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In 2023, Iowa had an estimated 620 new cases, 100 deaths, and 4,670 survivors of oropharyngeal cancer (OPC). Sometimes referred to generically as “oral cancer,” OPC is a squamous cell carcinoma affecting the pharynx, base of the tongue, and tonsils. Human papillomavirus (HPV) causes approximately 75% of OPCs, and new cases of OPC attributable to HPV are increasing more rapidly than non-HPV-linked cases.  

A HPV vaccination message from a dental professional can reinforce a message about the vaccine from a health care provider—or act as a cue to approach a health care provider about receiving the vaccine. Additionally, dental professionals reach some children who might not be seeing a medical provider regularly. A national study found that 12.5% of children eligible for the vaccine had not seen a medical doctor, but did have a dental visit, in the last year. Dental visits for routing cleanings can offer a regular point of clinical contact with children and their parents.

The University of Iowa Prevention Research Center for Rural Health’s CPCRN will work with Iowa Immunizes to implement Educate, Recommend, Refer in 40 rural dental practices. This intervention includes 3 interactive one-hour trainings which support dental professionals to confidently provide strong recommendations for the HPV vaccine to parents of eligible patients. The intervention includes support materials (i.e., a flipchart, script, parent brochure, referral prescription pad, and a list of local HPV vaccine providers) and coached practice sessions in changing office-related processes to accommodate conversations about the HPV vaccination. We have piloted this intervention with two dental offices in Iowa City. The providers in these offices referred all of their vaccine-eligible patients to receive the vaccine. They also reported that parents of their patients are receptive to learning about HPV and the HPV vaccine. The results from this pilot will be used to inform the scaled-up version of the intervention. Based on study findings and feedback from the larger intervention, we will then work to develop and translate materials to support further uptake of this program among dental professionals across the rest of the state and nation.

Additional projects:

•  Analyzing Iowa Immunization Registry Data:  Askelson, Kahl, Carrell, Janio, and Ryan have been analyzing state immunization data to identify geographic areas and characteristics that are associated with lower HPV vaccination uptake. The project is ongoing, and the team receives regular data updates. The analyses have been used to inform the public health departments efforts to encourage HPV vaccine uptake.
• Exploring integrated workforce collaborations to promote HPV vaccine uptake: Given the rise in HPV-associated oropharyngeal cancer, we chose to assess the feasibility and acceptability of making strong recommendations of HPV vaccination among otolaryngologists. Otolaryngologists treat oropharyngeal cancer, but generally do not discuss the HPV vaccine with patients. We conducted qualitative interviews with community-based otolaryngologists to understand their attitudes towards discussing HPV and the vaccine with patients. We have conducted a survey to collect information from otolaryngologists regarding barriers to and facilitators of recommending the HPV vaccine. We are in the process of analyzing this data.  

Resources, Media, & Publications 

Publications: 

• Janio, E. A., Walker, C., Steere, E., Seaman, A. T., Askelson, N., & Pagedar, N. A. "A Qualitative Study of Attitudes Toward HPV Vaccine Recommendation in Otolaryngology Clinics." Laryngoscope Investigative Otolaryngology 10.1 (2025): e70085.
• Ryan GW, Charlton ME, Scherer AM, Ashida S, Gilbert PA, Daly E, Askelson NM. Understanding Implementation of Evidence-Based Interventions to Address Human Papillomavirus Vaccination: Qualitative Perspectives of Middle Managers. Clin Pediatr (Phila). 2023 Oct;62(10):1193-1200. doi: 10.1177/00099228231154661. Epub 2023 Feb 10. PMID: 36762821.
• Askelson, N., Ryan, G., McKernan, S., Scherer, A., Daly, E., & Avdic, L. (2023). Engaging new partners in human papillomavirus (HPV) vaccine promotion: Considerations for training private practice dental professionals in HPV vaccine promotion. Journal of public health dentistry, 83(2), 185–192. doi: 10.1111/jphd.12566
• Ryan G, Gilbert PA, Ashida S, Charlton ME, Scherer A, Askelson NM. Challenges to Adolescent HPV Vaccination and Implementation of Evidence-Based Interventions to Promote Vaccine Uptake During the COVID-19 Pandemic: "HPV Is Probably Not at the Top of Our List". Prev Chronic Dis. 2022 Mar 31;19:E15. doi: 10.5888/pcd19.210378. PMID: 35358035; PMCID: PMC8992683.
• Ryan GW, Perry SS, Scherer A, Charlton ME, Ashida S, Gilbert PA, Askelson N. Factors contributing to missed opportunities for human papillomavirus vaccination among adolescents, ages 11 to 13, in Iowa. Vaccine X. 2022 Jul 9;11:100192. doi: 10.1016/j.jvacx.2022.100192. 
• Askelson, N.M., Kim, S., Jung, Y.S., Adam, E., Ryan, G., Novak, N., Kintigh, B., Callaghan, D., Carrel, M. (2020). Visualizing immunization registry data to identify places with lower HPV vaccination initiation in a rural state. Preventing Chronic Disease. 17: 190350. doi: 10.5888/pcd17.190350
• Askelson, N., Ryan, G., McKernan, S., Scherer, A., Daly, E., Avdic, L. A (2021, March). Mixed-Methods Examination of Factors Related to HPV Vaccination Promotion in Private Dental Settings, Iowa, 2019. Preventing Chronic Disease, 18: E26. doi: 10.5888/pcd18.200553.

