The purpose of this qualitative study was to explore perspectives of Whole Health (WH) coaches at the Veterans Health Administration (VHA) on meeting the needs of rural Veterans during the COVID-19 pandemic. The evaluation design employed a qualitative description approach, employing focus groups and in-depth interviews with a convenience sample of WH coaches across the VHA system. Fourteen coaches who work with rural Veterans participated in either one of three focus groups, individual interviews, or both. The focus group data and in-depth interviews were analyzed separately using thematic analysis, and findings were then merged to compare themes across both datasets. Four primary themes were identified: bridging social risk factors for rural Veterans, leveraging technology to stay connected with Veterans at-a-distance, redirecting Veterans to alternate modes of self-care, and maintaining flexibility in coaching role during COVID-19. One overarching theme was also identified following a post-hoc analysis driven by interdisciplinary team discussion: increased concerns for Veteran mental health during COVID-19. Coaches reported using a variety of strategies to respond to the wide-ranging needs of rural Veterans during the pandemic. Implications of findings for future research and practice are discussed. Health coaches represent one of the most rapidly growing allied health professions in the United States ,2,3,4,5.In 2018, the United States (US) Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Office of Patient Centered Care and Cultural Transformation began implementing the Whole Health (WH) initiative, an integrative health approach empowering and equipping Veterans to take charge of their health and wellbeing ,18,19,20Many WH coaches work with rural Veterans, an often hard-to-reach population sharing substantial barriers and constraints to healthcare access while representing a wide range of service eras and sociodemographic diversity ,32,33,34The coronavirus (COVID-19) pandemic disrupted the traditional face-to-face delivery of VHA health and wellness programs ,36. WhilThis paper is based on work conducted as part of an evaluation design to examine coaches’ efforts to extend WH to rural Veterans throughout the VHA. This project was sponsored by the VHA Office of Rural Health. The evaluation was deemed a quality improvement project by VA guidance  and was WH coaches are employees of the VHA, and a subset of these employees are Veterans. Qualifications for WH coaches typically include a bachelor’s or higher degree in a behavioral or social science, and specialized experience in helping clients reach wellness goals utilizing motivational interviewing and shared decision-making health coaching techniques . In addiWhole Health is a VA wide initiative; there are no particular inclusions or exclusions for Veterans participating in WH coaching aside from being enrolled for healthcare at the VHA. Some common health conditions of WH Veteran users may include chronic musculoskeletal pain and psychiatric conditions such as depressive disorder, anxiety disorders, and PTSD ,40,41.This evaluation design is based in a qualitative description approach , commonlDuring the planned analysis, data indicating the reasons why the coaches addressed Veterans’ needs during the pandemic began to emerge from the data. Therefore, a post-hoc analysis was conducted to identify patterns specific to the reasons why coaches engaged in actions that were identified in the primary analysis.The evaluation team developed the FG guide in collaboration with VHA WH stakeholders. Prior to initiating FGs, 33 potential participants who had expressed interest in the quality improvement project during a WH national Community-of-Practice Coaching call were sent a brief, web-based email questionnaire to elicit participant characteristics, coaching experience, and the percentage of rural Veterans coached.Three FGs were conducted in August and September 2020 during national lockdowns due to the pandemic. All FGs were conducted virtually using Zoom videoconferencing technology. Two to three project team members were present during each FG to facilitate discussion and help with troubleshooting issues. Each FG lasted 60 min. All FGs were audio recorded and participants provided verbal consent specifying their participation was voluntary and confidential.The semi-structured interview guide was informed by findings from the FGs and explored in greater depth (1) the role of coaches during the pandemic; and (2) barriers or facilitators coaches experienced when working with rural Veterans.FG participants, as well as those who had previously expressed interest, received an invitation for a follow-up one-on-one interview. Interviews took place between December 2020 and January 2021; this was a period when VHA facilities were beginning to re-open critical, in-person services to Veterans while also continuing to maintain options for socially distanced healthcare through telehealth modalities.All interviews were via Zoom calls. As with the FGs, multiple team members were present during each interview to facilitate discussion and troubleshoot any technical issues. Interview participants gave verbal consent to participate and to be audio and video recorded for the purpose of supporting analysis. Each interview lasted approximately 60 min.Participant demographic characteristics, coaching experience, and percentage of time coaching rural Veterans were summarized utilizing descriptive statistical analysis.Transcripts from FGs were generated from audio recordings using the VA’s centralized transcription service program. A thematic analysis was performed on the transcribed data to identify latent patterns in the data and develop preliminary themes, following established guidelines for thematic analysis . Three cInterview transcripts were generated from the audio recordings. Thematic analysis of the in-depth interviews was informed by the coding framework developed in the analysis of the FGs. This resulted in a new coding framework agreed upon by three members of the project and was inputted into an excel matrix. The final coding framework resulted in a validation of a priori themes of interest, refined themes initially identified from the FGs, and new themes that emerged after researchers read all transcripts. Rigor was enhanced by presentation of preliminary findings to the VHA WH coaching leads.After completing coding for the FG and interview data, the evaluation team worked together to review and refine results from both datasets. After several iterations, the final output of our analyses were themes, or interpretive concepts, around experiences of WH coaches reaching and engaging rural Veterans during the COVID-19 pandemic. Multiple rounds of comparison, reorganization, and refinement occurred before finalizing our findings.Through team discussion, primary themes were discussed and constantly compared with the data. This resulted in one overarching theme, whereby representative quotes were threaded throughout the primary findings.Participating coaches (14) hailed from nine states within the US representing the Northeast, Southeast, Midwest, and West. Participants were primarily female (66.7%). Coaches’ Veteran status was primarily non-Veteran (64%). Participants who reported practicing WH coaching for more than one year (67%) had an average of 2.1 years of coaching experience. All participants reported their coaching was conducted via telehealth since COVID-19, with more than half the participants reporting ≥50% of their caseload comprised of rural Veterans.FGs and follow-up interviews generated rich discussions about participants’ experiences engaging rural Veterans with the WH program and coaching during the pandemic. Four primary themes were identified: bridging social risk factors for rural Veterans, leveraging technology to stay connected with Veterans at-a-distance, redirecting Veterans to alternate modes of self-care, and maintaining flexibility in coaching role during COVID-19. The overarching theme was: increased concern for Veteran mental health during COVID-19.A major theme that emerged from the data was the urgency to address social risk factors and bridge gaps in support of rural Veterans during COVID-19. Subthemes included: lack of access to healthcare resources; lack of access to basic needs ; increased risks for housing displacement; and increased risks for social isolation.Participants described heightened concern for helping rural Veterans access fundamental resources within their local communities during the national US emergency response in March of 2020. In the words of one participant:I was scrambling, home-based primary care was scrambling, we were all scrambling to find a list of resources to get to these Veterans, because it was like, there’s no clinic. Like there’s nowhere for them to get, you know, there was no CVS . There’s no place to get the flu shot. There’s no place to get [undecipherable], there’s, like, all these things…, and then, on top of it all, we have COVID-19.Coaches we interviewed felt that while rural Veterans had the advantage of being almost “naturally socially distanced” due to the nature of being in a rural area, it was the challenges of meeting basic needs that caused coaches the most concern during the initial period of the pandemic.[when] they’re already hurting for cash… [and they need to] make an extra trip to go get healthy food and drink, it’s… [the ability] to be able to [have the transportation to] go [is the barrier].” For some rural Veterans, standing financial constraints were compounded by decreased access to food and transportation. One participant expressed how these standing constraints intersected in the lives of some rural Veterans “Another participant described how her clients were trying to ascertain how they would access basic foodstuffs in locations where store shelves were insufficiently stocked because of the severe wildfires that hit the Western US in 2020 in the midst of the pandemic:The problem with not having access to healthy foods, especially during the pandemic, [is that] the shelves are empty. I had two patients… in [area] which is mountains… [and] when it was the fires and everything, their grocery stores were empty… so those are the things that, that our rural [Veterans]… are dealing with. Because, between the fires and the pandemic, they’re not getting the shipments… I know that one lady, the one Veteran that I was dealing with last week… she was able to get a ride from a nephew, because she doesn’t drive, to go a little bit further and find a farmers market; so she was able to get some things; but the grocery store, it didn’t have anything [in stock].Moreover, this coach highlighted how important it was for her to stay connected to her rural Veteran clients during a time when many people in her region had been displaced by natural disaster. She described not wanting to “lose track” of rural Veterans who were at risk of housing displacement, and leveraging community connections to identify and relay information about specific resources needed by