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• W4386368703 abstract "Full text Figures and data Side by side Abstract Editor's evaluation Introduction Methods Results Discussion Data availability References Decision letter Author response Article and author information Metrics Abstract Background: The COVID-19 pandemic led to reductions in cervical cancer screening and colposcopy. Therefore, in this mixed method study we explored perceived pandemic-related practice changes to cervical cancer screenings and colposcopies. Methods: In 2021, a national sample of 1251 clinicians completed surveys, including 675 clinicians who performed colposcopy; a subset (n=55) of clinicians completed qualitative interviews. Results: Nearly half of all clinicians reported they were currently performing fewer cervical cancer screenings (47%) and colposcopies (44% of those who perform the procedure) than before the pandemic. About one-fifth (18.6%) of colposcopists reported performing fewer LEEPs than prior to the pandemic. Binomial regression analyses indicated that older, as well as internal medicine and family medicine clinicians (compared to OB-GYNs), and those practicing in community health centers (compared to private practice) had higher odds of reporting reduced screening. Among colposcopists, internal medicine physicians and those practicing in community health centers had higher odds of reporting reduced colposcopies. Qualitative interviews highlighted pandemic-related care disruptions and lack of tracking systems to identify overdue screenings. Conclusions: Reductions in cervical cancer screening and colposcopy among nearly half of clinicians more than 1 year into the pandemic raise concerns that inadequate screening and follow-up will lead to future increases in preventable cancers. Funding: This study was funded by the American Cancer Society, who had no role in the study’s design, conduct, or reporting. Editor's evaluation This important work provides evidence regarding the impact of the COVID-19 pandemic on cervical cancer screening and precancer treatments in the USA. As there are few screening registries, the study provides solid evidence using a survey of health providers' impressions to assess whether cervical cancer screening services declined during the pandemic. The work will be of interest to public health professionals working in cancer prevention. https://doi.org/10.7554/eLife.85682.sa0 Decision letter Reviews on Sciety eLife's review process Introduction Cervical cancer prevention programs have been among the most successful cancer prevention programs to date (Sawaya and Huchko, 2017). In the past decade, the addition of routine human papillomavirus (HPV) testing to screening programs has allowed safe extension of screening intervals through greater reassurance against subsequent cancer development among patients with negative results, and also led to more precise management of patients with abnormal results (Schiffman et al., 2011; Schiffman et al., 2018; Castle et al., 2018). However, longer screening intervals may lead to underscreening if patients are not recalled on schedule, and patients with high-risk medical conditions or prior abnormal screening histories need more frequent testing. The coronavirus 2019 (COVID-19) pandemic impacted the ability to perform routine cancer screenings, which may threaten progress made to date at reducing cervical cancer incidence and mortality (Wentzensen et al., 2021). At the onset of the pandemic, cancer screenings decreased substantially (Chen et al., 2021; Poljak et al., 2021; Amram et al., 2022; Smith and Perkins, 2022). Nationwide, cervical cancer screening rates fell rapidly in 2020 compared with previous years (Miller et al., 2021; Mayo et al., 2021). Limited evidence also suggests that colposcopy procedures were impacted during this time, though US data are lacking (Istrate-Ofițeru et al., 2021; Masson, 2021). As the pandemic has progressed, cancer screening rates have begun to rebound (Chen et al., 2021; McBain et al., 2021), but considerable challenges are still present. Initially patient fear and closed clinics affected ability to perform cervical cancer screening and colposcopy (Massad, 2022). Currently, lower screening rates continue due to high turnover and medical staff shortages, as well as longer wait times for scheduling appointments due to backlogs (Wentzensen et al., 2021; Smith and Perkins, 2022; Massad, 2022). Few studies have explored the impact of the COVID-19 pandemic on clinician perceptions of cervical cancer screening (Price et al., 2022) and colposcopy rates compared with prior to the pandemic. This paper examines the quantitative association of clinician characteristics with perceived changes in screening and colposcopy during the pandemic period. Additionally, through qualitative interviews, we explored how clinicians experienced pandemic-related changes in screening and colposcopy. Methods Participant recruitment Participant recruitment is detailed