Presentations:

• Sukalski J, Gradeler T, Janio E, Ryan G, McKernan S, Bucklin R, Askelson N. Enhancing HPV Vaccine Uptake: A Dental Provider Intervention to Promote HPV Vaccine Referrals in Iowa.  University of Iowa College of Public Health Rural Health Summit. 2025. 

• Askelson, N. (April 2025). Vaccine hesitancy in rural Iowa. National Academy of Medicine. Emerging Leaders Annual Meeting. Washington, DC. 

• Brown, V. & Askelson, N. M. (November 2024). Alternative settings to address community access and HPV vaccination uptake. International Papillomavirus Conference. Edinburgh, UK. 

• Sukalski J, McKernan S, Ryan G, Bucklin R, Janio E, Askelson N. Engaging new partners in human papillomavirus (HPV) vaccine promotion: Engaging dental professionals to address disparities. International Papillomavirus Conference. Edinburgh, UK. 2024. 

Posters: 

• Sukalski J, Gradeler T, Janio E, Ryan G, McKernan D, Bucklin R, Askelson N. Educate, Recommend, Refer: An Intervention to Prepare Dental Professionals to Promote the HPV Vaccine. National HPV Conference. Indianapolis, US. 2025. 

• [Accepted] Sukalski J, Gradeler T, Janio E, Ryan G, McKernan D, Bucklin R, Askelson N. Educate, Recommend, Refer: An Intervention to Prepare Dental Professionals to Promote the HPV Vaccine. in: Holden Comprehensive Cancer Center Annual Retreat. Iowa City, US. 2025. 

• Evett, S., Sukalski, J., McKernan, S., Ryan, G., Bucklin, R., Scherer, A., Steere, E., & Askelson, N. Educate, recommend, refer: Development and testing of an intervention to empower dental professionals to promote HPV vaccination. National Immunization Conference. 2024
• Askelson NM, Walker S, Ryan G, Daly E, Steere E, Evett S. Partnering with rural health systems to promote HPV vaccination in Iowa. Poster presented at the Public Health Conference of Iowa; March 27, 2024; Des Moines, IA.

Talks:

• Linn County Immunization Coalition. October 17, 2024.
• Oral Health Iowa Coalition. September 27, 2024.
• Educate, Recommend, and Refer: Development and testing of an intervention to empower dental professionals to promote HPV vaccination. HPV Cancer Consortium. April 2024.
• Training Iowa’s Oral Health Workforce to Educate, Recommend, and Refer the HPV Vaccine. National Oral Health Conference. April 2024. 
• University of Iowa College of Dentistry and Dental Clinics Collegiate Research Meeting. February 2024.
• Southwest Iowa’s Children’s Oral Health Coalition. Training module pilot. October 2022.
• Iowa Primary Care Association. Training module pilot. August 2022.

The UI CPCRN is supported by the Health Promotion and Disease Prevention Research Center cooperative agreement (U48DP006840), Centers for Disease Control and Prevention, U.S. Department of Health and Human Services (HHS) as part of financial assistance award totaling $1,500,000. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS or the U.S. Government.