meeting national immunization targets . Our quasettings ,33. Educsettings ,34–36. Tsettings –40. Particiaries ,41.HPV-Plus program was implemented, and were voiced not only among adolescents and parents, but also voiced among program implementers. This highlights the need for educational initiatives to be targeted towards multiple stakeholders: parents, adolescents, health workers, teachers, and program officials, to support the introduction of HPV vaccination programs particularly within school-based settings [HPV-Plus program as well as persisting knowledge gaps. There appeared a clear need for more educational messages in addition to other opportunities to be more directly engaged within the program. Studies that have assessed HPV vaccination program acceptability in both high-income countries and low- and middle-income countries (LMICs) have noted that positive attitudes of parents towards HPV vaccination is a strong predictor of HPV vaccination uptake by their children [Beyond knowledge, education must also address misinformation and rumors regarding the HPV vaccine. These were prevalent in the communities where the settings . Addresssettings ,25,43. Msettings . Across children ,40,44–46children ,44. Key children ,48.HPV-Plus program. Previous studies evaluating delivery strategies for HPV vaccines in LMICs have noted that adolescents have a wide array of health needs that can potentially be met through offering full-range services such as deworming, vision and hearing screening, sexual and reproductive health education, access to feminine hygiene products, mental healthcare, and vaccination services[HPV-Plus [The integration of other adolescent health services with HPV vaccination in school-based settings was positively received across stakeholder groups. A number of recent studies have reported that school-based delivery in LMICs is often preferred and has demonstrated high acceptability and efficacy, particularly when there is adequate engagement of key stakeholders during the pre-implementation phase,49,50. M services,55. The  services,38,57. AHPV-Plus ,58. ThusHPV-Plus program included a broader age range of adolescent boys and girls in comprehensive education, this group was not interviewed in our study due to resource limitations. Additionally, our study did not include perspectives of other key members who may have influenced the acceptability of the HPV-Plus program . This omissions, and the recruitment of adolescent girls who had received vaccination, may have contributed to selection bias, and important perspectives regarding the program may not have been captured. Despite these limitations, the sample in our study consisted of a diverse array of stakeholders, which facilitated data source triangulation which allowed the researchers to gain diverse perspectives and reinforcement of the credibility of the qualitative responses. In addition, there is a possibility that social desirability was present when participants provided responses that would be deemed favorable by interviewees. The time between the focused demonstration and our interviews may have affected participants’ recall, and some participants may have related their answers to experience of the scaled-up implementation rather than the original pilot; we do not see this as likely to bias toward either positive or negative associations.Our study is not without limitations. Given our study methods, the findings may not be generalizable to other settings; however, our results provide insight on the factors that contribute to HPV vaccine acceptability within low-resource settings in Tanzania. Although the As HPV vaccination programs continue to expand throughout Tanzania and other countries in sub-Saharan Africa, future studies are needed to identify best practices in improving program acceptability among stakeholders at all levels. Recently, the WHO Strategic Advisory Group of Experts on Immunization has recommended one-dose of HPV vaccines in LMICs after evaluating evidence that a single-dose schedule provides comparable efficacy to that of a two-dose regimen . AlthougHPV-Plus program was found to be acceptable overall by all stakeholders, both in provision of HPV vaccination and in its approach to integration of other adolescent health services. The comprehensive education component was reported as the most important contributor to acceptability and in driving uptake. Of all stakeholders, it was the parent group that requires greater involvement in education and program operations. Increasing HPV vaccine acceptability across all relevant stakeholders, including parents, students, community leaders, program planners, and program implementers will be critical in driving the success of the HPV-Plus program nationwide within Tanzania. Comprehensive health education that involves stakeholders at all levels must be prioritized to successfully heighten acceptability and uptake of HPV vaccines among communities. The school-based delivery of HPV-Plus was an acceptable means to integrate complementary adolescent health services, was seen to be more effective in reaching a higher proportion of adolescents and may function as a trusted service delivery platform that fosters confidence among participants.Tanzania’s S1 File(DOCX)Click here for additional data file.S1 Questionnaire(DOCX)Click here for additional data file.S1 Data(XLSX)Click here for additional data file.