elsewhere (Vadaparampil et al., 2023). Briefly, clinicians were eligible to participate if they were: (1) a physician or advanced practice provider (APP) (nurse practitioner [NP], physician assistant, or certified nurse midwife) practicing in internal medicine, family medicine, obstetrics and gynecology (OB/GYN), or women’s health; and (2) performed cervical cancer screening. Data were collected between March-August 2021 (surveys) and June-December 2021 (interviews). For context, the COVID-19 vaccine became available to healthcare providers in the US in early 2021. The US general public had widespread access to vaccination beginning in the summer of 2021. By the fall of 2021, the pandemic appeared to be less acute in the US, with healthcare organizations attempting to resume normal operations through the end of the year. Masking, social distancing and reduced capacities indoors, and enhanced cleaning procedures were public health practices in place with varying levels of intensity across the US at this time. Between March and August 2021, we recruited clinicians from: the National Association of Nurse Practitioners in Women’s Health (NPWH) email listserv, a healthcare physician panel representing a variety of specialties via Dynata (an online market research firm), and the American Society for Colposcopy and Cervical Pathology (ASCCP) mailing list. NPs were recruited via email blasts to NPWH listserv members (~N = 2500; ~20% response rate). ASCCP members were recruited via an external mail house using a protocol based on Dillman’s Total Design Method (N=1000; 21.8% response rate) (Dillman, 1978). An additional ~250 OB/GYNs and ~250 Internal Medicine and Family Medicine physicians were recruited using Dynata (response rate not available). All participants were compensated. Study participants from all three sources who completed the quantitative survey were asked if they would be willing to participate in phase two of the study that included a qualitative interview. A random sample of those who indicated willingness were later contacted for participation. Survey content and study variables As previously described (Vadaparampil et al., 2023), survey questions were based on Cabana’s Guideline Based Practice Improvement Framework (Cabana et al., 1999) and previous research by study co-investigators (Perkins et al., 2020; Malo et al., 2016). An expert panel (n=10), including physicians and APPs from multiple specialties reviewed the survey, and the survey was refined based on their feedback. Finally, the survey was piloted with target clinicians (N=27), revised, finalized, and distributed between March and August 2021. The survey covered several areas related to cervical cancer screening practices and management of abnormal screening results, including presentation of vignettes focused on screening intervals, management or treatment, and screening exit or continuation in relation to 2019 ASCCP risk-based management guidelines adoption, as well as a subset of items for clinicians who perform colposcopy. There were also items related to HPV self-sampling, as well as the impact of the COVID-19 pandemic on screening and follow-up (which is the focus of the present manuscript). Clinician and practice characteristics Age was measured in years and grouped into four categories. Gender identity was assessed as male, female, transgender, and other. Race was categorized as (1) Asian, (2) Black/African American, (3) White, and (4) mixed race, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, other. Ethnicity was identified as Hispanic/Latinx or non-Hispanic/Latinx. For all variables that allowed write-in/free responses, we individually examined responses to determine if they could be accurately re-classified within the pre-determined categories for each variable. Medical training was assessed as physician (MD, DO) or APP. Medical specialties were OB/GYN, family medicine, and internal medicine for physicians, and women’s health for APPs only. We combined training and specialty variables to create one clinician type variable with four groups: OB/GYN physicians, family medicine physicians, internal medicine physicians, and APPs. Practice type included: (1) academic medical center, (2) hospital-based practice (including hospitals and military, post-operative care, and long-term care facilities), (3) private practice/group practice, (4) community health/safety net setting (included federally qualified or community health centers, planned parenthoods, public health departments, and college health centers). Geographic location included four US regions (Northeast, South, Midwest, West); 9% of respondents who did not provide state or zip code were classified as non-responders. COVID-19 and pandemic-related behaviors and practice patterns The survey item used for our primary outcome assessed perceptions of how the pandemic affected cervical cancer screening practices (doing fewer; the same number; or more HPV screens than before the pandemic). Participants