Clinician and patient experiences with opportunistic offer of HPV self-testing in Aotearoa New Zealand primary care clinics: interview and survey findings

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H. Yang, Phyu Sin Aye, and 14 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8092746/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Mar, 2026 Read the published version in BMC Primary Care → Version 1 posted 11 You are reading this latest preprint version Abstract Background To support the introduction of human papillomavirus (HPV) self-testing in the New Zealand National Cervical Screening Programme, an implementation study of opportunistic self-test offer was undertaken in primary care clinics, with a home testing option and centralised follow-up. We aimed to explore the experience of study clinicians and participants. Methods Primary care clinicians trained to offer the self-test were invited to semi-structured interviews exploring their perception of receptivity to the opportunistic offer of self-testing, and challenges and enablers to implementation. Thematic analysis was undertaken on transcripts. Participants (aged 30-69 years) were sent a link to an online follow-up survey after HPV result notification. Survey results were analysed using descriptive statistics with thematic analysis of free text responses. Participant recruitment and data collection occurred between November 2021 and January 2024. Results Of the 40 clinicians trained to offer self-testing, 12 primary care clinicians from six Auckland ethnically diverse primary care sites completed an interview. ‘Positive reception’ was the strongest theme with clinicians reporting that overwhelmingly, participants were receptive to the HPV self-test offer. The four enabler themes were: ‘supportive practice systems’, ‘importance of the discussion’, ‘testing options for women’ and ‘specialised support and consistency’. Key challenge themes in implementing opportunistic self-testing were ‘competing demands’and ‘communicating what it’s all about’. Of the 3524 study participants, 394 responded to the online survey. Most (93%) found the amount of information they received about HPV self-testing ‘about right’ and were comfortable about doing the self-test opportunistically (86%). Considering their next cervical screening, more respondents preferred home-based self-testing options than self-testing at a clinic (46% versus 37%). Conclusion Offering the HPV self-test opportunistically to people due for screening when they visited their GP for another reason was generally well received and feasible for clinic staff. The choice to take kits home for sampling was an enabler of participation. Supportive systems and resources for clinicians will be important if opportunistic HPV self-testing is offered more widely in primary care, including further consideration of a central specialist team to provide follow-up and support for home testing, and potentially for participants with HPV detected. Trial registration This study did not reach the ICJME or WHO criteria for clinical trial registration. Cervical screening human papillomavirus (HPV) self-sampling at-home testing primary care clinician perspectives participant perspectives Māori health Pacific health health inequity implementation science Figures Figure 1 Figure 2 Introduction In 2023 the National Cervical Screening Programme (NCSP) in Aotearoa New Zealand (NZ) transitioned from cytology to human papillomavirus (HPV) testing as the primary screen, with the option of self-testing using a vaginal swab. NZ has longstanding disparities in screening rates, reflected in high cervical cancer rates among Māori, the Indigenous population, Pacific and under screened people ( 1 ). For the most part, an appointment at a general practice (GP) clinic is required to access cervical screening, however the self-test is well-suited to being offered ‘opportunistically’ when eligible patients present to their GP for other reasons. Opportunistic HPV self-testing is potentially an important strategy that could reach many of those who are overdue or have never been screened who visit a primary care provider. Primary care clinicians in Australia and the US have reported positive anticipation of the HPV self-test being integrated opportunistically into the GP encounter, seeing it as an important strategy for reducing screening disparities ( 2 – 6 ). A large-scale trial of opportunistic HPV self-testing with ‘non-attenders’ in ethnically diverse London practices (YouScreen) found it both feasible and acceptable, with a small increase in screening coverage in participating clinics ( 7 ). In NZ, there is an established role of nurses in primary care who are accredited to take cervical samples. As well as having a role in the renewed programme as ‘HPV screen takers’, health professionals who can facilitate HPV testing are well placed to provide opportunistic HPV self-testing in GP clinics. While for most the HPV self-test itself is straightforward to perform, integrating opportunistic self-testing into the workflow of a busy clinic is likely to come with significant logistical, resource and communication considerations. Additionally, for those who have HPV detected, skilled communication is needed to ensure that they understand their result and complete the recommended follow-up ( 8 , 9 ). As part of a broader research programme on the implementation of HPV self-testing, funded by the NZ Ministry of Health to help inform the programme change, we trialed opportunistic offer of HPV self-testing in six metropolitan Auckland general practices, together with communication of results and management of follow-up though a centralised nurse-led coordination team. The main participation findings have been reported elsewhere ( 10 ). Here we report the findings from in-depth interviews with clinicians involved in the study, exploring their views on 1) the receptiveness of participants to the opportunistic offer 2) the challenges and enablers to uptake and integration of the self-test into the clinic workflow and 3) the centralised support model. We also report the perspectives of study participants collected via a survey following notification of their HPV test result. Method Study setting The study took place in six GP clinics from November 2021 to January 2024 in Auckland, NZ, stopping just prior to the change in the NCSP to primary HPV screening. The GP clinics, which were part of a metropolitan primary healthcare organisation (PHO), were selected for the high proportions of enrolled Māori and Pacific people living in areas associated with high levels of socioeconomic deprivation and overall low cervical screening participation. Clinics in this PHO offer a mix of appointment and walk-in services. Staff are ethnically diverse and may move between clinics. Clinician and participant details Forty clinical staff (9 GPs and 31 nurses, most previously trained cervical screen takers) were trained to offer HPV self-tests for the study, using specifically designed credentialing modules. The clinic nurses had support from a central team of cervical screening research nurses that acted as an advisory resource and took responsibility for HPV test result communication and follow-up. The potentially eligible population (presenting to one of the six participating clinics in the study period and due screening) comprised 9,292 women (Māori 14.8%; Pacific 41.8%; Asian 35.6%; European/Other 7.8%). Those aged 30–69 years who were due for cervical screening and without a history of high-grade abnormalities were identified on the practice management system (PMS) dashboard when they presented to a participating clinic. In some clinics those due screening received a PMS-generated text message about the self-test availability while they were in the clinic waiting room. Potentially eligible participants were given a study brochure and verbal explanation of the HPV self-test and answered further eligibility questions (e.g. for gynaecological symptoms). Those who consented to participate were encouraged to complete the self-test in the consultation room or clinic bathroom. If they preferred, they could take a kit home, returning a sample to the clinic or a laboratory collection centre. Details about the HPV test, study participant data management system and results follow-up methods have been reported previously ( 10 ). Clinician interviews Clinicians trained to offer the self-test were invited to an interview at the end of the study. A semi-structured interview schedule was developed with open-ended questions that explored the following broad domains: receptivity to the opportunistic offer; challenges to the offer and uptake of the self-test; enablers to the offer and uptake of the self-test; and their experience of the central specialised support and results follow-up model (see Additional file 1 Interview Questions). Written consent for the in-person interviews was obtained from clinicians. Interviews took place in GP clinic rooms and, with permission, were audio recorded and transcribed verbatim. One participant declined audio recording and detailed notes were taken during the interview. Analysis was undertaken using Braun and Clarke’s six-phase framework for thematic analysis ( 11 ). Interview data was coded line by line, using a tabular format in Microsoft Word by one of the research team (AM). Codes were examined for common concepts. Themes were generated, further refined with other team members, and checked back with the original data set. Participant surveys Two cross-sectional online surveys were created in the Qualtrics XM platform, one for participants with HPV not detected (90% of participants), and one for participants with HPV detected test results. Survey questions were further developed from surveys used in our previous HPV studies and pre-tested with the eligible demographic group ( 12 , 13 ). Both surveys included questions on the information participants were given about the self-test, how comfortable they felt with their decision to have the self-test, and their test preferences when next due for cervical screening. Those who received an HPV detected result were also asked about their understanding of the