the Veterans:I’m like, we don’t want to lose track of our [rural Veterans]. Because if they’re displaced… it wasn’t like we were going to find them easily… And it was like trying to figure out, okay, what resources do we have for me to give them [her rural Veteran clients]? So, it was another thing where it was important to be connected to the community… I was getting the information, to be like, ‘okay… for people who have horses’… there was like whole teams of people who were taking their trailers to go save people’s horses. It is important to be… making those community connections, at any chance, any turn that you can, because in times of emergency, you might be able to find out a little bit more.Coaches also reported that Veterans they worked with had to travel further to acquire food and were compelled to rely on alternative forms of transportation to travel there, in a context where previous transport options were non-existent or unavailable. Consequently, the local suspension of transportation services also translated into reduced healthcare access for this population:[For my] rural patients, I do have several patients who have been impacted a lot by COVID, just simply transportation. You know, when public transportation stops, at a certain point, and then they depend on other kinds of transportation, those are patients who are having trouble just if they have to come to a regular appointment. Like, to get labs drawn. They literally can’t, because the rural transportation has stopped, and they don’t drive.Coaches working with rural-residing Veterans during this time described how important it was to maintain connections with them to try to address the gaps they were facing in meeting basic needs. In addition to the challenges around access to healthcare, transportation, and food, as well as increased risks for housing instability, coaches reported that COVID-19 also increased existing rural Veteran risks for social isolation. COVID-19 impacted the ability to meet in-person, something participating coaches noted rural-residing Veterans had expressed enthusiasm for:I work at 2 different CBOCs … At the CBOC which was completely rural…they were glad to have us there. They were glad to have something offered, so they were much more inclined to want to do something [with the WH program]… We went to a coffee talk a few months ago [pre-Covid19]… [and] from my CBOC, it was 35 miles away. Of course, we had Veterans coming in from way past that. And the question was asked: ‘What would it be like for you if we had a Whole Health van that came out to you, at least once a month’, and you saw 150 hands raise up and go—‘Yeah, we would love that’.Consequently, through social distancing protocols and suspension of WH group coaching opportunities, Veterans faced increased social isolation. One coach described the impact of the closure of spaces on her rural Veterans who had become accustomed to gathering for group coaching sessions:We have a couple ranches here, and so a lot of the times, when I would do my group sessions, I would take them to the ranch… they could also, on the side, do some equine therapy or other things that the ranch offers. [The ranch] cater[s] directly to our Veteran community. Every Wednesday is for women only, so we do a lot of things just for the women on Wednesdays… [and the ranch has] dinners on Thursdays, and Veterans are allowed out there at any time.… [But] they won’t let me have the groups at the ranch now…so that’s very hard, because these people really were getting a lot out of being together.Another important theme that emerged was staying connected with rural Veterans at-a-distance by leveraging technology. Staying connected became a priority for coaches working with rural Veterans in the context of lockdowns and social distancing. Coaches described rapidly pivoting to alternative modalities at the VHA to try to ensure uninterrupted access to WH, initially via telephone and then later through the VHA’s video telehealth platform, Veterans Video Connect (VVC):Within a week’s time we had flipped all of our face-to-face coaching, and individuals that were signed up for [in-person] Intro to Whole Health were switched over to telephone,…’VVC’ was going to be a part of how our VA did outreach, but it had not been implemented yet, so we… had to quickly implement… [using telephone to reach Veterans].COVID really just jumped ‘VVC’ into overdrive” . They also noted that not all Veterans were benefitting equally from the video telehealth platform, especially rural Veterans:While video telehealth had been part of the VHA for several decades now, WH had relied more on face-to-face contact with Veterans. However, coaches reported that “… As we’re all experiencing right now, we’re not really meeting the needs of [all] our Veterans, because [some] don’t have internet access [and] without having the internet, [rural Veterans] are not able to participate [in Whole Health].Another participating coach explained why some rural Veterans were not able to benefit from the virtual platform for delivering WH, ranging from the lack of broadband connections in rural areas and a lack of appropriate devices, to an insufficient amount of technology literacy:There were quite a few Veterans that just didn’t have internet. They didn’t have computers, laptop, or a PC… all they had was their phone… They were either… more frontier [with less reliable internet connection]… [or] older and being a little bit more rural, [they] preferred telephone. They didn’t want to mess with the VVC. They didn’t like it… the bandwidth didn’t work… or they couldn’t figure out their camera… [or the] microphone. Or they just flat out didn’t have a computer and they were trying, you know, to have a doctor’s appointment with their phone.For those rural Veterans without reliable internet, coaches reported that their options “dwindled”:It’s the ones that don’t have internet and are really, really, rural, that I struggle with the most as a health coach—and feeling, ‘how much can I… help them, when they want to work on these things [that are offered virtually]?’… my resource list… dwindles down a lot.To help bridge the gap for these rural Veterans, coaches described the ways in which VHA was increasing its capacity to bridge the digital divide:… the VA has just done a big switch here within the last several months, where all video appointment consults… go… to a ‘digital divide consult’… the social worker connects with the Veteran [and asks:] “Do you have a personal device, your cell phone or do you have a computer, or do you not have any [device]?” to try to explore that. And [they ask about] comfort levels if they do have a cell phone or a laptop. If they… have… Wi-Fi or internet, then we can go ahead and get them set up to get their test call and try it out and see if they like it. The majority of them don’t [have a device], so… [we put in a request] to get them a VA-issued iPad… And this was a topic point before COVID19, [but] really it has [been] accentuated during COVID19.even though he can’t leave the home and he can’t hear or see”. Once connected to the internet, coaches also described interdisciplinary efforts to ensure that WH could reach Veterans; for example, in the case of a rural Veteran with traumatic brain injury and a visual and an auditory disability, who needed special technologies to hear and communicate, the coach worked with the Veteran’s audiologist and an interdisciplinary team of providers to troubleshoot how to provide WH to him, “schedule his coaching sessions via telephone on his lunch hour… [from an] oil field, so he would literally be… an hour from any… town or any type of… access to anything”. Coaches reported that in some cases, rural Veterans who had internet access but were averse to learning the new technology, or preferred something they considered more convenient, opted for continuing their coaching via the telephone. One coach described a Veteran who lived and worked in a rural area, who would “So now that everybody is on VVC… the persons I coached said—”Can we do VVC instead of telephone, so I can see you? I said—Okay.” So we switched that to VVC right now.” While for some rural Veterans, the lack of broadband connection and/or aversion to using video telehealth modalities made connecting with Veterans via VVC challenging, others felt that the video technologies were expanding the potential for a kind of ‘face time’ that did not rely on being in person. As a coach explained, “With COVID-19 limiting gatherings, coaches reported working with rural-dwelling Veterans to find a way to shelter-in-place and practice self-care, despite the isolation. One participant described helping a Veteran problem-solve to find meaningful activities that could be conducted within her own home and with her grandchildren:[As a nearby gym was closing]… Veteran said, ‘I could go to Fort [name]’, which is two hours away. [But then Veteran says], ‘I can’t do that’. So, she’s been doing a lot of the home exercising on her own… she’s been doing a lot of self-care. [She said] “You know, I can spend my time out in the garden, keep myself busy, have the grandkids come over and they’ll help out… help me build a tomato [garden].” She’s been a lot more [focused on] self-care [at home than before pre-COVID].In a similar vein, another coach also spoke of doing more coaching and troubleshooting with rural Veterans, supporting their wellness, physically and mentally:During COVID I [have done] a lot of coaching, even more than usual, related to ‘how do you keep even doing anything at all?’ Physically, mentally, trying to stay well, when you have a hard time getting into a facility…and that facility meaning a gym or a workout center, or a clinic, but especially health-related things. And lots of really, really small towns or Veterans that are maybe 100 miles away from the closest decent-sized town.Participants also described innovating on WH content that would address the self-care needs of rural Veterans for whom access barriers were exacerbated and developed creative strategies for engaging Veterans in WH. One coach marveled at her success in adapting what was formerly an online yoga session to a phone call:A lot of them are suffering from low back pain… [I ask] “Well, have you ever thought about or would you ever be interested in learning [yoga]?” So I actually end up coaching yoga over my phone, and they do it. And… it’s amazing to me, without seeing yoga, just talking yoga, how much they can learn to do, or they’ll say “yes, well, I have my hands here, and I’m standing up” or “I’m folding forward at the waist”… it’s pretty interesting!Sharing calendar schedules filled with new course offerings that ranged from online mindfulness groups to exercise groups to remote cooking classes, another coaching participant described the virtual wellness classes that he offered weekly in addition to coaching:I think we’ve done a great job as I offer three mindfulness classes a week and on Tuesdays I have an all-female class… we’ve been offering live [online] yoga classes, live Tai Chi classes, plus ones that are pre-taped. So I think we’ve done a phenomenal job really reaching out to those that may not be working that just want something to do… If they have a low back pain, [I suggest] let’s try the yoga or Tai Chi… [offered] four or five times a week through VVC. So I think we’ve done a phenomenal job really reaching out to those Vets… [we have] all the way up from beginners the to the advanced groups… it gives them [something] to keep… active.Coaches described how the virtual platform allowed for unprecedented participation for rural Veterans in wellness programs:Now with COVID, [we] turned just about everything we have on [to] VVC… we find that there is more rural Veteran involvement… those Veterans, I find, have very big commitments [to an online exercise program], so they are very committed, and a lot of them go through, you know, health coaching as well.Coaches also described reaching out to rural-residing Veterans with a variety of other resources, such as an app in support of self-care and mental health during COVID-19:I don’t want to overwhelm them, but I tell them that I’m going to send them some interesting things. Like the apps. We got a COVID coach app that’s awesome. I love that app. And so, I’ll send them some information, and you know, the people that really, really want to make a change in their life are excited about all that.Coaches described reaching out to rural Veterans during a time of heightened isolation, but they also reported that not all Veterans were immediately receptive. For some Veterans, the pandemic itself was a rationale for keeping their distance and not engaging in WH programming:I’ve had several Veterans who just have kind of said ‘now is not the time for this. I just need to get [through this], you know I can’t be bothered’… That’s always disappointing but understandable. I mean, the truth is we do what we need to do to get through [things] in difficult times. And so you always leave the door open… I usually ask permission and say, “Can I call you in 30 days just to check in and see how you’re doing?” No one’s ever said no to that. So that’s nice.Considering the heightened social isolation, participants discussed how they adjusted their role as a coach during the pandemic to meet rural Veterans’ most pressing needs:One of the things we had started when COVID first hit,… we started outreaching as much as we could to every Veteran that we serve. We just started doing cold calls. Part of it was to check in to say, “Hey, we’re here, we’re alive, we haven’t forgotten you.” And the other is to see if there’s anything they’re interested in,… to see what they needed from us, whether it’s clinical, whether it’s ‘I just need an ear to talk to, because I’m lonely, stuck out here in the middle of nowhere’.This same coach reported that his ability to establish rapport with rural Veterans was enhanced by the same isolation his Veteran clients were facing:In some ways, [the isolation] makes it easier once you make the connection. When you make the connection, now they have somebody to talk to. They will admit that at times it can get very lonely out there, and they just want to talk to somebody, but they don’t trust enough people to talk to them. So, when they can make that connection, even if it’s over a phone—honestly, most of my rural coaching is done over the phone—they just want to be heard.regular appointments [rural Veterans] are getting, because they can’t get here [to the facility]”. During the pandemic, some coaches described being one of the main points of contact and one of the only “This was especially true during moments of crisis when many people were unsure about their risks for exposure. One coach described using her coaching role as a way to provide social and medical support for rural Veterans:They don’t want to come out at all. So… like you know, they’ve been… complaining [about symptoms], and I’m like, “You need to come to the emergency room, or you need to come in.” So I’m calling the RN: “Can you call them?… And it comes from that relationship, the importance of building relationships, especially with rural [Veterans] is important. For every single Veteran, but I feel like especially for rural Veterans, you have to have that relationship.This coach also explained that she found her coaching role to be an opportunity to help alleviate heightened anxieties during the pandemic:Every once in a while, if they’re coming in [to the facility] to take a COVID test, those are the things… they need support in… You know, thinking you have COVID is scary.Coaches also described being nimble in modifying their typical coaching protocol as the stressors of life under pandemic conditions increased for Veterans. For example, one coach expressed adapting his coaching protocol to for a Veteran “in need of someone to talk to”:[I coached a rural-dwelling Veteran] who was a single father and struggling… he was not working and [was] living off about 1400 dollars a month with a 14-year-old daughter that he was not having a good relationship [with]… Even though he wanted a weight loss goal… [as] we started developing some action plans…it seemed like every week, the primary conversation was his challenges with finances and being a provider for his daughter, he was so thankful. He said, “You calling me, I appreciate that. I needed someone to talk to because I think I’m pulling my hair out. She won’t wash the dishes. She won’t listen to me. She won’t do anything…” So he just needed someone to talk to… it really got to where it wasn’t coaching anymore. It was just being someone to actually listen to him. And because of his frustrations, I don’t mind being that that person, at points. It is outside the coaching role… but as a Veteran, I have a passion for other Veterans.This Veteran coach further described how maintaining dialogue to stay connected to Veterans outside of the coaching relationship was important during the pandemic for some Veterans experiencing substance use issues:We had to discontinue the coaching session… they need the services that we can’t offer [under coaching]… [the] prime goal is to manage their sobriety… So I have two of them that… I’m still talking to, but [have not] actually coached them at this point; they’re actually back into the inpatient services. I had a Veteran who had a mental health breakdown and so his Whole Health goal was to connect back with his primary care for his mental health condition before continuing coaching. So, we are their connection, [the connection] is still there.In addition, this coach reported staying abreast of Veterans who were also patients of the VHA’s Mental Health service. He followed their charts for evidence of missed appointments and used wellness checks as a touchstone for them:… If I’m working with [rural Veterans] that have a high-risk flag [on their medical record], and I haven’t heard from them two weeks… I’m going to do a wellness check. I’m going to call them and ask them, you know, “Are they okay? [I’ll] leave a couple of voicemails, do a chart review, and see if their mental health providers are… being able to contact them.” But it’s things like that, just making sure that those Veterans that I am charged for working with [are OK].Overall, participating coaches highlighted heightened flexibility in their roles as an aid for maintaining relationships with rural Veterans during the pandemic.This evaluation examined the experiences of WH coaches engaging rural Veterans during the COVID-19 pandemic. From their perspectives, key social determinants of health (SDOH)  were negParticipating WH coaches also extended their services and supports in response to what they perceived as social isolation and its negative impacts on the Veterans they served. Our findings are consistent with those reported in a recent study investigating COVID-19 impacts on Veterans’ health and wellbeing . These rWe also found that coaches attempted to support Veterans in navigating SDOH-related challenges, while remaining cognizant of the limits of their scope of practice as health coaches. Our findings echo the work of Jordan (2021) who asserted that, during times of crisis, it is appropriate for coaches to adopt a broader public health lens . CoachesWhile the behavioral, social, economic, environmental, and occupational factors that impact health have typically fallen outside the domain of the conventional biomedical system , unlike While working within the VA’s interdisciplinary team-based model of care, coaches in this evaluation drew upon their networks to enact what has been called a ‘science of cooperation’ that partners across health, social services, and local communities . CoachesThis wider perspective of practice also included innovating with the use of technologies to extend their reach to rural Veterans. Prior to COVID-19, the primary strategies used by coaches to introduce Veterans to WH relied on face-to-face, in-person interactions. Although the VA has long been at the vanguard of developing and implementing tele-based delivery of healthcare services to Veterans ,59,60,61The transition of health coaching to a tele-approach raises salient social science questions when we consider health coaches’ work through the lens of affective labor . AffectiThe increased use of remote technologies that resulted from COVID-19  has the Finally, we found that the COVID-19 pandemic exacerbated existing concerns for Veteran mental health. Veteran mental health is longstanding primary concern within the VHA . ResearcFindings provide the first appraisal of the VHA WH initiative from the perspective of coaches working specifically with rural Veterans during the COVID-19 pandemic. However, viewpoints were not obtained from Veterans or non-coaches regarding the impact of the pandemic on their WH experience which limits our ability to fully describe. Findings also contribute in-depth insight into a wide range of processes used by practicing VHA coaches; they do not, however, provide insights into practice trends that may have transferability beyond our sample. Future research studies are warranted, including those encompassing Veterans’ and other allied health professionals’ perspectives.This paper explored perspectives of Whole Health coaches on meeting the needs of rural Veterans during the COVID-19 pandemic. Coaches perceived that key social determinants of health were negatively impacted for many rural-dwelling Veterans during the pandemic in the areas of social and community context, health and health care, and neighborhood and built environment. In their ingenuity and commitment to supporting rural Veterans, coaches expanded their forms of support to respond to the wide-ranging needs of rural Veterans and attempted to bridge risk factors that were exacerbated for Veterans during the pandemic. Our findings suggest that health coaches may be well positioned to address Veterans’ health within a broader definition of wellness by leveraging additional forms of social support and tapping into expanded networks during times of crisis; however, more research is needed to examine the role and scope of coaches during such pivotal times.