were also asked to indicate whether they performed colposcopy (yes/no). Those who performed colposcopy then answered questions on how the pandemic affected their practices for (1) colposcopy (doing fewer; the same number; or more colposcopies than before the pandemic); and (2) loop electrosurgical excision procedure (LEEP) (provided LEEP on site before the pandemic and still doing so at same capacity; provided LEEP on site before the pandemic and still doing but at reduced capacity; provided LEEP on site before the pandemic and now are referring to another facility; have always referred to another facility for LEEP and continue to do so). Qualitative interview development, content, and interview processes The qualitative interview guide was developed based on Cabana’s Guideline Based Practice Improvement Framework (Cabana et al., 1999). The draft interview guide was reviewed by an expert panel (n=7) including clinicians from multiple primary care specialties. The interview guide was then refined based on expert feedback, pilot tested in a mock interview, further revised, and finalized. The final interview guide included in-depth exploration of cervical cancer screening and management items explored in the quantitative survey. We more deeply explored screening practices (barriers and facilitators to screening for each clinician’s patient panel), adherence to 2019 ASCCP guidelines (how clinicians assess if patients are due for screening, type of screening test used, screening interval used and reasoning) barriers to adoption of ASCCP guidelines, HPV self-sampling (benefits and concerns), and the impact of the pandemic on screening and management practices. Additionally, there was a subset of questions for colposcopists (on colposcopy training, LEEP self-performance versus referral, biopsy location). This manuscript focuses on qualitative findings relevant to the COVID-19 pandemic and its impact on screening and abnormal results follow-up (pause and resumption of screening or follow-ups during pandemic, catching up on missed screenings). Pandemic-related items focused on how the pandemic changed cervical cancer screening practices, pauses to screening or abnormal follow-up (colposcopy or treatment services) approaches for patients who missed screening or follow-up appointments during the pandemic, including strategies for re-engagement. Three co-authors (HF, RBP, AM) trained in qualitative methodology and with expertise in cervical cancer screening conducted qualitative interviews via video conference between June and December 2021. Interviews were audio recorded and transcribed verbatim. This study was approved by Moffitt Cancer Center’s Scientific Review Committee and was reviewed by an Institutional Review Board. The study was given exempt determination by Moffitt’s IRB, Advarra (MCC #20048), and Boston University’s IRB (BMC IRB# H-41533). All study participants viewed (for surveys) or were read (for interviews) an information sheet in lieu of reading and signing an informed consent form. Analytic plan Quantitative analyses We assessed descriptive statistics of clinician and practice characteristics and behaviors. We conducted separate binomial logistic regressions examining the associations of clinician and practice characteristics with responses to items assessing the impact of the pandemic on reported number of cervical cancer screening and on colposcopies (doing the same or more versus fewer than before the pandemic). Age, race, ethnicity, gender, region, clinician type, and practice type were included in the full model for each outcome, as clinician characteristics have previously been associated with cervical cancer screening practices (Almeida et al., 2013; Becerra-Culqui et al., 2018; Haas et al., 2021). For all logistic regression models, we used manual backward selection to individually remove variables exceeding a p-value of 0.10 from each model, but determined a priori that clinician type, practice type, and region would be retained in all models regardless of the corresponding p-values based on the importance of these factors in determining screening and colposcopy practices during the pandemic (Almeida et al., 2013; Becerra-Culqui et al., 2018; Haas et al., 2021; Horner et al., 2011). Given the few studies that have explored factors associated with clinician perspectives of changes in cervical cancer screenings and colposcopies during the pandemic, we selected a value for inclusion and significance of 0.10. This strikes a balance between the commonly accepted method of using the AIC (Akaike’s information criterion, which implicitly assumes a significance level of 0.157), and the often-used significance level of 0.05. Quantitative analyses were conducted in SPSS Version 26. Qualitative analyses Pandemic-related qualitative interview items were coded using thematic content analysis (Elo and Kyngäs, 2008). A priori codes were developed based on the questions in the initial interview guide and a codebook was