Reaching under‐screened/never‐screened indigenous peoples with human papilloma virus self‐testing: A community‐based cluster randomised controlled trial

Abstract

Background Indigenous women in the high‐income countries of Canada, Australia, New Zealand and USA, have a higher incidence and mortality from cervical cancer than non‐Indigenous women. Increasing cervical screening coverage could ultimately decrease cervical cancer disparities. Aims To increase cervical screening for under‐screened/never‐screened Māori women. Materials and Methods This study was a cluster randomised controlled trial. Inclusion criteria were women aged 25–69, last screened ≥4 years ago, in Northland, New Zealand. The intervention arm was the offer of a human papilloma virus (HPV) self‐test and the control arm was the usual offer of standard care – a cervical smear. The primary outcome was rate of cervical screening in the intervention group compared to control in Māori, the Indigenous peoples of New Zealand. Six primary care clinics were randomly allocated to intervention or control. Results Of 500 eligible Māori women in the intervention arm, 295 (59.0%) were screened. Of 431 eligible Māori women in the control arm, 94 (21.8%) were screened. Adjusting for age, time since last screen, deprivation index, Māori women in the intervention arm were 2.8 times more likely to be screened than women in the control arm (95% CI: 2.4–3.1, P‐value <0.0001). Conclusions Offer of HPV self‐testing could potentially halve the number of under‐screened/never‐screened Māori women and decrease cervical morbidity and mortality. These results may be generalisable to benefit Indigenous peoples facing similar barriers in other high‐income countries.

Acceptability of human papillomavirus (HPV) self-sampling among never- and under-screened Indigenous and other minority women: a randomised three-arm community trial in Aotearoa New Zealand

“…Both women who were not followed up have a recall notice in the practice management system for discussion and the offer of related future follow-up. Follow-up was higher in our study than in the trial by MacDonald et al 13 (78%) and the iPAP trial 19 (62%). Most HPV-positive women (18/24; 75%) needed a short interval of phone support to achieve clinically appropriate follow-up; however, 5/24 women (20%) needed additional support (e.g., a home visit for a follow-up cytology test) and 4% (1/24) of women needed very intensive support (e.g., multiple phone-calls and visits to discuss options plus transport and support to attend colposcopy).…”

“…In our study, 7.6% of the women who took a self-sample were positive for a hrHPV type, similar to the proportion in the iPap trial (8.5%) 19 , but lower than that in the He Tapu Te Whare Tangata trial (11.0%) 13 (the latter trial included younger women known to have higher HPV prevalence). Our positivity proportion is at the lower end of the range found in the above-mentioned recent meta-analysis (6.0-29.4%) 2 .…”

“…The absolute participation proportions were therefore considerably higher; however, the odds ratio (reflecting a relative difference) was lower than that reported in our study (OR 9.7, 95%CI 3.0-31.5). The differences in participation may be due to different recruitment approaches: MacDonald et al 13 used texting, email, letters, phone calls, and outreach services (nurses and kaiāwhina (non-clinical community Māori health workers)) to invite women to screening. As with the iPAP study, there are also likely to be differences in the target populationsoverdue vs. our never-screened and highly under-screened populations and no European participants in our study.…”

Acceptability of human papillomavirus (HPV) self-sampling among never- and under-screened Indigenous and other minority women: a randomised three-arm community trial in Aotearoa New Zealand

“…A recent community-based cluster-randomised controlled trial ( He Tapu Te Whare Tangata ) in Aotearoa New Zealand, which involved intense recruitment of all overdue women, found that 59.0% of Māori women took up the face-to-face offer to self-sample compared to 21.8% who attended for a smear, with an adjusted risk ratio of 2.8 (2.4-3.1) [13] . The absolute participation proportions were therefore considerably higher; however, the odds ratio (reflecting a relative difference) was lower than that reported in our study (OR 9.7, 95%CI: 3.0-31.5).…”

“…The World Health Organization's strategy to accelerate the elimination of cervical cancer notes the need to examine screening implementation in the local context [12] . One recent study of self-testing in Aotearoa New Zealand assessed the impact of intense recruitment of all overdue women [13] . In contrast, our approach concentrated on the least served high-priority populations of never- and under-screened Māori, Pacific, and Asian women and was designed to reflect how self-sampling will probably be implemented in Aotearoa New Zealand.…”