Human papillomavirus is a primary cause of cervical cancer and genital warts. HPV vaccine can prevent high-grade cervical lesions as well as cervical cancer. The aim of this study was to analyze the prevalence and genotype distribution of human papillomavirus among women in Guangxi before and after the HPV vaccine was approved for use in China.From January 2016 to May 2021, 41,140 women were tested for HPV infection. HPV genotyping included 15 high-risk HPV (HR-HPV) and 6 low-risk HPV (LR-HPV) genotypes. Total prevalence, annual trend, and specific age group prevalence and genotype distribution were analyzed.The overall HPV infection rate was 18.10% among Guangxi women self-referred to clinic for gynecologic problems in southern China. During 2016–2018, the prevalence of HPV infection showed an upward trend, from 18.21% in 2016 to 21.99% in 2018, and later it showed a downward trend, from 18.35% in 2019 to 12.26% in May 2021. Pure HR-HPV genotypes (14.36%) were found in more infections than pure LR-HPV genotypes (2.77%) and mixed genotypes (0.97%). Two peaks of HPV infection were found in the ≤ 25 years (22.94%) and 56–65 years (21.25%) groups. The six most prevalent HR-HPV genotypes were HPV 52 (4.06%), 16 (2.70%), 58 (2.24%), 51 (1.87%), 39 (1.52%), and 53 (1.52%). The three most prevalent LR-HPV genotypes were HPV 6 (1.31%), CP8304 (1.01%), and 11 (0.82%). Infection with a single HR-HPV genotype was the most common type of infection, with an overall infection rate of 12.30%. Infection with two HPV genotypes was the most common multiple HR-HPV infection type, with an infection rate of 2.35%.The cervical HPV infection rate of women in Guangxi is very high, and there is significant age specificity. There is a need to increase HPV vaccination of young people and the screening of middle-aged and elderly people. Human papillomavirus (HPV) infection is the main causative factor of cervical cancer; specifically, persistent infection with high-risk HPV (HR-HPV) genotypes. Studies have confirmed that more than 80% of women have had at least one HPV infection  and thatAmerican Society of Colposcopy and Cervical Pathology (ASCCP)  issued aThe bivalent HPV vaccine (which protects against HPV 16/18) was approved in China in July 2016, and the quadrivalent vaccine (HPV 6/11/16/18) and nine‑valent vaccine (HPV 6/11/16/18/31/33/45/52/58) were introduced in May 2017 and April 2018, respectively. This study analyzed the status of HPV infection in Guangxi over the past 6 years and examined the trend of HPV infection and genotype distribution. The purpose of this work was to generate information that would allow improvements in the performance of the corresponding healthcare work.The study population consisted of women who attended the gynecological clinic of Minzu Hospital in the Guangxi Zhuang Autonomous Region from January 2016 to May 2021. Reasons for their HPV testing include gynecological exams, urethritis, vaginitis, irregular vaginal bleeding, cervicitis, and condyloma acuminatum undiagnosed abdominal pain. The age of the patients ranged from 14 to 87 years old. Information about their HPV test results was collected retrospectively.A speculum was used to expose the cervix, and a dry cotton swab was used to remove cervical secretions. A cervical brush was placed in the cervical canal and unidirectionally rotated four to five times to ensure that sufficient epithelial cells were obtained. The cervical brush was then placed into a sample preservation tube with preservation solution and the cap tightened. The sample tubes were compatible with the HPV genotyping test kit of Chaozhou Hybribio Biochemical Co., Ltd. (China). In accordance with the manufacturer’s instructions, all samples were sent to the laboratory within 24 h and stored at 4 °C, and HPV testing was performed within one week.All collected samples were genotyped for HPV using the HPV Genotyping Test Kit (polymerase chain reaction (PCR) + flow-through hybridization; Chaozhou Hybribio Biochemical Co., Ltd., Guangdong, China). The test has been approved by the State Food and Drug Administration (Permit Number: 0041040) and can detect 21 HPV genotypes: 6, 11, 16, 18, 31, 33, 35, 39, 42, 43, 44, 45, 51, 52, 56, 58, 59, 66, 68, and CP8304.DNA extraction, amplification, and hybridization and interpretation of the results were carried out in accordance with the instructions of the kit. DNA was extracted using an automated nucleic acid extraction apparatus . An ABI 9700 PCR instrument was used to perform gene amplification. An automatic nucleic acid molecule rapid hybridization instrument (HBHM-3000S) was used for reverse dot hybridization. Negative and positive controls were established throughout the experiment. At the same time, internal quality control and external quality evaluation were carried out, and the results were in line with the requirements of the laboratory.P < 0.05 was considered statistically significant. GraphPad Prism 5.0 software was used for drawing.The data were added to an Excel spreadsheet, filtered, and stratified by age . Analyses were conducted with SPSS version 20.0. HPV infection rate differences across years and age groups were calculated using the chi-square test. 2 = 238.352, df = 5, P < 0.001). The highest overall HPV infection rate was found to be in 2018 (21.99%), while the lowest HPV infection rate was found to be in 2021 (12.26%). During 2016–2018, the prevalence of HPV infection showed an upward tendency, and it showed a downward tendency from 2019 to May 2021.This study included 41,140 women who attended Minzu Hospital in the Guangxi Zhuang Autonomous Region. The overall HPV infection rate was 18.10%  during the study period of January 2016 to May 2021 . Two peaks of HPV infection were found in the ≤ 25 years (22.94%) and 56–65 years (21.25%) groups . The HPV infection rates were significantly different among the age groups . The rate then generally declined from 18.35% in 2019 to 12.26% in 2021. Luo et al.  showed t9%. The rParticipants were placed into six groups according to their age . Two peaks of HPV infection were detected in the ≤ 25 years 22.94%) and 56–65 years (21.25%) groups  was higher than that with pure LR-HPV 2.77%) and mixed HPV . The related studies can provide data references for vaccine development. HPV 6 and 11 infections were mainly concentrated in the ≤ 25 years group, and infection with these genotypes was found to be low in the other age groups.In summary, the HPV infection rate in Guangxi is high (18.10%), it had an upward trend from 2016 to 2018, a downward trend after 2018, and was dominated by single high-risk genotypes. The highest rates of HPV infection were in women ≤ 25 years and 56–65 years. The main genotypes were HPV 52, 16, 58, 51, 39, and 53. The 46–55 years group had the highest HPV 16 infection rate, and the highest HPV 18 infection rate was found in the 36–45 years group.Given that China is a developing country with a population of 1.4 billion, that the most prevalent HR-HPV genotypes vary across regions, and that there is significant age specificity, understanding HPV genotype distribution is essential for better planning of cervical cancer screening and HPV vaccine development. It is necessary to increase HPV vaccination of young people and the screening of middle-aged and elderly people.