developed to operationalize and define each code. The qualitative analysis team independently reviewed the data twice. In the first coding pass, the team hand-coded the data with the initial codes and made notes on possible new codes. After the first round of coding, they discussed notes on possible new codes. After reaching consensus, the codes were revised and they again independently reviewed the transcripts and updated code categories from the first coding pass. The second coding pass serves to ‘clean up’ codes unanticipated in the first coding pass and identify emergent themes not identified in the initial coding scheme (Krueger, 1998). All transcripts were coded by at least two coders. Coding discrepancies were resolved by discussion in weekly group meetings to achieve consensus. Coding was conducted in a shared data sheet for ease of completing coding in a centralized database across varying institutions. Results Quantitative findings Potential participants (N=1373) viewed the study information sheet and completed screening items; 103 were ineligible due to not performing cervical cancer screening or having an ineligible training/specialty (e.g., pharmacy). Nineteen additional responses were removed as duplicates, nonsensical write-in responses, or ineligibility not previously identified via demographic items, resulting in a final sample of 1251 participants (509 recruited via NPWH [web], 524 from Dynata [web], and 218 from ASCCP [204 mail, 14 web]). See Figure 1. Figure 1 Download asset Open asset Flow diagram depicting potentially eligible, enrolled, and final analytic samples. Table 1 describes clinician practice characteristics, behaviors, and screening practices. The total clinician sample was primarily White (77.8%), non-Hispanic (91.9%), and female (74.7%), with adequate representation from each age group. Regions of practice were distributed across the US (Northeast 18.4%, South 28.9%, Midwest 21.7%, West 22.1%, no response 9%). About half of participants were women’s health NPs or other APPs specializing in women’s health (48.7%), one-quarter were OB/GYN physicians (26.6%), and the remainder were internal (8.7%) and family medicine (16.0%) physicians. Over half of clinicians (54.0%, n=675) indicated that they perform colposcopies. Colposcopist characteristics were generally comparable to those of the full sample (Table 1). Of note, colposcopists were slightly older (32% aged 50–59; 29% aged 60+), and more often OB/GYN physicians (47.0%), compared with the full sample. Table 1 Demographic and practice characteristics for the full sample of respondents, and sub-groups of colposcopists and qualitative interview participants. VariableTotal sampleColposcopist sub-groupQualitative interview sub-groupN%Valid NN%Valid NN%Valid NClinician characteristicsAge125067452 Less than 4027722.210515.6815.4 40–4931325.015723.31732.7 50–5934427.521632.01223.1 60+31625.319629.01528.8Gender identity125067455 Female (includes transgender/gender non-binary and other)*93474.747470.33869.1 Male31625.320029.71730.9Race124567155 Asian15112.17110.61018.5 Black/African American614.9304.511.9 Mixed race/other†645.1385.759.3 White96977.853279.33870.4Hispanic/Latinx1018.11247517.667223.655Clinician type (training and specialty)125067455APP (total)Sub-groups:Nurse PractitionerCertified Nurse MidwifePhysician Assistant609521711148.785.611.71.824420236636.282.814.82.567421191138.290.44.84.8 MD/DO OB/GYN33226.631747.01629.1 MD/DO family medicine20016.09313.81221.8 MD/DO internal medicine1098.7203.0610.9Practice characteristics, patterns, and behaviorsType of practice125167551 Academic medical center15412.38813.047.8 Hospital-based practice (includes ‘other’)16913.58512.6713.7 Private practice/group practice67854.239558.52752.9 FQHC/community health center/planned parenthood or public health department25020.010715.91325.5 US region125167555 Northeast23018.412218.1814.5 South36128.919028.11018.2 Midwest27121.712117.9814.5 West27722.115222.559.1 Non-responders1129.09013.32443.6 * Due to small numbers, transgender/non-binary/other were unable to be analyzed as their own category. They were assigned to female for analyses because female was the most common response. No difference was noted when grouped with male. † Due to small numbers, the following categories were combined: mixed race n=36, Hawaiian/AAPI n=3, American Indian/Alaska Native n=3, other n=22. Table 2 details participants’ perceptions of their performance of screening, colposcopy, and LEEP at the time of the survey, which was conducted between March and August 2021 (fewer, same, more than before the pandemic). Responses indicated that, over 1 year into the pandemic, 47% of all clinicians reported they were currently performing fewer cervical cancer screenings than before the pandemic and 44.1% of colposcopists were performing fewer colposcopies than prior to the pandemic. Among colposcopists, about one-fifth reported disruptions in LEEP; 18.6% reported performing fewer LEEPs than prior