Barriers to HPV self-sampling and cytology among low-income indigenous women in rural areas of a middle-income setting: a qualitative study

Abstract

BackgroundData is needed about barriers to self-collection of Human Papillomavirus (HPV) samples and cytology among low-income, disadvantaged women living in rural areas of lower-income countries as these women are at increased risk of cervical cancer mortality.MethodsIndividual interviews (n = 29), focus groups (n = 7, 5–11 participants) and discussion groups (n = 2, 18–25 participants) were organized with women from three indigenous ethnic groups residing in rural areas in Mexico, after they were provided with free, self-sampled HPV tests. These groups are low-income, underserved by healthcare and have historically been on the receiving end of racism and social exclusion. Descriptive, qualitative content analysis was done, including two cycles of coding.ResultsInterview and focus/discussion group data indicate women had limited understanding of HPV’s role in cervical cancer etiology. They identified HPV’s existence, that cytology detects cervical cancer, the need for regular testing and that cervical cancer is sexually transmitted. Organizational barriers to clinic-based cytology included irregular supplies of disposable speculums, distance to clinics and lack of clear communication by healthcare personnel. Women considered self-collected HPV-testing easy, less embarrassing and less painful than cytology, an opportunity for self-care and most felt they understood how to take a self-sample after a 20-min explanation. Some women feared hurting themselves when taking the self-sample or that they would take the sample incorrectly, which they worried would make the test useless. Attending HPV-testing in groups facilitated use by allowing women to discuss their doubts and fears before doing self-collection of the sample or to ask other women who were the first to do the self-sampling what the experience had been like (whether it hurt and how easy it was). Lack of indoor bathrooms was a barrier to doing HPV self-sampling at home, when those homes were resource-poor (one-room dwellings).ConclusionsLow-income, indigenous Mexican women residing in rural, underserved areas identified their need for cervical cancer screening but encountered multiple barriers to cytology-based screening. They found a number of advantages of HPV self-sampled tests. Employing self-collected HPV-testing instead of cytology could resolve some but not all gender-related, organizational or technical quality-of-care issues within cervical cancer detection and control programs.Electronic supplementary materialThe online version of this article (10.1186/s12885-017-3723-5) contains supplementary material, which is available to authorized users.

Time and temperature dependent analytical stability of dry-collected Evalyn HPV self-sampling brush for cervical cancer screening

“…The CSi study showed that 50% of the distributed self-samples were returned to the laboratory within 2 weeks, 75% within 45 days, and 90% within 50 days. At 180 days (6 months) 99% of all samples were received [6] , which is also consistent with other study observations [9] , [25] , [26] , [27] , [28] , [29] , [30] . Moreover, the 6 months stability time point also reflect the fact that as a screening service provider we do not control the return date of the brushes, but can only encourage participants to return the brushes using a reminder strategy [6] .…”

“…HPV self-sampling is an approach to improve screening coverage by offering screening non-attenders an alternative to the physician taken screening sample [9] , [26] , [27] and thereby overcoming some of the main reported reasons for non-attendance [20] . HPV self-sampling can also facilitate implementation of cervical screening in less favored regions where screening has not previously been a priority and/or where medical infrastructure is less developed [27] , [28] .…”

Self-Sampling for Human Papillomavirus Testing: Increased Cervical Cancer Screening Participation and Incorporation in International Screening Programs

“…However, many individuals do not comply with standard screening guidelines, often for a combination of reasons. For example, poor patient compliance may be caused by lack of time for a clinical visit, embarrassment related to the pelvic exam, and/or previous discomfort or pain during a Pap smear ( 34 , 75 , 76 ). Sociocultural and socioeconomic barriers may also cause women to postpone or decline regular cervical cancer screening.…”

“…In a study among 1,069 woman in Mexico, women reported that the Pap test caused more discomfort, pain, and embarrassment than self-sampling ( 34 ). In a series of interviews with low-income indigenous Mexican women who were given self-sampling kits, most women identified the need to be screened for cervical cancer, but identified multiple barriers to making a clinic visit; the self-sampling kits were found less embarrassing and less painful than sampling by a healthcare professional ( 76 ). In a questionnaire of 3,049 women in Argentina who were invited to self-sample, most women preferred this method because it interfered much less with their daily responsibilities and was less time-consuming than a visit to a clinic ( 77 ).…”

“…However, in a recent study among 1,769 women presenting to two University of Washington clinics for routine cervical cancer screening, about 40% of participants were concerned that self-sampling might be inferior to clinician-collected samples, although both patients as well as physicians were supportive of the concept of self-sampling for HPV testing ( 81 ). In some studies, women reported that they were afraid to hurt themselves during sampling ( 76 , 77 , 82 ).…”