The ED and TAMV were not significantly different between the patients and controls (p = 0.4985 and p = 0.1564). No sonographic parameter was significantly different between LSIL and HPV condyloma. The mean PI, RI, and VI were significantly lower in LSIL than in the controls. For HPV condyloma, a PI of 1.07 had an 84.6% sensitivity, 85.0% specificity, and an AUC of 88.8%; for LSIL, a PI of 1.08 had a 100% sensitivity, 85% specificity, and an AUC of 94.2%; for HPV infection (HPV condyloma + LSIL), a PI of 1.08 had a 94.9% sensitivity, 85% specificity, and an AUC of 92.4%. Hotspot vascular classification and micro-vessel flow velocity waveforms may provide a potential practical method for the auxiliary diagnosis of cervical HPV infection. The PI may represent a valuable index for distinguishing the micro-vessel flow velocity waveforms in LSIL and HPV condyloma. Since the case numbers were limited in the current study, further validation is needed. To assess hotspot micro-vessel flow velocity waveforms in human papillomavirus (HPV) cervical infections using transvaginal power Doppler ultrasound (TV-PDU) and to explore the associations of these sonographic parameters with HPV condyloma and low-grade squamous intraepithelial lesions (LSIL) of the cervix. A total of 39 patients with cervical HPV infections with abnormal cytology and colposcopy results  were enrolled to assess the vascular classification of the cervix and micro-vessel flow velocity using TV-PDU before treatment; 40 individuals with a pathologically normal cervix were used as the control group; seven parameters were measured, including vascular grading classification , lowest pulsatility index (PI), resistance index (RI), peak systolic velocity (PS), end-diastolic velocity (ED), time average maximum velocity (TAMV), and the vascular index (VI = PS/ED). According to vascular classification, most LSILs were class I , followed by class II  and class III . Most HPV condylomas were class I , and one was class II . PI, RI, VI ( Human papillomavirus (HPV) is a DNA virus from the Papillomaviridae family, containing more the 450 genomes of almost distinct types which have been isolated and sequenced ,2. Many The main objective of this study was to attempt to perform a detailed assessment of the morphology and blood flow velocity of micro-vessel hotspots in the cervix using transvaginal power Doppler ultrasound (TV-PDU), specifically in patients with LSIL and HPV condyloma, because of the possibility of regression being significantly higher in this category compared to in HSIL group . MoreoveA total of 50 patients with colposcopic findings of LSIL of the cervix were enrolled at Taipei Veteran General Hospital from January 2016 to December 2018. All colposcopic examinations were performed by one of the authors (P.-H.W.) to avoid interobserver variation after finishing the examination by transvaginal ultrasound. The inclusion criteria were outpatients who underwent colposcopic examination and biopsy due to Pap smear results as LSIL, and the final pathological reports confirmed the diagnosis of LSIL of cervix. Additionally, the inclusive criteria stated that the study subjects should have a positive HPV DNA test. This study excluded non-HPV pelvic infections, or other unrelated LSIL clinical situations, such as cervical myomas, large Nabothian cysts, and other cervical masses. The inconsistent reports of LSILs between Pap smear and final pathological reports were also excluded. Other exclusion criteria included pregnancy, and post-menopausal status. Finally, 26 cases met the inclusion criteria; 13 women with colposcopy-guided-biopsy- and pathologically-confirmed cervical condyloma were included in the current study. A total of 40 women were recruited as the control group, with the inclusion criteria for the control group stating normal cervical cytology, a negative HPV test, normal transvaginal ultrasound of the cervix and uterus, and no abnormal pathology of the cervix, vagina, or uterus upon pelvic examination. The general characteristics of the patients are presented in All 79 women were scanned using a color Doppler ultrasound  equipped for color Doppler imaging and color Doppler angiography in the semi-lithotomy position with an empty urinary bladder within 24 h of undergoing treatment. A 7.0 MHz curved array endo-vaginal probe was used; the field of view was set to 112 degrees. The uterine cervix was scanned and identified carefully in a longitudinal view in grayscale mode. After shifting to angio mode, the color gain was adjusted from 105 to 115, the scale was adjusted to pulse repetition frequency (PRF) and set from 800–900 Hz to filter out the low-strength signals, and the temporal filter was adjusted to 1.0 to exclude the blue color within the region of interest (box). Vascularity within the uterine cervix was detected in the axial view. We selected the section within the uterine cervix with the most significant blood flow color signals and the most apparent hotspots in the region of interest. The number of hotspots observed under power mode color Doppler ultrasound was classified into three classes .After visually classifying the grade of vascularity in the power mode color Doppler ultrasound, we activated pulse Doppler mode and adjusted the Doppler gate over the target color area to set the proper gate distance and adjust the angle of the sampling site to less than 60 degrees. We defined the detectable Doppler signals as a series of reproducible, similar arterial waveforms obtained for at least three separate consecutive cardiac cycles. Good Doppler signals were processed and analyzed using online spectra. All measurements were calculated manually, including the peak systolic velocity (PS), end-diastolic velocity (ED), time-averaged maximum velocity (TAMVV), pulsatility index (PI), resistance index (RI), and vascular index (VI). If more than one set of satisfactory samples was achieved, the lowest set of PI, RI, and VI values was recorded. The pulsatility index was defined as the ratio of the difference between the peak systolic and end-diastolic velocity to the mean velocity. The resistance index was defined as the ratio of the difference between the peak systolic velocity and end-diastolic velocity to the peak systolic velocity. The vascular index was defined as the peak systolic velocity divided by end-diastolic velocity (PS/ED). One author (Y.C.W.) performed and assessed all scans to avoid interobserver variation.p-values < 0.05 were considered statistically significant.The difference in vascular grading between the study groups was analyzed using Fisher’s exact test. Cervical micro-vessel flow waveform parameters were analyzed using the Kruskal–Wallis test. A Post hoc analysis was conducted using the Benjamin–Hochberg procedure. Spearman’s rank correlation was used to assess the relationship between vascular grading and waveform parameters. Clopper-Pearson’s exact method was used to estimate the testing accuracy confidence intervals. The Statistical Package for the Social Sciences (SPSS) for Windows, version 22.0 , was used for all data analysis, including the intra-observer reproducibility and receiver operating curve analysis. p = 0.052). The mean age of the 79 individuals included in this study was 37.8 (23–58 years old). The mean age of the case group (39.9 ± 11.9) and control group (35.8 ± 6.1) was not significantly different (The pick-up rate for vascularity was 100% (39/39) for the case group and 27.5% (11/40) for the control group. The absence of vascularity was classified as class 0. In the control group, 72.5, 25.0, and 2.5% of cases were classified as class 0, class I, and class II, respectively. No individuals in the control group were classified as class III. Of the 39 patients with LSIL and HPV condyloma of the cervix, 30 (76.9%) cases were classified as class I , 8 20.5, and 1 .p < 0.000). The Fisher exact test with multiple comparison adjustments also revealed significant differences between the HPV condyloma subgroup and control group (p < 0.000) and the LSIL subgroup and control group (p < 0.000). However, the difference in the vascular classifications of the HPV condyloma subgroup and LSIL (CIN I) subgroup was insignificant (p = 0.786). The vascular classification of the cervix correlated negatively with the PI , RI , VI (S/D), and PS , but not with the ED  or TAMV  of the subgroup with HPV condyloma were classified as class I, 1  as class II, and 0 as class III. In the subgroup with LSIL of the cervix, 18 patients  were classified as class I, 7  as class II, and 1  as class III. The vascular classification was significantly higher in the subgroup with HPV cervix infection than in the control group (p = 0.0000). Similarly, the mean RI was significantly different between the cases (0.61 ± 0.04) and the control group . The mean VI was also significantly different between the cases (2.59 ± 0.30) and controls . Moreover, the PI, RI, and VI differed significantly between the HPV condyloma subgroup and the control group (p < 0.01). PI, RI, and VI differed significantly between the LSIL (CIN I) subgroup and the control group  and the control group  of 84.9%, a negative predictive value (NPV) of 84.7%, and an accuracy of 88.8% for HPV condyloma. An RI cutoff value of 0.62 had a sensitivity of 69.2%, a specificity of 85.0%, a PPV of 82.2%, an NPV of 73.4%, and an accuracy of 78.7% for HPV condyloma. A VI cutoff value of 2.58 had a sensitivity of 69.2%, a specificity of 85.0%, and an accuracy of 76.3% for HPV condyloma A.A PI cutoff value of 1.08 had a sensitivity of 100%, a specificity of 85.0%, a PPV of 87%, an NPV of 100%, and an accuracy of 94.2% for LSIL of the cervix. A RI cutoff value of 0.65 had a sensitivity of 88.5%, a specificity of 72.5%, a PPV of 76.3%, an NPV of 86.3%, and an accuracy of 81.9% for LSIL. A VI cutoff value of 2.86 had a sensitivity of 92.3%, a specificity of 67.5%, and an accuracy of 81% for LSIL B.A PI cutoff value of 1.08 had a sensitivity of 94.9%, a specificity of 85%, a PPV of 86.4%, an NPV of 94.3%, and an accuracy of 92.4% for HPV infection. An RI cutoff value of 0.65 had a sensitivity of 84.6%, a specificity of 72.5%, a PPV of 75.5%, an NPV of 82.5%, and an accuracy of 80.8% for HPV infection. A VI cutoff value of 2.82 had a sensitivity of 84.6%, a specificity of 70%, and an accuracy of 79.4% for HPV infection C.The PI of the cervix was the most useful sonographic index for distinguishing the micro-vessel flow velocity waveforms of HPV condyloma, LSIL (CIN I), and HPV infections of the cervix .The intraclass correlation coefficients (ICCs) for all measurements were moderate: the ICC for PI was 0.606 , 0.636 (0–0.902) for RI, 0.638 (0–0.902) for PS, 0.678 (0–0.913) for ED, 0.671 (0–0.911) for TAMV, and 0.649 (0–0.902) for VI.Bacterial and viral pelvic infections are significant diseases among young and adult females; they affect the female reproductive organs, including the vagina, cervix, womb, fallopian tubes, and ovaries. HPV is the most common viral infection of the reproductive tract and a leading sexually transmitted infection worldwide ,17. The Our analyses based on a visual classification system reveal that most cases of HPV infection presenting as cervical condyloma were classified as class I , and most cases of LSIL were classified as class I or class II 25/26, 96.2%). The hotspots were not detected in most of the control group members , and only 10/40 (25%) of the control group were classified as class I. Thus, if the classification is greater than or equal to class I, the case can be regarded as HPV infection of the cervix. The sensitivity of the classification system for detecting HPV infection (LSIL+HPV condyloma) was 100%, and the specificity was 72.5% . Thus, t, 96.2%. p < 0.001) [Belitsos et al. found that three 3D-power Doppler ultrasound indices  were significantly higher in a group with precancerous lesions than in a control group (< 0.001) . In thei< 0.001) . Schulte< 0.001) .p < 0.01; As in our previous study, we assessed the main sonographic parameters in patients with pelvic inflammatory disease presenting as acute cervicitis . Three mp > 0.05). This finding may be because the representative axial Doppler sections did not have significant vascularity, or the control group was not completely healthy but only tested negative for HPV infection. Their second finding was a significantly lower RI for the cervical arteries (0.66 ± 0.86) in the positive high-risk HPV group than in the control group (0.70 ± 0.06) [Dogan et al.  reported ± 0.06) ; this re ± 0.06) ,32, espeThere is no doubt that there are some limitations in the current study, including a small sample size, absence of consideration of the potential influence of the menstrual cycle, and no further specific tests to exclude other possibilities of infection. Additionally, we did not perform any additional study to exclude the possibility of concealed underlying diseases, which may influence peripheral circulation. However, by history taking and physical examination, all subjects in the current study appeared “normal” and “healthy”, except those study subjects who had problems with HPV condyloma or LSIL of the cervix. Additionally, in standard routine practice at our hospital, a Pap smear and colposcopic examination are often recommended for premenopausal women when the menstruation period has ended. If the vascular classification is greater than or equal to class I, the sensitivity of the classification system for detecting HPV infection (LSIL+HPV condyloma) was 100%, and the specificity was 72.5%. For cervical HPV infections, a PI cutoff of 1.08 had a sensitivity of 94.9% and a specificity of 85.0% . Thus, the cervical PI may represent a valuable index for detecting micro-vessel flow waveforms in HPV infections, especially in LSIL and HPV condyloma. This study may provide an alternative and practical method for diagnosing cervical HPV infections using transvaginal ultrasound, although further validation will be needed due to the small sample size in the current study.


To update resource-stratified, evidence-based recommendations on secondary prevention of cervical cancer globally.American Society of Clinical Oncology convened a multidisciplinary, multinational Expert Panel to produce recommendations reflecting four resource-tiered settings. A review of existing guidelines, formal consensus-based process, and modified ADAPTE process to adapt existing guidelines was conducted. Other experts participated in formal consensus.This guideline update reflects changes in evidence since the previous update. Five existing guidelines were identified and reviewed, and adapted recommendations form the evidence base. Cost-effectiveness analyses provided indirect evidence to inform consensus, which resulted in ≥ 75% agreement.Human papillomavirus (HPV) DNA testing is recommended in all resource settings; visual inspection with acetic acid may be used in basic settings. Recommended age ranges and frequencies vary by the following setting: maximal: age 25-65 years, every 5 years; enhanced: age 30-65 years, if two consecutive negative tests at 5-year intervals, then every 10 years; limited: age 30-49 years, every 10 years; basic: age 30-49 years, one to three times per lifetime. For basic settings, visual assessment is used to determine treatment eligibility; in other settings, genotyping with cytology or cytology alone is used to determine treatment. For basic settings, treatment is recommended if abnormal triage results are obtained; in other settings, abnormal triage results followed by colposcopy is recommended. For basic settings, treatment options are thermal ablation or loop electrosurgical excision procedure; for other settings, loop electrosurgical excision procedure or ablation is recommended; with a 12-month follow-up in all settings. Women who are HIV-positive should be screened with HPV testing after diagnosis, twice as many times per lifetime as the general population. Screening is recommended at 6 weeks postpartum in basic settings; in other settings, screening is recommended at 6 months. In basic settings without mass screening, infrastructure for HPV testing, diagnosis, and treatment should be developed.www.asco.org/resource-stratified-guidelines.Additional information is available at  The purpose of this guideline is to provide updated expert guidance on the secondary prevention of cervical cancer to clinicians, public health authorities, policymakers, and laypersons in all resource settings. The target population is women in the general population at risk for developing cervical cancer (specific target age depends on the resource level).There are large disparities regionally and globally in incidence of and mortality resulting from cervical cancer, in part because of disparities in the provision of mass screening and primary prevention. Different regions of the world, both among and within countries, even within districts, differ with respect to access to prevention and, also, treatment.1 Sexual and gender minority people, particularly sexual and gender minority people of color, are also less likely to undergo cervical cancer screening given a myriad of barriers to primary care including stigma and structural discrimination.5In addition, marginalized populations within the United States face barriers to cervical cancer screening. Black, Asian, Pacific Islander, Native Hawaiians/other Pacific Islanders, American Indians or Alaskan Natives, and Hispanics are less likely to receive screening compared with White people to undergo cervical cancer screening.6 In 2021 and 2019, the WHO published updated guidelines on screening and treatment and the use of thermal ablation, respectively, for eligible women in all settings; this guideline reinforces those recommendations; in addition, updated US guidelines from American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP), and US Preventive Task Force were published. The screening modalities addressed by these five guidelines, as well as in this guideline, include cytology , visual inspection , and human papillomavirus (HPV) DNA testing (screening); for evaluation of positive results, the WHO guidelines include colposcopy, and for treatment, excisional and ablative treatments. The screening tests are sometimes used and have been studied alone or in combination. The guidelines that ASCO reviewed are described in the Data Supplement  published its first guideline on secondary prevention of cervical cancer in 2016.ASCO has established a process for resource-stratified guidelines, which includes mixed methods of guideline development, adaptation of the clinical practice guidelines of other organizations, and formal expert consensus. This article summarizes the results of that process and presents updated resource-stratified recommendations, which are based, in part, on formal consensus and adaptation from existing guidelines on the screening, triage of screening results, and treatment of women with cervical cancer precursor lesions , which states, in part, that WHO recommendations “recognize that most of the available evidence on cervical cancer is based on study populations of cisgender women” and “sexual and reproductive health service providers and cervical cancer prevention services must consider the needs of – and provide equal care to – all individuals independently of gender identity or its expression.”9 Separate ASCO resource–stratified guidelines provide guidance on the treatment of women with invasive cervical cancer11 and primary prevention.12ASCO uses an evidence-based approach to inform guideline recommendations. In developing resource-stratified guidelines, ASCO has adopted its framework from the four-tier approach  for cervical cancer screening and the management of women with abnormal screening results for each resource level ?Women who are asymptomatic for human papillomavirus (HPV) infection.Public health authorities, cancer control professionals, policymakers, obstetricians/gynecologists, primary care providers, lay public.A multinational, multidisciplinary Expert Panel was convened to develop clinical practice guideline recommendations on the basis of a systematic review of existing guidelines and an expert consensus process.Author's note: ASCO's view is that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available in their setting. The guidelines are intended to complement, but not replace local guidelines.HPV DNA testing is recommended in all resource settings, either self- or clinician-collected.The recommended age ranges (years) and frequencies in each setting are as follows:maximal, age 25-65 years every 5 yearsenhanced, age 30-65 years, if two consecutive negative tests at 5-year intervals, then 10 yearslimited, age 30-49 years every 10 yearsbasic, not more than every 10 years (with a plan to transition to not less than every 5 years).VIA may be used in basic settings and should move to population-based screening with HPV testing at the earliest opportunity.Maximal and enhanced: age 65 years with consistently negative results during the past ≥ 15 years.Limited and basic: age 49 years, resource-dependent, see specific recommendations.In basic settings, when a molecular (HPV) test is used for screening and has a positive result, visual assessment for treatment may be used to determine