to the pandemic, while 1.3% reported no longer being able to offer LEEP at their facility and therefore referring all patients out who required this service. The remaining colposcopists either reported performing LEEP at the same level (51.1%) or continued to refer out (28.9%). Table 2 COVID-19 and pandemic-related responses for the full sample of respondents and for colposcopists. VariableTotal sampleColposcopist sub-sampleN%Valid NN%Valid NHow has the pandemic affected your cervical cancer screening practice? (data collected March-July 2021)1246672 Doing fewer Pap/HPV/co-tests now than before the pandemic58647.029543.9 Doing the same number of Pap/HPV/co-tests now than before the pandemic60448.534551.3 Doing more Pap/HPV/co-tests now than before the pandemic564.5324.8How has the pandemic affected your colposcopy practice? (data collected March-July 2021)-671 Doing fewer colposcopies now than before the pandemic---29644.1 Doing the same number of colposcopies now than before the pandemic---35252.5 Doing more colposcopies now than before the pandemic---233.4How has the pandemic affected the ability to provide LEEP in your practice? (data collected March-July 2021)-667 We provided LEEP to patients on site before COVID-19 and are still doing so with the same capacity---34151.1 We provided LEEP to patients on site before COVID-19 and are still doing so but with reduced capacity---12418.6 We provided LEEP to patients on site before COVID-19 but now are referring to another facility---91.3 We have always referred to another facility for LEEP and continue to do so19328.9 In binomial logistic regression models for reported reductions in cervical cancer screening tests, gender and ethnicity were sequentially removed due to p-values exceeding 0.10. See Table 3, Panel A, for table displaying logistic regression findings and Figure 2, Panels A–E, for forest plots depicting adjusted odds ratios and 95% confidence intervals for variables associated with odds of reporting reduced cervical cancer screening in 2021 compared with before the COVID-19 pandemic. In the final model, older age, non-White race, family or internal medicine physician specialty, and practicing in a community health/safety net setting were significantly associated with the likelihood of reporting reductions in cervical cancer screenings in 2021 compared to before the COVID-19 pandemic. Older age was associated with reported reductions in cervical cancer screening (p<0.001). Compared with clinicians over age 60, younger age groups were significantly less likely to report reduced cervical cancer screenings (<40 [aOR = 0.47, 95% CI: 0.33–0.66, p=0.000], 40–59 [aOR = 0.64, 95% CI: 0.46–0.90, p=0.009], 50–59 [aOR = 0.70, 95% CI: 0.51–0.97, p=0.029]). Race was marginally associated with reported reduced cervical cancer screening (p=0.085). Compared with White clinicians, Black (aOR 1.65, 95% CI: 0.96–2.84, p=0.070) and mixed race/other clinicians (aOR = 1.69, 95% CI: 0.99–2.88, p=0.055) more frequently reported reduced screenings. Clinician type was significantly associated with odds of reporting reduced screening during the pandemic (p<0.001). Compared with OB/GYN physicians, reduced screening was more frequently reported by internal medicine (aOR = 2.59, 95% CI: 1.62–4.13, p<0.001) and family medicine physicians (aOR = 1.64, 95% CI: 1.14–2.36, p=0.008). Practice type was significantly associated with odds of reporting reduced screening during the pandemic (p=0.014). Compared with those in private practice, those practicing in community health/safety net settings more often reported reduced screening (aOR = 1.62, 95% CI: 1.17–2.23, p=0.003). As specified in the Methods section, the model was adjusted for provider region, despite its lack of significant association with changes in screening (p=0.391). Figure 2 Download asset Open asset Forest plots depicting adjusted odds ratios and 95% confidence intervals for variables associated with odds of reporting reduced cervical cancer screening (N=1239) in 2021* compared with before the COVID-19 pandemic. Variables associated with odds of reporting reduced cervical cancer screening include Panel A: Age; B: Race; C: Region; D: Clinician Type; E: Practice Type. *Note. Data collected during the COVID-19 pandemic period of March 2021–July 2021, with participants asked to report whether they were doing ‘fewer’ or ‘the same number or more Pap/HPV/co-tests now than before the pandemic’. Table 3 Final models for variables associated with odds of reporting reduced cervical cancer screenings (Panel A) and with odds of reporting reduced colposcopies (Panel B) in 2021* compared with before the COVID-19 pandemic. Panel A. Final model of clinician and practice characteristics associated with odds of reporting reduced cervical cancer screenings in 2021 compared with before the COVID-19 pandemic (N=1239). Using backward selection, the following variables sequentially fell out of the model (p>0.10): (1) gender, (2) ethnicity. (A priori we planned to