test result, how worried they felt about their test result and their main concern, how comfortable they felt about attending a follow-up, and what would help them to attend a follow-up smear or colposcopy (see Additional file 2 Survey Questions). Both surveys contained demographic questions on self-identified ethnicity in accordance with NZ ethnicity data protocols ( 14 ), and age group in four categories. Study participants with HPV not detected results were sent a link to the online survey as part of their negative test result text message (from November 2021 – September 2023). Participants with an HPV detected result were sent a survey link one day after a phone call from the study nurse discussing HPV management recommendations and support, to capture understanding and concerns soon after the conversation (from November 2021 – January 2024). Results were extracted into Excel for analysis ( 15 ). Descriptive analysis was performed on quantitative survey responses to present numbers and percentages for individual subgroups and overall. Chi-squared tests were used to determine the statistical significance of the differences. A p-value of < 0.05 was considered statistically significant. The analyses were conducted using Excel ( 15 ) and Stata 18 ( 16 ). Thematic analysis was undertaken on free text responses. Ethics and approvals Ethical approval was obtained as part of approval for the wider research project from the NZ Health and Disability Ethics Committee (HDEC), reference number 21/STH/141. Approval for data access was obtained from the NCSP and from the National Kaitiaki Group, which oversees the use of data from wāhine Māori (Māori women) from the NCSP Register. This study adhered to the Declaration of Helsinki. Results Clinician interviews Twelve clinicians completed post-study interviews (30% response rate, n = 40) during March – April 2023, which lasted 30–60 minutes. All six participating clinics were represented among interviewees. Eleven interviewees were practice nurses, ten of whom were trained smear takers, and one was a GP. While age and ethnicity were not uniformly collected, the participating clinicians were predominantly female and of Asian ethnicity. Themes are discussed using sample quotes under each of the domains of Receptiveness, Challenges and Enablers as covered in the interview schedule. Receptiveness to the offer Three main themes were identified from clinicians’ accounts of the response to the opportunistic self-test offer: ‘Positive reception’, ‘Hesitancy’ and ‘Defer or decline’. ‘ Positive reception ’ was a dominant theme. Clinicians reported that overwhelmingly, those attending the clinic were receptive to being offered the HPV self-test opportunistically if they were due screening and were generally ‘happy to do it.’ There were two subthemes in relation to this receptivity. ‘Autonomy and convenience’ clinicians reported that participants appeared to value the sense of autonomy provided by the self-test and the convenience of being able to complete cervical screening when attending the clinic for another reason When they find out that they can do this test by themselves, they're quite delighted. [Practice Nurse 0023] They can do it within two minutes … while they’re waiting for the doctor…. and just do it in our bathroom. [Practice Nurse 0012] ‘ Different to the smear’ many of the clinicians described how offering the self-test contrasted with their previous experience approaching people about a clinician-taken smear test, which had often encountered resistance. Several commented on the participation of those who had repeatedly declined cervical screening Before when we offered the smear, mostly they said, ‘Uh, no, I don't want to…. I didn't have a shower, I didn’t…’, you know, there’s a lot of excuses, but now… [Practice Nurse 0026] ‘ Hesitancy’ While less common than positive reception, clinicians also described reluctance from some to doing a self-test, with two subthemes related to the test and testing environment. ‘Comfort with time and place’ reflects concerns and preferences for when, where and how the test was done, particularly about ‘feeling safe ’ to do it in the clinic facilities. There were often limited spaces available to do the test, and some participants were uncomfortable with using the clinic bathroom due to hygiene concerns, lack of privacy or a sense of safety from a cultural perspective. Some patients they say ‘Oh, this means I just go into your toilet and do it?’ and you can see their face and they’re thinking .. ‘Oh my goodness …it's not really comfortable’. [Practice Nurse 0012] ‘Uncertainty about the test’ A few clinicians encountered hesitancy about the new self- test for cervical screening, particularly among older participants, both confidence in its accuracy and ‘fear of doing it wrong’ Some of them are maybe a bit sceptic[al] in terms of how it will change the smear in comparison to just doing the swab. What will it test? [Practice Nurse 0014] ‘Defer or decline’ Clinicians also encountered a few who were not at all receptive to the invitation to do a self-test. Two subthemes indicate the range among these responses ‘Personal readiness’ some participants appeared not ready or willing to engage in decision making about cervical screening at the time, due either to personal factors, such as feeling unwell, tired or menstruating, or situational factors that made the opportunistic offer impractical, such as ‘being in a rush’ or having children with them Some of them will want to think about it. They say, no, we're gonna come back . [Practice Nurse 0022] Sometimes they come with the kids, so it's hard to do them. [Practice Nurse 0022] ‘Not for me’ While interviewees generally reported that few strongly declined the self-test offer (perception of the proportion of declines was variable), some described instances where participants believed they didn’t need the test because of their age or not being sexually active or had a previous negative experience with screening. There were one or two quite strong ones - said they didn’t need the test. [Practice Nurse 0016] Challenges Clinicians encountered some challenges in implementing opportunistic self-testing. Two themes were identified: ‘Competing demands’ and ‘Communicating what it's all about’. ‘Competing demands’ of other clinical priorities was a strong theme. Many of the clinicians described having to prioritise clinical tasks, some highlighting cervical screening in the context of ‘so much screening’ required or described how ‘being rushed’ worked against taking time to present the screening in a way that would be receptive to participants. Time constraints were greatly exacerbated during the COVID-19 lockdowns occurring in the early part of the study period. So this is one of the five or six other screening activities that I have to tick off. Okay, that doesn't always happen….especially on the weekends when we're short staffed …and occasionally, I might miss offering that option. [GP 0027] ‘Communicating what it's all about’ Patients were not expecting to discuss cervical screening at their appointment and clinicians described challenges explaining the new self-test ‘so they know what it’s all about’. This was made more challenging by the linguistic diversity among clinic patients and by varying levels of health literacy. Most of the patients know about smear tests…the word itself, they know it's related to cancer. We say we are now testing the virus itself that's causing cancer, then they have lots of questions, or sometimes they were just staring at you. [Practice Nurse 0012] Some patients maybe don't have the medical background to understand what we mean by the virus, to understand the difference. [Practice Nurse 0012] Enablers Four themes were evident in relation to what facilitated the self-test offer and readiness to participate: ‘Supportive practice systems’, ‘Importance of good discussion’, ‘Testing options for women’ and ‘Specialised support and consistency’. Clinicians identified a range of ‘Supportive practice systems’ , including both technological aids and staff management factors, that assisted them with opportunities to offer the self-test. The Practice Management System (PMS) dashboard highlighting patients due for screening was seen as a successful initiative that facilitated quick identification of potentially eligible patients: That dashboard really helped - the red sign will show if they were overdue, we just didn't have to do so much opening of files to see when the last test was. [Practice Nurse 0013] In clinics where a PMS-generated text message was sent to those due screening in the waiting room, clinicians reported that they found it a useful opener that prompted a conversation about cervical screening: So women will just come in, they will say ‘I've got a text message’. And then we'll talk about it. So that's when we will offer it. [Practice Nurse 0026] Other interviewees highlighted clinic process and management factors – such as the patient triage system and supportive teamwork – that increased opportunities for offering the self-test: The doctors were really supportive…. we tailed [offered the self-test] onto the end of the doctor's consultation. [Practice Nurse 0020] ‘Importance of the discussion’ Many of the clinicians talked about the value of ‘face-to-face’ discussion for explaining the self-test, and taking time to achieve a good understanding: I find that if you take time, and explain clearly, women are more receptive of it [GP 0027] Placing the cervical screening discussion in the context of other screening and prevention discussions was helpful. One interviewee elaborated on this: So preventative screening is something I try to do with every consultation .. that includes the smoking status update as well as the alcohol intake kind of thing: ‘Hey, do you mind if I take a few minutes to talk about screening?’ And I haven't come across a woman that says no. [GP 0027] Reassurance and support were key components of a good discussion, relating both to accuracy of the test and providing reassurance that a self-test could be done correctly. Written information about the self-test played a more supportive role to discussion, although a few clinicians described how the pictorial instructions, and demonstration with a swab, were helpful to support understanding of how to do the test: I actually opened the swab and showed them where the line is and, once they saw the line, they realised that, you know, that long swab didn't have to go up forever [Practice Nurse 0020] Being able to offer ‘Testing options for women’ was clearly a facilitator of uptake, both the offer of nurse-supported testing and particularly the option of home testing. We did have a few ladies that we had to do it for them. …or we guide them through it, we stay in the room with them, and then we let them know how to do it [Practice Nurse 0014] When they say they don't have time, we will say, ‘Oh, you can actually take this kit home’. [Practice Nurse 0023] Clinicians reported that the most common reason for taking a kit home test was discomfort with testing in the clinic. Taking the sample in their own space at home provided a greater sense of hygiene, comfort and safety: ‘they feel safer to do it at home’. The option of taking a kit home was also helpful to mitigate the time constraints where patients were ‘rushing in and rushing out’, had children with them, or wanted more time to read through the information. Finally, the ‘Specialised support and consistency’ provided by the centralised specialist nurse team was an enabling theme. While a few clinicians commented on role change confusion, because as a smear taker, you deal with the results as they come to you’, in general, they saw the support of the specialised team as advantageous. Perceived benefits were not only from a resource perspective ̶ results communication by the central team was one thing less to worry about ̶ but they also valued the team’s clinical and communication expertise, particularly where clinic staff felt ‘confused about clinical guidelines’ or ‘not very good with explaining’ results. One interviewee expressed a strong preference for an ongoing centralised model to ensure consistent and reliable screening practices, and consistent management of screening results. I think it ’ s a great advantage to have because, if you take all smear takers, everyone's ability to read results in time and knowledge of where to do what when, there's a huge variation. And we can mitigate that by having a centralised trained team that knows who to screen and how to screen, then we can manage results a lot more safely and more proactively… [GP 0027] Participant survey results Overall, 11.2% (n = 394) of all participants with an HPV self-test result (n = 3524) responded to the online survey (December 2011 - September 2023). The response rate was higher in those with an HPV detected result (33.4%; n = 112 of 335) than in those with an HPV not detected result (8.9%; n = 282 of 3159) (p < 0.001). The respondents were reasonably diverse in terms of self-reported prioritised ethnicity: Māori (15%), Pacific (28%), Asian (38%), European/Other (13%) and not answered (7%). There was a similar number of respondents across each of three age bands from 30–59 years (24% to 28% each), with fewer (16%) aged ≥ 60 years (see Additional file 3). Compared to the self-tested participants, there was a lower proportion of Pacific and a higher proportion of European/Other ethnicity groups and lower proportion of the 30–39-year age group in the survey respondents’ sample (p < 0.05). Additionally, there was a lower proportion of HPV not detected, and a higher proportion of HPV detected participants in the survey sample compared to the self-tested participants (p < 0.05) (see Additional file 3). Amount of information on self-testing Most (93%, n = 365) respondents stated that the amount of information they received about the HPV self-test was ‘about right’. Several participants also gave free text comments with a theme of ‘Appreciation of the explanation’ : I was well informed of my choices [Pacific participant, 60–69 years] A small proportion of respondents (4%, n = 14) wanted to know more, with a theme of ‘Specifics about the test’ , such as the accuracy or benefits of the HPV self-test. Comfort level with decision to self-test The majority (86%, n = 337) of survey respondents were comfortable with their decision to do the self-test. Of the survey respondents who provided free text comments (n = 131) most (84%, n = 110) were highly favourable regarding their experience of the opportunistic self-test, with the main theme ‘Ease and autonomy’ : It was easy, quick and private [Pacific participant, 50–59 years] I was surprised with this such an easy self-test [European/Other participant, 40–49 years] Didn’t hesitate when the nurse told me about this self-test because I get to do it myself whereas before I don’t go to my cervical appointments [Pacific participant, 50–59 years] Themes from the more ambivalent comments were ‘Uncertainties about the test’ , such as concern about whether they had performed it correctly and the longer testing interval, and ‘location of testing’, several respondents expressing discomfort with testing in the clinic bathroom: As an obese woman I did have a little trouble getting in a position to do the test, I couldn’t do it sitting as directed in the instructions [Māori participant, 50–59 years] Please provide a stretcher or bed while doing the self-test in the clinic [Pacific participant, 60–69 years] Didn’t feel very confident. I hope I did it correctly as next is due in 5 years [Asian participant, 60–69 years]. Furthermore, free texts from participants who tested at home (n = 30) were universally positive with dominant themes of ‘relief and dignity’ and ‘convenience’: I sincerely appreciated the option to ‘self-test’ in the comfort and privacy of my own home… I didn't have to go through the emotions of discomfort and feeling whakama of exposing my tinana (body), but rather proud that I was in control … Mihi maioha (thankyou) for restoring my dignity and mana (power/spiritual power). [Māori 50–59 years] Simple to do at home …no time off work to go into a clinic and just drop off at the local lab on the way to work. [Māori participant, 50–59 years] It’s in my own comfort space. [Pacific participant, 40–49 years] Next test preference When asked about their next cervical screening, most survey respondents (84%, n = 329) stated a preference for the self-test. Overall, 37% (n = 147) of respondents to this question specified a preference to do the self-test at a clinic, 32% (n = 124) a mailed test kit to do at home, and 15% (n = 58) to pick up a test kit from a clinic or pharmacy to do at home (see Additional file 4). When restricted to participants' preferences for self-test at a clinic or home-based self-testing for their next test, a slightly higher proportion of Māori participants (51%, n = 25 of 49) preferred a self-test at a clinic; while more European/Other participants (67%, n = 30 of 45) preferred home-based self-testing; however, the differences were non-significant (p = 0.515). While more participants with HPV not detected results (58%, n = 141 of 243) showed a preference for home-based self-testing, a larger proportion of HPV detected participants (52%, n = 45 of 86) preferred a self-test at a clinic (Fig. 1 ), these results were not statistically different (p = 0.097). Understanding of HPV result Of the respondents to the survey with HPV detected results, 78% (n = 87) reported having good understanding of their test result after a cervical screening nurse had discussed it with them, and 21% (n = 23) were neutral (Fig. 2 ). HPV human papillomavirus To protect participant confidentiality and privacy, values of less than 6 are combined with at least one other value. Figure 2 . Number of HPV detected survey participants responding to questions on ‘understanding of HPV result’, ‘worry about HPV results’, ‘clarity about next steps’ and ‘comfort level to attend colposcopy’ (Māori n = 15, Pacific n = 36, Asian n = 33, European/Other n = 14, Not stated n = 14, Total n = 112) Worry about HPV detected result Regarding their level of concern about the HPV detected result, of the 110 respondents to this question, 10% (n = 11) reported being very worried, 33% (n = 36) a bit worried, 13% (n = 14) were neutral, 23% (n = 25) were mostly OK, and 22% (n = 24) were not at all worried (Fig. 2 ). The dominant theme from the reasons for worry about HPV detected results was ’anxiety about cancer’, with a sub-theme relating to the additional burden of uncertainty and ‘having something else to worry about’: I'm also glad that I have done the test and the outcome did get me worried a bit. As long as I follow through with all my tests, I can feel better about myself and choices I make. [Māori participant, 40–49 yrs] I'm thinking of my children. [Pacific participant, 50–59 years] Not knowing how long I had the virus, how I got it and when will it go away. [Asian participant, 50–59 years] Clarity and comfort with follow-up testing Most respondents with HPV detected (81%, n = 91 of 112) felt clear about ‘what happens next’ (Fig. 2 ). Most (66%, n = 74) felt comfortable about attending a colposcopy, with those who were less comfortable most commonly selecting ‘more information about what to expect’ (n = 19). Discussion Our study explored clinician experiences of implementing opportunistic offer of HPV self-testing in GP clinics serving a diverse and under-screened population, with a centralised follow-up team, as well as the participant experience. The study was conducted prior to the New Zealand implementation of primary HPV screening with offer of self-testing and helped inform the decision to support this policy change. COVID-19 lockdowns took place during the study timeframe. Receptivity According to clinicians, most participants were very receptive to being offered the self-test when they attended the GP clinic for any reason. This finding, together with positive reports about the offer from most survey respondents, supports quantitative findings from the main study indicating that HPV self-testing offered opportunistically was broadly acceptable ( 10 ). Recent international reviews and meta-analyses have reported on the relative success of HPV self-test invitation strategies involving a face-to-face invitation ( 17 – 20 ). Compared to other approaches, direct offer of the HPV self-test in primary care clinics has the benefit of an in-person explanation in a generally trusted setting that can support uptake of the offer. However, receptivity must be considered within the overall context of known systemic access barriers to primary care that disproportionately impact Māori wāhine (women) ( 21 ). Patient-centred barriers and enablers The clinicians reported that clear, unhurried, kanohi ki te kanohi (face-to-face) discussion was a key factor supporting understanding and participation in the self-test, and that putting the self-test offer in the context of other screening and prevention discussions was helpful. Survey participants also reported a good understanding of self-testing including clear follow-up steps from nurse communication which likely supported their comfort level with self-testing ( 12 ). The importance of the clinician-patient relationship, good communication and adequate information are similar themes found in other qualitative studies of HPV self-testing in Australian and NZ primary care settings ( 2 , 22 ). Clinicians in our study attended in-depth training on offering the HPV self-test, including scenarios of difficult or uncertain situations. Communication challenges reported by the clinicians often related to the diversity of background health knowledge and languages of the clinic population, suggesting that ‘layered’ communications in a range of formats and level of detail are needed. Clinician cultural safety and competence a have been identified as significant barriers in primary health care ( 23 , 24 ). A previous study on the acceptability of self-testing among never/under screened Māori wāhine found culturally competent engagement was an important factor influencing uptake ( 25 ). Continuing to strive for alignment with tikanga (cultural protocols and processes) in mainstream primary health services as well as workforce diversity, representing the population being served, and culturally safe health interactions to reduce trauma are key ways of addressing inequity ( 26 – 28 ). Notable among barriers reported by clinicians regarding uptake of the self-test was the fact that many were not comfortable with the time and place for doing the test at the clinic, or the available facilities for comfort or accessibility. Participants in this and similar studies have commented on clinic bathrooms being cramped, feeling ‘unhygienic’, not sufficiently private, or culturally not feeling like a safe place for self-sampling ( 19 ). For Māori, the womb (te whare tangata, the house in which human life grows), can have particular significance and sacredness ( 27 ). Research among Māori wāhine and Indigenous Australian women has shown that self-testing increased body autonomy ( 26 , 30 ). This and other cultural factors including connections to the body and whenua (land) for Māori wāhine together with cultural safety are likely impacting the safety and comfort of the testing environment and overall trust and willingness to participate in cervical screening ( 27 , 29 , 30 ). These aspects need to be considered within the wider context of structural barriers to health care impacting Māori including colonisation and breaches of Te Tiriti o Waitangi (the founding agreement of Aotearoa New Zealand) ( 21 ). Similar considerations arise for many Pacific women ( 31 ). Furthermore, personal or situational circumstances made self-testing onsite difficult for some participants. The possibility of taking a self-test kit home mitigated these barriers for many. Despite the initial offer to test in the clinic, clinicians reported that the option to take kits home supported participation, providing a greater sense of comfort, safety or convenience. While all were offered the self-test in a clinic, nearly half of our survey respondents preferred to do a home-based sample when they are next due screening. This result supports our previous study findings ( 10 ) and other studies that have found ‘home’ to be the preferred setting for cervical self-sampling, including for wāhine Māori ( 12 , 25 , 32 – 34 ). Additionally, non-speculum clinician collected samples could be an option for those who fear incorrectly administering the self-test or have difficulty collecting a self-sample due to physical impairments or disabilities ( 35 ). Clinician implementation barriers and enablers From the clinician interviewee accounts, the opportunistic offer of self-test was feasible to integrate into the clinic workflow. Nevertheless, they encountered some implementation challenges. There was a strong theme of competing demands on clinicians, not least from requirements to undertake opportunistic screening for other conditions, and these time constraints in busy clinics are likely to have made the offer to all potentially eligible patients challenging. This finding aligns with other studies that reported or anticipated competing priorities within consultations as a barrier to implementing opportunistic offer of the self-test ( 36 , 37 ). In contrast, other clinician implementation barriers reported were gaps in knowledge and understanding and mixed attitudes to self-testing, specifically two thirds of GPs and nurses were either neutral or preferred sample collection by clinicians, in a study among primary healthcare staff (GPs, nurses and other health care workers) in Australia ( 38 ). In our study, the self-test was mostly delivered by nurse cervical screen takers, either before or after the consultation with the doctor, countering some concern that opportunistic self-sampling might cause workflow disruptions or shorten the patient-doctor encounter time ( 6 ). The interviews in our study also indicated that well-designed technological aids and supportive staff management processes can be employed to support opportunistic offer and uptake of the test. These included a PMS dashboard identifier of those eligible for a self-test and the text message icebreakers. Centralised support team Clinicians appreciated the support and management of results by the central specialist nurse research team. Our survey finding that an HPV detected result is worrying for many participants is consistent with other studies finding anxiety, shame, or fear of cancer associated with a HPV detected test result ( 8 , 39 ). Support for a centralised team as an ongoing service model was partly based on its advantages as an experienced team of cervical screening specialists offering safe, consistent and proactive results management. Participant experience of results communication and follow-up appeared to support this perception, and a high level of results follow-up achieved in our study ( 10 ). Another key service role of the central team was follow-up of kits taken home. Follow-up of samples not returned has been anticipated as a challenging area in the new self-test era and there is an identified need for robust support systems ( 5 , 40 ) that could have benefits for both clinicians and patients. Overall, next test preference was for self-testing at home in our study and a previous New Zealand study ( 12 ), however, HPV detected participants most frequently preferred self-testing at a clinic whereas self-testing at home was preferred by HPV non-detected participants in our study, although, these were not significantly different. Strengths This investigation into the experiences of clinicians and participants enriches the quantitative findings from our study of opportunistic HPV self-testing. We identified real-world challenges and enablers for clinicians working in busy clinics with culturally and linguistically diverse populations. Many of those presenting to the practice were overdue for cervical screening and are the priority group for increasing participation. We were able to explore their receptiveness to opportunistic offer, some of the barriers to uptake of the test in clinic and some pragmatic enablers. Limitations Several factors may limit the generalisability of our study to other primary care clinics. The ethnicity and socioeconomic status of the patient population in the participating clinics does not reflect all populations in New Zealand and the response from participants and challenges faced by nurses may be different in other regions. The clinicians were predominantly non-New Zealand trained nurses, and their age and ethnic group was not systematically collected therefore we were not able to present comparable information for clinician perspectives as for participant perspectives. This PHO already incorporates opportunistic interventions into their patient consultation model, whereas this way of working may be less readily accommodated in clinics with more traditional general practice models. The study was conducted during the COVID-19 pandemic, which is likely to have exacerbated staffing shortages and pressures. Despite measures taken to support survey participation, the response rate was low (11.2% of participants with a test result), particularly for those with HPV not detected results who comprised 90% of participants sent the survey. Finally, the study took place prior to the national roll-out of HPV self-testing, with the intent of informing programme change, along with additional studies from our research programme and other groups. Testing for HPV with a self-swab was a significant departure from previous experience of cervical screening, requiring in-depth first-time explanations. It was also offered as a research study. The response from patients may be different once the test is more established as usual care. Conclusion The insights from clinicians and participants involved in a study of opportunistic offer of the HPV self-test in GP clinics support the acceptability of this approach and its feasibility for clinic staff. Most participants were comfortable with communication about self-testing and follow-up and decision to self-test. There were some indications of preference at the next test for home-testing by HPV non-detected and clinic testing by HPV detected participants. Wider implementation of the opportunistic offer of HPV self-testing in New Zealand primary care could increase screening coverage among those not currently accessing screening. Flexibility in the choice of taking kits home for sampling is an important enabler to participation. The study highlights the importance of resources and systems to support clinicians in primary care to offer the HPV self-test opportunistically. Further investigation of a centralised specialist team model to provide support and follow-up of those who take a kit home and potentially overseeing HPV results management, could be useful for future programme planning. List of abbreviations GP General Practitioner HDEC NZ Health and Disability Ethics Committee HPV Human papillomavirus NCSP National Cervical Screening Programme NZ New Zealand PHO Primary healthcare organisation PMS Practice management system US United States Declarations Ethics approval and consent to participate This study was approved by the New Zealand Health and Disability Ethics Committee (HDEC), reference number 21/STH/141. Data access was approved by the NCSP programme and by the National Kaitiaki Group, which oversees the use of data from wāhine Māori (Māori women) from the NCSP Register. The study was approved through localities research office approvals in the three Auckland districts where the study was conducted. A Māori data sovereignty assessment was conducted and approved as part of ethics and localities approval. A privacy and security assessment was conducted and approved. All individuals in the study provided informed consent. This study adhered to the Declaration of Helsinki. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Funding This study was funded by Health New Zealand | Te Whatu Ora’s Te Toka Tumai Auckland District, Waitematā District, and Counties Manukau District, Tamaki Health, and Health New Zealand | Te Whatu Ora’s National Screening Unit (formerly the Ministry of Health, New Zealand). Author Contribution Conceptualisation – KB, AM, CB, JG, KMMethodology - KB, AM, CB, JG, SSSoftware – AM, JG, CN, LYaValidation – CN, LYaFormal analysis – AM, LYa, CN, PSAInvestigation – SC, CB, GM, JK, DF, RM, JGResources - KBData curation – LYa, CNWriting - original draft – AM, LYo, LYa, SS, KB, CN, CBWriting - review and editing – all authorsVisualisation – CN, LYa, CB, PSA, LYoSupervision – JG, SC, KB, PC, WB, CB, GM, RM, AM, DF, JK, KM, SSProject administration – KB, AM, JGFunding acquisition – KB Acknowledgement We thank the study participants for their contribution to informing the roll out of HPV primary screening with a primary choice of self-test in Aotearoa New Zealand. We acknowledge the leadership and dedication of the nurse-led co-ordination team (Seshnee Pillay, Fiona Gillet, Frances Kendall, Isha Gaikwad, Natacha Toledo Yanez), the HPV call centre and mail-out staff (Melissa Murray, Awhina Brockbank, Paris Fale, Eden Wharerau, Faenza Williams-Fonohema, Brooke Crawford, Louise Swann, Angelina Taungahihifo) and kaiawhina (cultural support; Marara Metekingi). We thank the Group Manager of the Māori Health Pipeline team Scott Abbot and the Māori engagement manager Erin Stirling for their ongoing support. We thank Dr Mahesh Patel (Clinical Director), Rachael Sculley (Nurse Leader), and Reshmi Lata Chand (senior nurse) at Tamaki Health for support with results management and troubleshooting in clinics, all the staff at the participating primary care clinics, and Rodney Burger for technical data support. We acknowledge the support of a range of laboratory staff at Pathlab. We thank the National Kaitiaki Group and National Cervical Screening Programme for their feedback on the initial proposal, the project in flight and this manuscript. We thank the Procon team, Ken Leech and Arthur Mate for their support with the bespoke IT software. We thank the colposcopy teams in the Auckland region who participated in this study. We thank the Equity, Scientific and Technical team for their support with data processes, including Group Manager Wendy Bennett, analysts Michael Walsh and Jean Wignall, and technical data specialist Malcolm Fletcher. Data Availability The data used and analysed during the current study contain identifiable individual patient information, including that of Māori. The data are not publicly available due to the data confidentiality and privacy restrictions and Māori data sovereignty considerations but are available from the corresponding author on reasonable request and corresponding approvals. References Ministry of Health. Wai 2575 Māori Health Trends Report. Wellington: Ministry of Health; 2019. Chandrakumar A, Hoon E, Benson J, Stocks N. Barriers and facilitators to cervical cancer screening for women from culturally and linguistically diverse backgrounds; a qualitative study of GPs. BMJ Open. 2022;12(11):e062823. Pratt R, Barsness CB, Lin J, Desai J, Fordyce K, Ghebre R, et al. Integrating HPV self-collect into primary care to address cervical cancer screening disparities. Prev Med Rep. 2024;38:102599. Zammit C, Creagh N, Nightingale C, McDermott T, Saville M, Brotherton J, et al. I'm a bit of a champion for it actually': qualitative insights into practitioner-supported self-collection cervical screening among early adopting Victorian practitioners in Australia. Prim Health Care Res Dev. 2023;24:e31. Ingamells S, Bell R, Nip J, Innes C, Te Whaiti S, Tino A, et al. Perceived barriers to self-collected HPV testing for cervical cancer screening, and knowledge of HPV: a survey of primary healthcare smear-takers across Aotearoa New Zealand. N Z Med J. 2024;137(1590):57–76. Le A, Rohweder C, Wheeler SB, Lafata JE, Teal R, Giannone K, et al. Self-Collection for Primary HPV Testing: Perspectives on Implementation from Federally Qualified Health Centers. Prev Chronic Dis. 2023;20:E93. Lim AWW, Deats K, Gambell J, Lawrence A, Lei J, Lyons M et al. Opportunistic offering of self-sampling to non-attenders within the English cervical screening programme: a pragmatic, multicentre, implementation feasibility trial with randomly allocated cluster intervention start dates (YouScreen). eClinicalMedicine. 2024:102672. McBride E, Tatar O, Rosberger Z, Rockliffe L, Marlow LAV, Moss-Morris R, et al. Emotional response to testing positive for human papillomavirus at cervical cancer screening: a mixed method systematic review with meta-analysis. Health Psychol Rev. 2021;15(3):395–429. McLachlan E, Anderson S, Hawkes D, Saville M, Arabena K. Completing the cervical screening pathway: Factors that facilitate the increase of self-collection uptake among under-screened and never-screened women, an Australian pilot study. Curr Oncol. 2018;25(1):e17–26. Bartholomew K, Yang LPH, Neville C, Maxwell A, Aye PS, Grant J et al. Opportunistic offer of human papillomavirus (HPV) self-testing in ethnically diverse primary care clinics in Aotearoa New Zealand: an implementation study [pre-print available from https://www.researchsquare.com/article/rs-6858056/v1] Terry GHN, Clarke V, Braun V. The SAGE handbook of qualitative research in psychology. London: Sage; 2017. Sherman SM, Brewer N, Bartholomew K, Bromhead C, Crengle S, Cunningham C, et al. Human papillomavirus self-testing among unscreened and under-screened Māori, Pasifika and Asian women in Aotearoa New Zealand: A preference survey among responders and interviews with clinical-trial nonresponders. Health Expect. 2022;25(6):2914–23. Bartholomew K, Grant J, Maxwell A, Bromhead C, Gillett F, Saraf R, et al. Feasibility and acceptability of telehealth and contactless delivery of human papillomavirus (HPV) self-testing for cervical screening with Māori and Pacific women in a COVID-19 outbreak in Aotearoa New Zealand. N Z Med J. 2022;135(1565):83–94. Ministry of Health. HISO 100001 2017 Ethnicity data protocols. Wellington: Ministry of Health; 2017. Microsoft. Excel (Microsoft 365 subscription). Microsoft Corporation; 2024. StataCorp. Stata statistical software: release 18 [software]. StataCorp LLC; 2023. Yeh PT, Kennedy CE, de Vuyst H, Narasimhan M. Self-sampling for human papillomavirus (HPV) testing: a systematic review and meta-analysis. BMJ Glob Health. 2019;4(3):e001351. Ngu SF, Lau LS, Chan CY, Ngan HY, Cheung AN, Chan KK. Acceptability of self-collected vaginal samples for human papillomavirus testing for primary cervical cancer screening: comparison of face-to-face and online recruitment modes. BMC Public Health. 2024;24(1):1104. Rose SB, McBain L, Garrett SM, Bell R, Innes C, Te Whaiti S, Tino A, Sykes P. I felt so empowered, respected and shame free.' Let's test for HPV participants' experience of HPV primary screening. J Prim Care. 2024;17(2):134–45. Costa S, Verberckmoes B, Castle PE, Arbyn M. Offering HPV self-sampling kits: an updated meta-analysis of the effectiveness of strategies to increase participation in cervical cancer screening. Br J Cancer. 2023;128(5):805–13. Waitangi Tribunal. Hauora: Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry Wai 2575. Lower Hutt. New Zealand: Waitangi Tribunal; 2023. Rose SB, McBain L, Garrett SM, Bell R, Innes C, Te Whaiti S, Tino A, Sykes P. I felt so empowered, respected and shame free.’ Let’s test for HPV participants’ experience of HPV primary screening. J Prim Health Care. 2024;17(2):134–45. Graham RM-AB. Experiences of Māori of Aotearoa New Zealand’s public health system: a systematic review of two decades of published qualitative research. Aust N Z J Public Health. 2020;44(3):193–200. Curtis E, Loring B, Jones R, Tipene-Leach D, Walker C, Paine SJ, et al. Refining the definitions of cultural safety, cultural competency and Indigenous health: lessons from Aotearoa New Zealand. Int J Equity Health. 2025;24(1):130. Adcock A, Cram F, Lawton B, Geller S, Hibma M, Sykes P, et al. Acceptability of self-taken vaginal HPV sample for cervical screening among an under-screened Indigenous population. Aust NZ J Obstet Gynaecol. 2019;59(2):301–7. Palmer SC, Gray H, Huria T, Lacey C, Beckert L, Pitama SG. Reported Māori consumer experiences of health systems and programs in qualitative research: a systematic review with meta-synthesis. Int J Equity Health. 2019;18(1):163. Adcock A, Stevenson K, Cram F, MacDonald EJ, Geller S, Hermens J, et al. He Tapu Te Whare Tangata (sacred house of humanity): Under-screened Māori women talk about HPV self-testing cervical screening clinical pathways. Int J Gynaecol Obstet. 