whether the woman should be treated with thermal ablation or loop electrosurgical excision procedure (LEEP).For other settings, HPV genotyping with cytology or cytology alone may be used.Women with negative triage results should receive a follow-up HPV test in 12 months .In limited settings, women with abnormal results from triage should receive colposcopy, if available, or treatment, if it is not.In maximal and enhanced settings, women with abnormal and/or positive results from triage should receive colposcopy.In basic and limited settings, treatment options are thermal ablation or LEEP, if a high level of quality assurance is recommended (for LEEP).In enhanced and maximal settings, LEEP  or, where LEEP is contradicted, ablative treatments may be offered.A 12-month post-treatment follow-up including HPV testing is recommended for all settings.Women who are HIV-positive or immunosuppressed for other reasons should be screened with HPV as soon as diagnosed, twice as many times in a lifetime as the general population.The management of abnormal results for screening for women with HIV and positive results of triage is the same as in the general population.Women who are postpartum should be offered primary screening 6 weeks postpartum in basic settings and at 6 months in other settings.Screening may be discontinued in women who have received a total hysterectomy for benign causes with no history of cervical dysplasia or HPV. Women who have received a subtotal hysterectomy (with an intact cervix) should continue receiving routine screening.In basic settings without current mass screening, infrastructure for HPV testing, diagnosis, and treatment should be developed.Complete recommendations are given in Appendix Table Ahttps://www.asco.org/practice-patients/guidelines/resource-stratified. Patient information is available at www.cancer.net.Definitions for the quality of the evidence and strength of recommendation ratings are available in Appendix Table AASCO believes that cancer and cancer prevention clinical trials are vital to inform medical decisions and improve cancer care and that all patients should have the opportunity to participate.This clinical practice guideline addresses four overarching clinical questions: (1) What are the best method(s) for screening for each resource stratum? (2) What is the best triage and/or management strategy for women with positive results or other abnormal  results? (3) What are the best management strategies for women with precursors of cervical cancer? (4) What screening strategy should be recommended for women who have received HPV vaccination?In addition, the guideline addresses screening and management strategies for defined special populations.These recommendations were developed by an ASCO Expert Panel with multinational and multidisciplinary representation, which included a patient representative and an ASCO guidelines staff member with health research methodology expertise , and the latter by members of the Expert Panel convened by ASCO.www.asco.org/guideline-methodology) provides additional information about the guideline update process. This is the most recent information as of the publication date.The ASCO Expert Panel and guidelines staff will work with cochairs to keep abreast of any substantive updates to the guideline. On the basis of the formal review of the emerging literature, ASCO will determine the need to update. The ASCO Guidelines Methodology Manual . All members of the Expert Panel completed ASCO's disclosure form, which requires disclosure of financial and other interests, including relationships with commercial entities that are reasonably likely to experience direct regulatory or commercial impact as a result of promulgation of the guideline. Categories for disclosure include employment; leadership; stock or other ownership; honoraria, consulting or advisory role; speaker's bureau; research funding; patents, royalties, other intellectual property; expert testimony; travel, accommodations, expenses; and other relationships. In accordance with the Policy, the majority of the members of the Expert Panel did not disclose any relationships constituting a conflict under the Policy.The Expert Panel was assembled in accordance with ASCO's Conflict of Interest Policy Implementation for Clinical Practice Guidelines  were also reviewed. Because of lack of evidence for some clinical questions, formal expert consensus was used.The identified guidelines were published between 2018 and 2021. Five were all or in part systematic review (SR)–based guidelines.6An overview of and information on these guidelines' clinical questions, target populations, development methodology, and key evidence is presented in the Data Supplement. The evidence and guidelines supporting unchanged recommendations are reviewed in the previous guideline publication.Recommendation 1.1 : In maximal-resource settings, cervical cancer screening with HPV DNA testing should be offered every 5 years from ages 25 to 65 years (either self- or clinician-collected). On an individual basis, women may elect to receive screening until 70 years of age. Recommendation 2.1 (Enhanced): In enhanced-resource settings, cervical cancer screening with HPV DNA testing should be offered to women 30-65 years of age, every 5 years  (either self- or clinician-collected). Recommendation 3.1 (Limited): In limited settings, cervical cancer screening with HPV DNA testing should be offered to women 30-49 years of age every 10 years, corresponding to two to three times per lifetime (either self- or clinician-collected). Recommendation 4.1 (Basic): Health systems in basic settings should move to population-based screening with HPV testing at the earliest opportunity (either self- or clinician-collected). If HPV DNA testing for cervical cancer screening is not available, then VIA should be offered with the goal of developing health systems. Screening should be offered to women 30-49 years of age, at least every 10 years (increasing the frequency to every 5 years resources permitting). 27 and the addition is a change from the previous ASCO guideline. Self-collection may be more acceptable to some people, including transgender people, less resource-intensive than clinician-collected samples, and its accuracy is like clinician-collected samples.28 WHO based its recommendation on a meta-analysis of HPV testing on self-collection versus clinician-collected samples, Arbyn et al29 originally performed in 2018 and updated in 2020, which showed similar specificity and sensitivity on polymerase chain reaction–based HPV DNA testing. In addition, it may be more cost-effective. Self-collection is highly sensitive and feasible; regions should start pilot projects at a minimum.All the primary screening recommendations now include self-collection as an option for samples to test. This is consistent with WHO guidance, discussed in the IARC Handbook,ASCO continues to recommend HPV DNA screening over cytology or cotesting  in all settings and 5-year frequency in maximal and enhanced settings, with encouragement that limited and basic settings move toward this frequency.The 2016 guideline reviewed several CEAs—this section presents data from CEAs conducted since then.Maximal-resource settings: A cost-effectiveness study modeling screening of unvaccinated women in Sweden found that primary HPV testing was more cost-effective than alternative strategies.30 A cost-effectiveness study on the basis of a randomized clinical trial (RCT) in Canada found that primary HPV testing was less costly and more effective at detecting precursor lesions than cytology-based screening. A modeling study from Norway found that self-collected HPV testing may be more cost-effective than clinician-collected HPV testing31 screening programs, and other studies project that HPV self-collection offered to underscreened women may increase health benefits and be cost-effective.33Limited-resource settings: Several CEAs in middle-income countries  have also examined primary HPV screening intervals of 5 years and found these to be an efficient use of resources.36 In settings where screening coverage is low, it is generally more cost-effective to expand coverage of unscreened women rather than increasing the number of lifetime screenings among women who already have access.3742Depending on the delivery model and uptake among underscreened women, HPV self-collection may be a cost-effective strategy to expand coverage in low-resource settings and among underscreened people, including transgender people, in higher-resource settings.Health systems in basic settings should move to population-based screening with HPV testing at the earliest opportunity (either self- or clinician-collected). If HPV DNA testing for cervical cancer screening is not available, then VIA should be offered with the goal of developing health systems. Screening should be offered to women 30-49 years of age, not more than every 10 years (with a plan to transition to not less than every 5 years). This section specifically regards the portion that says “Health systems in basic settings should move to population-based screening with HPV testing at the earliest opportunity (either self- or clinician-collected). If HPV DNA testing for cervical cancer screening is not available, then VIA should be offered with the goal of developing health systems.”7 p. xi, recommendation 1 and recommendation 21 [latter for those with HIV]). WHO considered the balance of benefits and risks when comparing VIA and HPV DNA testing and based the recommendation on RCTs and modeling.These updated recommendations are based on the WHO guideline and formal consensus. WHO recommends “using HPV DNA detection as the primary screening test rather than VIA or cytology” : If the results of the HPV DNA test are positive, clinicians should then perform triage with reflex cytology  and/or HPV genotyping for HPV 16/18 (with or without HPV 45) or with VIA. If institutions are currently using reflex cytology, they should transition from cytology to HPV genotyping. Qualifying statement: In limited settings, the preference is to do direct treatment, with triage using partial genotyping.In basic settings, visual assessment for treatment (VAT) after positive HPV DNA results is recommended to determine the appropriate type of treatment Fig . RegardiThe Panel recommends that in basic settings where a molecular (HPV) test is used as the primary screening test, and further triage testing is not feasible, all positive results are referred for VAT to determine whether ablation or excisional procedures should be used for treatment. When programs use self-collection, partial