retain clinician type, practice type, and region even when p>0.10.)Overall pBSEOdds ratiopCIAge<0.001 <40–0.770.180.47<0.0010.33-0.66 40–59–0.440.170.640.0090.46-0.90 50–59–0.350.160.700.0290.51-0.97 60+ (ref)-----Race0.085 Mixed race/other0.520.271.690.0550.99–2.88 Black/African American0.500.281.650.0700.96–2.84 Asian0.030.191.030.8820.71–1.50 White (ref)-----Region0.391 No response–0.380.250.690.1230.42–1.11 South0.080.181.080.6500.77–1.52 Midwest–0.030.190.970.8590.67–1.40 West0.050.191.050.7950.73–1.51 Northeast (ref)-----Clinician type<0.001 AAP–0.030.150.970.8460.72–1.31 MD/DO Internal Med0.950.242.59<0.0011.62–4.13 MD/DO Fam Med0.490.191.640.0081.14–2.36 MD/DO OB/GYN (ref)-----Practice type0.014 Academic medical center0.030.191.030.8890.71–1.48 Hospital-based practice–0.110.190.900.5540.62–1.29 Public health dept/ FQHC/community health center/planned parenthood0.480.161.620.0031.17–2.23 Private practice/group practice (ref)-----Panel B. Final model of clinician and practice characteristics associated with odds of reporting reduced colposcopies in 2021 compared with before the COVID-19 pandemic for colposcopists only (N=669). Using backward selection, the following variables sequentially fell out of the model (p>0.10): (1) ethnicity, (2) race, (3) age. (A priori we planned to retain clinician type, practice type, and region even when p>0.10.)Overall pBSEOdds ratiopCIGender0.063 Male0.380.201.460.0630.98–2.18 Female (ref)-----Region0.414 No response0.080.301.080.7850.61–1.94 South0.430.241.540.0770.96–2.47 Midwest0.270.271.300.3200.77–2.20 West0.330.251.390.2000.84–2.28 Northeast (ref)-----Clinician type0.052 Advanced practice professional0.260.201.300.1970.87–1.92 MD/DO Internal Med1.330.543.790.0131.33–10.80 MD/DO Fam Med0.000.251.000.9950.62–1.62 MD/DO OB/GYN (ref)-----Practice type.266 Academic medical center0.150.251.160.5540.71–1.88 Hospital-based practice0.090.251.090.7250.67–1.79 Public health dept/ FQHC/community health center/planned parenthood0.470.241.590.0481.01–2.53 Private practice/group practice (ref)----- * Note. Data collected during the COVID-19 pandemic period of March 2021–July 2021, with participants asked to report whether they were doing ‘fewer, the same number, or more Pap/HPV/co-tests’ or ‘colposcopies’ ‘now than before the pandemic’. In models with the subset of colposcopists, ethnicity, race, and age were sequentially removed from models due to p-values exceeding 0.10. See Table 3, Panel B, for table displaying logistic regression findings and Figure 3, Panels A–D, for forest plots depicting adjusted odds ratios and 95% confidence intervals for variables associated with odds of reporting reduced colposcopies in 2021 compared with before the COVID-19 pandemic. Among colposcopists, male gender and internal medicine specialty were associated with odds of reporting fewer colposcopies during the pandemic. Males reported reduced colposcopies marginally more often than females (aOR = 1.46, 95% CI: 0.98–2.18, p=0.063), and internal medicine physicians more often reported significantly reduced colposcopies than OB/GYN physicians (aOR = 3.79, 95% CI: 1.33–10.80, p=0.013). US region was not associated with perceived colposcopy reduction (p=0.414). Similarly, although the overall association between practice type and perceived colposcopy reduction was not statistically significant (p=0.266), clinicians in community health/safety net settings reported reduced colposcopy more often than their peers in private practice (aOR = 1.59, 95% CI: 1.01–2.53, p=0.048). Figure 3 Download asset Open asset Forest plots depicting adjusted odds ratios and 95% confidence intervals for variables associated with odds of reporting reduced colposcopies (N=669), in 2021* compared with before the COVID-19 pandemic. Variables associated with odds of reporting reduced colposcopies include Panel A: Gender; B: Region; C: Clinician Type; D: Practice Type. *Note. Data collected during the COVID-19 pandemic period of March 2021–July 2021, with participants asked to report whether they were doing ‘fewer’ versus ‘the same number or more colposcopies now than before the pandemic’. Qualitative interview findings A subset of 55 clinicians participated in qualitative interviews. The demographic characteristics of the qualitative interview sub-sample resembled that of the full sample (Table 1); they were primarily White (70%), non-Hispanic (96%), and female (69%). More than one-third (38.5%) were APPs, 29% were OB/GYN physicians, and the remainder were internal (11%) and family medicine (22%) physicians; about half (47%) indicated they perform colposcopies. Table 4 illustrates themes describ" @default.
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• W4386368703 title "Editor's evaluation: Examining the association of clinician characteristics with perceived changes in cervical cancer screening and colposcopy practice during the COVID-19 pandemic: a mixed methods assessment" @default.
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