2021;155(2):275–81. Wilson D, Moloney E, Parr JM, Aspinall C, Slark J. Creating an Indigenous Māori-centred model of relational health: a literature review of Māori models of health. J Clin Nurs. 2021;30(23–24):3539–55. Cook C, Clark T, Brunton M. Optimising cultural safety and comfort during gynaecological examinations: Accounts of Indigenous Māori women. Nurs Prax NZ. 2014;30(3):19–34. Marques B, Freeman C, Carter L. Adapting traditional healing values and beliefs into therapeutic cultural environments for health and well-being. Int J Environ Res Public Health. 2021;19(1). Foliaki S, Matheson A. Barriers to cervical screening among Pacific women in a New Zealand urban population. Asian Pac J Cancer Prev. 2015;16(4):1565–70. Camara H, Zhang Y, Lafferty L, Vallely AJ, Guy R, Kelly-Hanku A. Self-collection for HPV-based cervical screening: a qualitative evidence meta-synthesis. BMC Public Health. 2021;21(1):1503. Nishimura H, Yeh PT, Oguntade H, Kennedy CE, Narasimhan M. HPV self-sampling for cervical cancer screening: a systematic review of values and preferences. BMJ Glob Health. 2021;6(5). Rose SB, McBain L, Bell R, Innes C, Te Whaiti S, Tino A, et al. Experience of HPV primary screening: a cross-sectional survey of 'Let's test for HPV' study participants in Aotearoa New Zealand. J Prim Health Care. 2025;17(2):123–33. Landy R, Hollingworth T, Waller J, Marlow LA, Rigney J, Round T, et al. Non-speculum sampling approaches for cervical screening in older women: randomised controlled trial. Br J Gen Pract. 2022;72(714):e26–33. Creagh NS, Saunders T, Brotherton J, Hocking J, Karahalios A, Saville M, et al. Practitioners support and intention to adopt universal access to self-collection in Australia's National Cervical Screening Program. Cancer Med. 2024;13(10):e7254. Lim AW, Hollingworth A, Kalwij S, Curran G, Sasieni P. Offering self-sampling to cervical screening non-attenders in primary care. J Med Screen. 2017;24(1):43–9. Cheng E, Stubbs JM, Achat HM. Self-collection for HPV-based cervical screening: knowledge and attitudes of Australian health care workers in an area with low screening rates, July-November 2023. Public Health Rep. 2024:333549241299272. Rose SB, McBain L, Bell R, Innes C, Te Whaiti S, Tino A, Sykes P. 'Kind of scared but happy something was detected.' Cross-sectional survey of Let's Test for HPV participants to understand perspectives on an HPV detected result. Aust N Z J Obstet Gynaecol. 2024. Borchowsky K, Rush M, Mullally T, McBain L, Hudson B, McMenamin J, et al. Primary care experiences in the 'Let's test for HPV' study: a qualitative analysis. J Prim Health Care. 2023;15(2):147–54. Footnotes We utilise the Curtis et al ( 23 ) definitions of cultural safety and cultural competence in use in NZ. Cultural safety refers to the ongoing responsibility that healthcare professionals and healthcare organisations have to critically examine and address the influence of their own culture - including power, privileges, biases, attitudes and prejudices - and the potential impact these may have on patient interactions and delivery of health services with the goal of developing culturally safe care as defined by patients and the community. Cultural competence describes the cultural knowledge, skills and ways of working that health professionals need to provide high quality healthcare that is equitable for all populations. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":8926,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the number of next test preferences of HPV detected (n=112) and HPV non-detected respondents (n=282)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8092746/v1/e7036faa58f0352672e03352.png"},{"id":97113151,"identity":"bbc3faa3-a857-46e3-836d-2d30979cd0d8","added_by":"auto","created_at":"2025-12-01 06:54:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":23350,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of HPV detected survey participants responding to questions on ‘understanding of HPV result’, ‘worry about HPV results’, ‘clarity about next steps’ and ‘comfort level to attend colposcopy’ (Māori n=15, Pacific n=36, Asian n=33, European/Other n=14, Not stated n=14 Total n=112)\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8092746/v1/2164bf4a11c37b08648f28d3.png"},{"id":104252205,"identity":"aca40c0d-1037-4713-963b-5eff48993e28","added_by":"auto","created_at":"2026-03-09 16:17:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1084354,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8092746/v1/cf328373-eaf1-4786-9613-43d36e9378cf.pdf"},{"id":97113138,"identity":"10226661-c1a2-4b97-9010-4a0de5b558a9","added_by":"auto","created_at":"2025-12-01 06:54:12","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":26292,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfiles1and2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8092746/v1/ea6af83b2a2588b0cf25d373.docx"},{"id":97113144,"identity":"92ba6fab-48de-4f32-aa50-860fc89bd603","added_by":"auto","created_at":"2025-12-01 06:54:12","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25680,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfiles3and4.docx","url":"https://assets-eu.researchsquare.com/files/rs-8092746/v1/d012adc225eb8f57c7a0d1d1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinician and patient experiences with opportunistic offer of HPV self-testing in Aotearoa New Zealand primary care clinics: interview and survey findings","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn 2023 the National Cervical Screening Programme (NCSP) in Aotearoa New Zealand (NZ) transitioned from cytology to human papillomavirus (HPV) testing as the primary screen, with the option of self-testing using a vaginal swab. NZ has longstanding disparities in screening rates, reflected in high cervical cancer rates among Māori, the Indigenous population, Pacific and under screened people (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). For the most part, an appointment at a general practice (GP) clinic is required to access cervical screening, however the self-test is well-suited to being offered \u0026lsquo;opportunistically\u0026rsquo; when eligible patients present to their GP for other reasons. Opportunistic HPV self-testing is potentially an important strategy that could reach many of those who are overdue or have never been screened who visit a primary care provider.\u003c/p\u003e\u003cp\u003ePrimary care clinicians in Australia and the US have reported positive anticipation of the HPV self-test being integrated opportunistically into the GP encounter, seeing it as an important strategy for reducing screening disparities (\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). A large-scale trial of opportunistic HPV self-testing with \u0026lsquo;non-attenders\u0026rsquo; in ethnically diverse London practices (YouScreen) found it both feasible and acceptable, with a small increase in screening coverage in participating clinics (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn NZ, there is an established role of nurses in primary care who are accredited to take cervical samples. As well as having a role in the renewed programme as \u0026lsquo;HPV screen takers\u0026rsquo;, health professionals who can facilitate HPV testing are well placed to provide opportunistic HPV self-testing in GP clinics. While for most the HPV self-test itself is straightforward to perform, integrating opportunistic self-testing into the workflow of a busy clinic is likely to come with significant logistical, resource and communication considerations. Additionally, for those who have HPV detected, skilled communication is needed to ensure that they understand their result and complete the recommended follow-up (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAs part of a broader research programme on the implementation of HPV self-testing, funded by the NZ Ministry of Health to help inform the programme change, we trialed opportunistic offer of HPV self-testing in six metropolitan Auckland general practices, together with communication of results and management of follow-up though a centralised nurse-led coordination team. The main participation findings have been reported elsewhere (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Here we report the findings from in-depth interviews with clinicians involved in the study, exploring their views on 1) the receptiveness of participants to the opportunistic offer 2) the challenges and enablers to uptake and integration of the self-test into the clinic workflow and 3) the centralised support model. We also report the perspectives of study participants collected via a survey following notification of their HPV test result.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy setting\u003c/h2\u003e\u003cp\u003eThe study took place in six GP clinics from November 2021 to January 2024 in Auckland, NZ, stopping just prior to the change in the NCSP to primary HPV screening. The GP clinics, which were part of a metropolitan primary healthcare organisation (PHO), were selected for the high proportions of enrolled Māori and Pacific people living in areas associated with high levels of socioeconomic deprivation and overall low cervical screening participation. Clinics in this PHO offer a mix of appointment and walk-in services. Staff are ethnically diverse and may move between clinics.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eClinician and participant details\u003c/h3\u003e\n\u003cp\u003eForty clinical staff (9 GPs and 31 nurses, most previously trained cervical screen takers) were trained to offer HPV self-tests for the study, using specifically designed credentialing modules. The clinic nurses had support from a central team of cervical screening research nurses that acted as an advisory resource and took responsibility for HPV test result communication and follow-up.