• Rose Gunn, Laura K Ferrara, Caitlin Dickinson, Isabel Stock, Jennifer Griffith-Weprin, Amy Wiser, Brigit Hatch, L J Fagnan, Patricia A Carney, and Melinda M Davis.
• Oregon Rural Practice-based Research Network, Oregon Health & Sciences University, Portland, Oregon.
• Am J Prev Med. 2020 Sep 1; 59 (3): 377-385.

IntroductionDespite the safety and efficacy of the human papillomavirus vaccine, thousands are impacted by human papillomavirus and its related cancers. Rural regions have disproportionately low rates of human papillomavirus vaccination. Primary care clinics play an important role in delivering the human papillomavirus vaccine. A positive deviance approach is used to identify workflows, organizational factors, and communication strategies in rural clinics with higher human papillomavirus vaccine up-to-date rates. Positive deviance is a process by which exceptional behaviors and strategies are identified to understand factors that enable success.MethodsRural primary care clinics were rank ordered by human papillomavirus vaccine up-to-date rates using 2018 Oregon Immunization Program data, then recruited via purposive sampling of clinics in the top and bottom quartiles. Two study team members conducted previsit interviews, intake surveys, and 2-day observation visits with 12 clinics and prepared detailed field notes. Data were collected October-December 2018 and analyzed using a thematic approach January-April 2019.ResultsFour themes distinguished rural clinics with higher human papillomavirus vaccine up-to-date rates from those with lower rates. First, they implemented standardized workflows to identify patients due for the vaccine and had vaccine administration protocols. Second, they designated and supported a vaccine champion. Third, clinical staff in higher performing sites were comfortable providing immunizations regardless of visit type. Finally, they used clear, persuasive language to recommend or educate parents and patients about the vaccine's importance.ConclusionsPositive deviance identified characteristics associated with higher human papillomavirus vaccine up-to-date rates in rural primary care clinics. These findings provide guidance for rural clinics to inform human papillomavirus vaccination quality improvement interventions.Copyright © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

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