HPV-based screening is important for curbing and preventing cervical cancer. The recent evidence-based guideline adoptions for primary HPV testing in 2018 by the USPSTF and 2020 by the ACS signal an important change in cervical cancer screening efforts. HPV self-sampling, in particular, may help to facilitate the uptake of primary HPV testing and cervical cancer screening adherence. However, knowledge about cervical cancer and other sociodemographic factors (e.g., age, educational level) remain well-documented important drivers of screening uptake and adherence in minority women.[7, 62] This is the first cross-sectional study to explore a sample of racially and ethnically-diverse women’s awareness, self-efficacy, and preferences of HPV self-sampling and potential correlates of those outcomes.
Across all outcomes, this study found no factors that were consistently correlated with awareness, self-efficacy, and preferences for HPV self-sampling. One key finding is that few women, including those that are racially- and ethnically-diverse, had heard of HPV self-sampling. These results indicate that the dissemination of HPV self-sampling within US contexts is still in its infancy, and further, may not be reaching all women, regardless of race/ethnicity. However, the low level of awareness is consistent with previous US-based research where HPV self-sampling interventions are only beginning to be introduced.[63, 64] Additionally, the majority of research development and assessments of HPV self-sampling interventions have occurred in international contexts (e.g., Mexico, Netherlands) and the implementation traction of this modality has been slow in the US, with only one large pragmatic trial conducted in Seattle, Washington (Kaiser Permanente). The low level of HPV self-sampling awareness in this study, across all racial and ethnic groups, suggests a strong opportunity to promote widespread educational efforts around this new tool within US contexts.
Despite not having heard of HPV self-sampling, many women reported a high self-efficacy to complete an HPV self-sampling test. The strongest negative correlates of high self-efficacy were neutral and unpleasant experiences with previous Pap tests. These findings may suggest that women, who have had neutral or unfavorable pelvic exams in the past for Pap test screening, may be less likely to feel confident in conducting their own tests. Several studies examining self-efficacy in HPV self-sampling interventions have found that women with previous negative screening experiences were more likely to report pain and be averse to initiating self-sampling.[66, 67] In the present study, Asian women were also found to be less likely to report high self-efficacy. This finding is consistent with many studies that have examined the feasibility of HPV self-sampling within Asian women.[68–70] Compared to Non-Hispanic white women, Asian women have been found to be less experienced with tampon use and less confident with inserting a foreign object like a brush into the vagina, such as in the case of HPV self-sampling test kits. Additional theory-based HPV self-sampling interventions are needed to further elucidate predictors of high self-efficacy and further explore whether these predictors differ across racial/ethnic groups.
With regard to the location of where women would like to have their HPV tests conducted, this study found that many may potentially prefer the clinic-based approach. Within the clinic-based approach, women can either conduct their own self-collection or have a clinician perform the collection onsite at the clinic (i.e., point of care). Only one pilot study has implemented clinic-based HPV self-sampling and conferred positive results supporting an increase uptake in cervical cancer screening and adherence to follow-up of abnormal results. Support for the clinic-based approach has also been documented in several pre-implementation studies and protocols of HPV self-sampling interventions.[71, 72] Advantages to the clinic location include having providers be present in the exam rooms to address questions from patients in real-time, allowing patients to examine the brush and testing kit first-hand, providing a sanitary and private location for self-collection, and mitigating challenges around the return of missing or lost samples with the mail-based approach. Future research efforts should explore the feasibility, efficacy and effectiveness of various delivery approaches, including point-of-care, for HPV self-sampling.
This study also found that many women prefer to self-collect for HPV testing. While no significant correlates were identified, the biggest barriers to all women taking up HPV self-testing was the strong reliance on provider expertise and the perceived concordance and reliability of the test. These two barriers have been extensively researched and written about in prior studies, and will continue to act as a potential barrier to HPV self-sampling uptake for all women.[24, 34] However, many HPV self-sampling interventions with laboratory validation studies have shown and demonstrated that self-collected samples are equally concordant with clinician-collected samples.[31, 73] Future implementation studies on HPV self-sampling should focus on strategies to mitigate these concerns around collection concordance and promote women’s self-efficacy to collect their own cervicovaginal samples.
This study, moreover, found that women were less likely to prefer HPV self-sampling over traditional Pap tests. Older women, in particular, were less likely to choose the self-sampling approach as their preferred cervical cancer screening strategy. This finding corroborates many existing studies that have found that self-driven healthcare technologies are generally harder and/or perceived to be less acceptable for older women than younger women.[74, 75] Although no significant correlates were identified across all women and racial/ethnic groups, the primary reason why the Pap test was the preferred cervical cancer strategy was because of the strong reliance on providers. The strong trust that exists between women and their healthcare providers have consistently been reported in many cancer screening interventions, including HPV self-sampling, as an important facilitator for cervical cancer screening uptake.[40, 76–78] Future HPV self-sampling research efforts should examine educational interventions targeted at healthcare providers to educate and encourage patients on the importance of self-collection options.
Given the pre-implementation context of this study – the limited awareness of HPV self-sampling and the perceptions of potentially conducting an HPV self-sampling test across various settings – it is unclear if the link between these women’s perceived self-efficacy and preferences to perform an HPV test will be consistent with their actual experiences. Pragmatic HPV self-sampling interventions need to be more widely implemented and tested so that all women not only become aware of this new modality but also experience the self-collection and its respective location options, before further scale-out and adaptations of an HPV self-sampling practice can be instituted in US contexts. Until greater population uptake of HPV self-sampling has occurred in the United States, it remains unknown the extent to which this method may be preferable to Pap tests for reducing cervical cancer disparities among minority women.
Strengths and limitations
The strengths of the study included a racially- and ethnically-diverse sample and research that was grounded in Anderson’s Behavioral Model of Health Services Use. Some limitations, however, should be noted. First, the non-random and convenience sampling of survey respondents may have introduced selection bias in the recruitment process. Participants who took part in the survey may have been more willing to explore alternative cervical cancer screening modalities than those who chose not to participate; as a result, these findings may not generalize to the larger female population. Secondarily, this study did not have sufficient sample sizes to determine if any meaningful differences exist across racial/ethnic groups. In addition, the large amount of missing data for the preferred cervical cancer strategy outcome may be a result of a survey design flaw. This particular survey item asked participants to select one of two images related to HPV self-sampling or Pap test as response options; the pictorial responses may have confused participants who are frequently used to seeing response options in text form. The prevalence of preferred cervical cancer strategies, therefore, may be underreported. Finally, the online survey was fielded during the coronavirus of 2019 (COVID-19) pandemic, when home-based self-testing interventions were proliferating. This effect might have influenced potential interest and uptake of self-testing interventions, including HPV self-sampling, which may have introduced another form of selection bias.