\u003c/p\u003e\u003cp\u003eThe potentially eligible population (presenting to one of the six participating clinics in the study period and due screening) comprised 9,292 women (Māori 14.8%; Pacific 41.8%; Asian 35.6%; European/Other 7.8%). Those aged 30\u0026ndash;69 years who were due for cervical screening and without a history of high-grade abnormalities were identified on the practice management system (PMS) dashboard when they presented to a participating clinic. In some clinics those due screening received a PMS-generated text message about the self-test availability while they were in the clinic waiting room. Potentially eligible participants were given a study brochure and verbal explanation of the HPV self-test and answered further eligibility questions (e.g. for gynaecological symptoms). Those who consented to participate were encouraged to complete the self-test in the consultation room or clinic bathroom. If they preferred, they could take a kit home, returning a sample to the clinic or a laboratory collection centre. Details about the HPV test, study participant data management system and results follow-up methods have been reported previously (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eClinician interviews\u003c/h3\u003e\n\u003cp\u003eClinicians trained to offer the self-test were invited to an interview at the end of the study. A semi-structured interview schedule was developed with open-ended questions that explored the following broad domains: receptivity to the opportunistic offer; challenges to the offer and uptake of the self-test; enablers to the offer and uptake of the self-test; and their experience of the central specialised support and results follow-up model (see Additional file 1 Interview Questions).\u003c/p\u003e\u003cp\u003eWritten consent for the in-person interviews was obtained from clinicians. Interviews took place in GP clinic rooms and, with permission, were audio recorded and transcribed verbatim. One participant declined audio recording and detailed notes were taken during the interview. Analysis was undertaken using Braun and Clarke\u0026rsquo;s six-phase framework for thematic analysis (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Interview data was coded line by line, using a tabular format in Microsoft Word by one of the research team (AM). Codes were examined for common concepts. Themes were generated, further refined with other team members, and checked back with the original data set.\u003c/p\u003e\n\u003ch3\u003eParticipant surveys\u003c/h3\u003e\n\u003cp\u003eTwo cross-sectional online surveys were created in the Qualtrics\u003csup\u003eXM\u003c/sup\u003e platform, one for participants with HPV not detected (90% of participants), and one for participants with HPV detected test results. Survey questions were further developed from surveys used in our previous HPV studies and pre-tested with the eligible demographic group (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Both surveys included questions on the information participants were given about the self-test, how comfortable they felt with their decision to have the self-test, and their test preferences when next due for cervical screening. Those who received an HPV detected result were also asked about their understanding of the test result, how worried they felt about their test result and their main concern, how comfortable they felt about attending a follow-up, and what would help them to attend a follow-up smear or colposcopy (see Additional file 2 Survey Questions). Both surveys contained demographic questions on self-identified ethnicity in accordance with NZ ethnicity data protocols (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), and age group in four categories. Study participants with HPV not detected results were sent a link to the online survey as part of their negative test result text message (from November 2021 \u0026ndash; September 2023). Participants with an HPV detected result were sent a survey link one day after a phone call from the study nurse discussing HPV management recommendations and support, to capture understanding and concerns soon after the conversation (from November 2021 \u0026ndash; January 2024). Results were extracted into Excel for analysis (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Descriptive analysis was performed on quantitative survey responses to present numbers and percentages for individual subgroups and overall. Chi-squared tests were used to determine the statistical significance of the differences. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant. The analyses were conducted using Excel (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and Stata 18 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Thematic analysis was undertaken on free text responses.\u003c/p\u003e\n\u003ch3\u003eEthics and approvals\u003c/h3\u003e\n\u003cp\u003eEthical approval was obtained as part of approval for the wider research project from the NZ Health and Disability Ethics Committee (HDEC), reference number 21/STH/141. Approval for data access was obtained from the NCSP and from the National Kaitiaki Group, which oversees the use of data from wāhine Māori (Māori women) from the NCSP Register. This study adhered to the Declaration of Helsinki.\u003c/p\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eClinician interviews\u003c/h2\u003e\u003cp\u003eTwelve clinicians completed post-study interviews (30% response rate, n\u0026thinsp;=\u0026thinsp;40) during March \u0026ndash; April 2023, which lasted 30\u0026ndash;60 minutes. All six participating clinics were represented among interviewees. Eleven interviewees were practice nurses, ten of whom were trained smear takers, and one was a GP. While age and ethnicity were not uniformly collected, the participating clinicians were predominantly female and of Asian ethnicity.\u003c/p\u003e\u003cp\u003eThemes are discussed using sample quotes under each of the domains of Receptiveness, Challenges and Enablers as covered in the interview schedule.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eReceptiveness to the offer\u003c/h3\u003e\n\u003cp\u003eThree main themes were identified from clinicians\u0026rsquo; accounts of the response to the opportunistic self-test offer: \u0026lsquo;Positive reception\u0026rsquo;, \u0026lsquo;Hesitancy\u0026rsquo; and \u0026lsquo;Defer or decline\u0026rsquo;.\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026lsquo;\u003c/b\u003e\u003cem\u003ePositive reception\u003c/em\u003e\u0026rsquo; was a dominant theme. Clinicians reported that overwhelmingly, those attending the clinic were receptive to being offered the HPV self-test opportunistically if they were due screening and were generally \u0026lsquo;happy to do it.\u0026rsquo; There were two subthemes in relation to this receptivity.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u0026lsquo;Autonomy and convenience\u0026rsquo;\u003c/strong\u003e\u003cp\u003eclinicians reported that participants appeared to value the sense of autonomy provided by the self-test and the convenience of being able to complete cervical screening when attending the clinic for another reason\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWhen they find out that they can do this test by themselves, they're quite delighted.\u003c/em\u003e [Practice Nurse 0023]\u003c/p\u003e\u003cp\u003e\u003cem\u003eThey can do it within two minutes \u0026hellip; while they\u0026rsquo;re waiting for the doctor\u0026hellip;. and just do it in our bathroom.\u003c/em\u003e [Practice Nurse 0012]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cb\u003e\u0026lsquo;\u003c/b\u003eDifferent to the smear\u0026rsquo;\u003c/strong\u003e\u003cp\u003emany of the clinicians described how offering the self-test contrasted with their previous experience approaching people about a clinician-taken smear test, which had often encountered resistance. Several commented on the participation of those who had repeatedly declined cervical screening\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eBefore when we offered the smear, mostly they said, \u0026lsquo;Uh, no, I don't want to\u0026hellip;. I didn't have a shower, I didn\u0026rsquo;t\u0026hellip;\u0026rsquo;, you know, there\u0026rsquo;s a lot of excuses, but now\u0026hellip;\u003c/em\u003e [Practice Nurse 0026]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cb\u003e\u0026lsquo;\u003c/b\u003eHesitancy\u0026rsquo;\u003c/strong\u003e\u003cp\u003eWhile less common than positive reception, clinicians also described reluctance from some to doing a self-test, with two subthemes related to the test and testing environment.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;Comfort with time and place\u0026rsquo;\u003c/em\u003e reflects concerns and preferences for when, where and how the test was done, particularly about \u0026lsquo;feeling safe\u003cb\u003e\u0026rsquo;\u003c/b\u003e to do it in the clinic facilities. There were often limited spaces available to do the test, and some participants were uncomfortable with using the clinic bathroom due to hygiene concerns, lack of privacy or a sense of safety from a cultural perspective.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eSome patients they say \u0026lsquo;Oh, this means I just go into your toilet and do it?\u0026rsquo; and you can see their face and they\u0026rsquo;re thinking .. \u0026lsquo;Oh my goodness \u0026hellip;it's not really comfortable\u0026rsquo;.\u003c/em\u003e [Practice Nurse 0012]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u0026lsquo;Uncertainty about the test\u0026rsquo;\u003c/strong\u003e\u003cp\u003eA few clinicians encountered hesitancy about the new self- test for cervical screening, particularly among older participants, both confidence in its accuracy and \u0026lsquo;fear of doing it wrong\u0026rsquo;\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eSome of them are maybe a bit sceptic[al] in terms of how it will change the smear in comparison to just doing the swab. What will it test?