genotyping may be more possible because of its lower cost than that of cytology. Partial genotyping is preferred because it is less resource-intensive, and if the patient does not have a high-risk variant of HPV, they may not need treatment. The Panel added a qualifying statement preferring provision of direct treatment in limited settings to reduce the number of visits that a person in the screening algorithm must make. Direct treatment of everyone who has positive primary screening results, aka screen-and-treat, can reduce the possibility of losing patients to follow-up.16 Although even large programs might not have that option, over time, most programs will transition to self-sampling with partial genotyping. The recommendations are based on the trade-off between feasibility and desirability of high-quality impact, noting that different health systems and countries will have to weigh clinical performance with the ability to perform certain treatments and tests.If direct treatment is not feasible or acceptable, the options could be either partial genotyping or treating only those who are HPV 16/18–positive or VIA-based triage, as enumerated in the 2019 ASCCP guidelines.46 HPV screen-and-treat has generally been found to be a more cost-effective strategy, because of limited screening opportunities in lower-resource settings and the need to maximize detection of people at high risk of cervical cancer; however, the high burden of HPV in some settings may overwhelm the capacity to provide treatment, making triage testing necessary. Few studies have examined the cost-effectiveness of HPV 16/18 genotyping in limited settings, but it appears to have similar costs and only slightly lower benefits than HPV screen-and-treat.7The cost-effectiveness of HPV screen-and-treat versus HPV screen-triage-treat algorithms  has been evaluated in several studies.Recommendation 3.3 (Limited): If cytology triage results are abnormal , women should be referred to quality-assured colposcopy , during which biopsies of any acetowhite (or suggestive of cancer) areas should be taken, even if the acetowhite lesion might appear insignificant. If colposcopy is not available, then perform VAT. Addition of clarification of use of colposcopy in limited: The Panel added women who are ineligible for thermal ablation to the cytology triage recommendation. If a person has positive results and is eligible for thermal ablation and with a low suspicion of cancer, they can proceed to treatment without colposcopy, in part, to lessen number of recalls. However, if clinicians have a higher suspicion of cancer and patients have factors making them ineligible for ablation, colposcopy is used to rule out cancer. This is in line with the ASCCP guidance and the WHO thermal ablation guideline.There are no changes in the maximal and enhanced setting recommendations.Recommendation 4.2 (Basic): If the results of available HPV testing are positive, clinicians should then perform VAT followed by treatment with thermal ablation and/or loop electrosurgical excision procedure, depending on the size and location of the lesion. Recommendation 4.3 (Basic): If primary screening is VIA and results are positive, then treatment should be offered with thermal ablation and/or loop electrosurgical excision procedure, depending on the size and location of the lesion. Ablation is now recommended in basic settings .In 2016, the ASCO guideline did not recommend thermal ablation over other treatments for patients with precursor lesions in the basic setting; it was already recommended in limited settings. More evidence has become available since that time. WHO produced a guideline on thermal ablation, published in 2019, comparing ablation with cryotherapy and surgical approaches. For the 2019 version, WHO used evidence from RCTs, SRs, and meta-analyses and data from ongoing trials and assessed the evidence with Grading of Recommendations, Assessment, Development and Evaluations. They found no difference between benefits and harms of cryotherapy and thermal ablation.18 Therefore, ablation is more feasible and at lower cost, and providers may find it more acceptable and usable with less delay than cryotherapy. Therefore, the Expert Panel states a preference for ablation and recommends institutions transition from cryotherapy.Cryotherapy is less feasible, has issues with availability of parts of its process , and is more costly.Overall: There are no changes in the maximal and enhanced setting recommendations, except for self-collection.Recommendations for populations such as those with HIV have not changed and are consistent with WHO recommendations.The previous recommendation to continue screening in women who have received HPV vaccination is still in force. Recommendations for women who have received HPV vaccination have not changed, and these populations should continue to receive screening. HPV-based screening at 5-year intervals is recommended for women who have received HPV vaccination until there are further data on the efficacy of the currently available HPV vaccines in preventing all cases of CIN2+.47The 2016 guideline contained a section on new technologies being investigated for all resource setting levels. Most are still under investigation. Novel technologies—under development or undergoing field tests—for treating precancerous lesions include ablative technologies such as thermocoagulation, portable cryotherapy devices that rely less on gas, therapeutic vaccines, antivirals, and topical applications.The secondary prevention of cervical cancer is a cost-effective strategy to reduce the incidence and mortality of cervical cancer. CEAs discussed in this guideline support the use of HPV DNA tests in maximal, enhanced, limited, and basic resource settings. However, there are specific implementation issues regarding providing screening and treatment in limited and basic settings in primary care, outside of research studies.49 These strategies can improve screening uptake and linkage to treatment for screen-positive women. Although several novel biomarkers for triage of HPV-positive women remain to be validated, incorporating triage tests that identify women at high risk of cervical precancer may improve the cost-effectiveness of screening if fewer women can be treated while avoiding false-negative screening results. In addition to providing value, accurate triage tests may avert overburdening health care systems in settings with a high prevalence of HPV.In addition to cost and policy implications discussed in the 2016 guideline and in this version, other delivery strategies may involve some combination of screening campaigns, mobile clinics, and HPV self-sampling.The draft recommendations were released to the public for open comment from April 12 through April 22, 2022. Response categories of “Agree as written,” “Agree with suggested modifications,” and “Disagree. See comments” were captured for every proposed recommendation with 34 written comments received. A total of 85%-100% of the 34 responses either agreed or agreed with slight modifications to the recommendations, and 0%-15% of the responses disagreed. Expert Panel members reviewed comments from all sources and determined whether to maintain original draft recommendations, revise with minor language changes, or consider major recommendation revisions. All changes were incorporated before Evidence-Based Medicine Committee review and approval.ASCO guidelines are developed for implementation across health settings. Barriers to implementation include the need to increase awareness of the guideline recommendations among front-line practitioners and women in general populations and also to provide adequate services in the face of limited resources. Implementation should reflect the latest implementation research. The guideline Bottom Line Box was designed to facilitate the implementation of recommendations. This guideline will be distributed widely, including through many forms of ASCO communications and the ASCO website.There were limitations in the evidence regarding screening after HPV vaccination and emerging technologies. Future research is suggested in these areas.In addition to addressing research limitations, future research is needed in other areas, eg, self-collection, biomarkers, needs and preferences of women/people with cervixes, improving screening for transgender people, cost-effective strategies, low-cost technology, and the impact of vaccination on screening.Education of medical and public health communities to change practices and incorporate new technologiesParticipation and sponsorship from policymakersPartnerships with institutions, regions, and countries with treatment facilitiesCoordinated volume purchasing and procurement of HPV testingImprovement of health information systems to have better follow-up and treatment of women with positive screening resultsQuality controlMonitoring and evaluationAssessing the impact of COVID-19 diseaseAddressing policy and health system barriers may include the following:ASCO believes that cancer and cancer prevention clinical trials are vital to inform medical decisions and improve cancer care and that all patients should have the opportunity to participate.www.asco.org/resource-stratified-guidelines. Patient information is available at www.cancer.net.Additional information including a supplement with additional tables and clinical tools and resources is available at 50 Transgender and nonbinary people, in particular, may face multiple barriers to oncology care including stigmatization, invisibility, and exclusiveness. One way that exclusiveness or lack of accessibility may be communicated is through gendered language that makes presumptive links between gender and anatomy.54 With the acknowledgment that ASCO guidelines may affect the language used in clinical and research settings, ASCO is committed to creating gender-inclusive guidelines. For this reason, guideline authors use gender-inclusive language whenever possible throughout the guidelines. In instances in which the guideline draws upon data on the basis of gendered research , the guideline authors describe the characteristics and results of the research as reported.ASCO is committed to promoting the health and well-being of individuals regardless of sexual orientation or gender identity.11 (https://ascopubs.org/doi/full/10.1200/GO.22.00027 and https://ascopubs.org/doi/full/10.1200/JGO.2016.003954)Management and Care of Women With Invasive Cervical Cancer12 (https://ascopubs.org/doi/full/10.1200/JGO.2016.008151)Primary Prevention of Cervical Cancerhttp://ascopubs.org/doi/10.1200/JCO.2017.75.2311)Patient-Clinician Communication (