\u003c/em\u003e [Practice Nurse 0014]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u0026lsquo;Defer or decline\u0026rsquo;\u003c/strong\u003e\u003cp\u003eClinicians also encountered a few who were not at all receptive to the invitation to do a self-test. Two subthemes indicate the range among these responses\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u0026lsquo;Personal readiness\u0026rsquo;\u003c/strong\u003e\u003cp\u003esome participants appeared not ready or willing to engage in decision making about cervical screening at the time, due either to personal factors, such as feeling unwell, tired or menstruating, or situational factors that made the opportunistic offer impractical, such as \u0026lsquo;being in a rush\u0026rsquo; or having children with them\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eSome of them will want to think about it. They say, no, we're gonna come back\u003c/em\u003e. [Practice Nurse 0022]\u003c/p\u003e\u003cp\u003e\u003cem\u003eSometimes they come with the kids, so it's hard to do them.\u003c/em\u003e [Practice Nurse 0022]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u0026lsquo;Not for me\u0026rsquo;\u003c/strong\u003e\u003cp\u003eWhile interviewees generally reported that few strongly declined the self-test offer (perception of the proportion of declines was variable), some described instances where participants believed they didn\u0026rsquo;t need the test because of their age or not being sexually active or had a previous negative experience with screening.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThere were one or two quite strong ones - said they didn\u0026rsquo;t need the test.\u003c/em\u003e [Practice Nurse 0016]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eChallenges\u003c/h2\u003e\u003cp\u003eClinicians encountered some challenges in implementing opportunistic self-testing. Two themes were identified: \u0026lsquo;Competing demands\u0026rsquo; and \u0026lsquo;Communicating what it's all about\u0026rsquo;.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u0026lsquo;Competing demands\u0026rsquo;\u003c/strong\u003e\u003cp\u003eof other clinical priorities was a strong theme. Many of the clinicians described having to prioritise clinical tasks, some highlighting cervical screening in the context of \u0026lsquo;so much screening\u0026rsquo; required or described how \u0026lsquo;being rushed\u0026rsquo; worked against taking time to present the screening in a way that would be receptive to participants. Time constraints were greatly exacerbated during the COVID-19 lockdowns occurring in the early part of the study period.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eSo this is one of the five or six other screening activities that I have to tick off. Okay, that doesn't always happen\u0026hellip;.especially on the weekends when we're short staffed \u0026hellip;and occasionally, I might miss offering that option.\u003c/em\u003e [GP 0027]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u0026lsquo;Communicating what it's all about\u0026rsquo;\u003c/strong\u003e\u003cp\u003ePatients were not expecting to discuss cervical screening at their appointment and clinicians described challenges explaining the new self-test \u0026lsquo;so they know what it\u0026rsquo;s all about\u0026rsquo;. This was made more challenging by the linguistic diversity among clinic patients and by varying levels of health literacy.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eMost of the patients know about smear tests\u0026hellip;the word itself, they know it's related to cancer. We say we are now testing the virus itself that's causing cancer, then they have lots of questions, or sometimes they were just staring at you.\u003c/em\u003e [Practice Nurse 0012]\u003c/p\u003e\u003cp\u003e\u003cem\u003eSome patients maybe don't have the medical background to understand what we mean by the virus, to understand the difference.\u003c/em\u003e [Practice Nurse 0012]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eEnablers\u003c/p\u003e\u003cp\u003eFour themes were evident in relation to what facilitated the self-test offer and readiness to participate: \u0026lsquo;Supportive practice systems\u0026rsquo;, \u0026lsquo;Importance of good discussion\u0026rsquo;, \u0026lsquo;Testing options for women\u0026rsquo; and \u0026lsquo;Specialised support and consistency\u0026rsquo;.\u003c/p\u003e\u003cp\u003eClinicians identified a range of \u003cem\u003e\u0026lsquo;Supportive practice systems\u0026rsquo;\u003c/em\u003e, including both technological aids and staff management factors, that assisted them with opportunities to offer the self-test.\u003c/p\u003e\u003cp\u003eThe Practice Management System (PMS) dashboard highlighting patients due for screening was seen as a successful initiative that facilitated quick identification of potentially eligible patients:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThat dashboard really helped - the red sign will show if they were overdue, we just didn't have to do so much opening of files to see when the last test was.\u003c/em\u003e [Practice Nurse 0013]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn clinics where a PMS-generated text message was sent to those due screening in the waiting room, clinicians reported that they found it a useful opener that prompted a conversation about cervical screening:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eSo women will just come in, they will say \u0026lsquo;I've got a text message\u0026rsquo;. And then we'll talk about it. So that's when we will offer it.\u003c/em\u003e [Practice Nurse 0026]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOther interviewees highlighted clinic process and management factors \u0026ndash; such as the patient triage system and supportive teamwork \u0026ndash; that increased opportunities for offering the self-test:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThe doctors were really supportive\u0026hellip;. we tailed\u003c/em\u003e [offered the self-test] \u003cem\u003eonto the end of the doctor's consultation.\u003c/em\u003e [Practice Nurse 0020]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;Importance of the discussion\u0026rsquo;\u003c/em\u003e Many of the clinicians talked about the value of \u0026lsquo;face-to-face\u0026rsquo; discussion for explaining the self-test, and taking time to achieve a good understanding:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI find that if you take time, and explain clearly, women are more receptive of it\u003c/em\u003e [GP 0027]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePlacing the cervical screening discussion in the context of other screening and prevention discussions was helpful. One interviewee elaborated on this:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eSo preventative screening is something I try to do with every consultation .. that includes the smoking status update as well as the alcohol intake kind of thing: \u0026lsquo;Hey, do you mind if I take a few minutes to talk about screening?\u0026rsquo; And I haven't come across a woman that says no.\u003c/em\u003e [GP 0027]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eReassurance and support were key components of a good discussion, relating both to accuracy of the test and providing reassurance that a self-test could be done correctly. Written information about the self-test played a more supportive role to discussion, although a few clinicians described how the pictorial instructions, and demonstration with a swab, were helpful to support understanding of how to do the test:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI actually opened the swab and showed them where the line is and, once they saw the line, they realised that, you know, that long swab didn't have to go up forever\u003c/em\u003e [Practice Nurse 0020]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBeing able to offer \u003cem\u003e\u0026lsquo;Testing options for women\u0026rsquo;\u003c/em\u003e was clearly a facilitator of uptake, both the offer of nurse-supported testing and particularly the option of home testing.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWe did have a few ladies that we had to do it for them. \u0026hellip;or we guide them through it, we stay in the room with them, and then we let them know how to do it\u003c/em\u003e [Practice Nurse 0014]\u003c/p\u003e\u003cp\u003e\u003cem\u003eWhen they say they don't have time, we will say, \u0026lsquo;Oh, you can actually take this kit home\u0026rsquo;.\u003c/em\u003e [Practice Nurse 0023]\u003c/p\u003e\u003cp\u003eClinicians reported that the most common reason for taking a kit home test was discomfort with testing in the clinic. Taking the sample in their own space at home provided a greater sense of hygiene, comfort and safety: \u0026lsquo;they feel safer to do it at home\u0026rsquo;. The option of taking a kit home was also helpful to mitigate the time constraints where patients were \u0026lsquo;rushing in and rushing out\u0026rsquo;, had children with them, or wanted more time to read through the information.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFinally, the \u003cem\u003e\u0026lsquo;Specialised support and consistency\u0026rsquo;\u003c/em\u003e provided by the centralised specialist nurse team was an enabling theme. While a few clinicians commented on role change confusion, because as a smear taker, you deal with the results as they come to you\u0026rsquo;, in general, they saw the support of the specialised team as advantageous. Perceived benefits were not only from a resource perspective ̶ results communication by the central team was one thing less to worry about ̶ but they also valued the team\u0026rsquo;s clinical and communication expertise, particularly where clinic staff felt \u0026lsquo;confused about clinical guidelines\u0026rsquo; or \u0026lsquo;not very good with explaining\u0026rsquo; results. One interviewee expressed a strong preference for an ongoing centralised model to ensure consistent and reliable screening practices, and consistent management of screening results.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI think it\u003c/em\u003e\u0026rsquo;\u003cem\u003es a great advantage to have because, if you take all smear takers, everyone's ability to read results in time and knowledge of where to do what when, there's a huge variation. And we can mitigate that by having a centralised trained team that knows who to screen and how to screen, then we can manage results a lot more safely and more proactively\u0026hellip;\u003c/em\u003e [GP 0027]\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eParticipant survey results\u003c/h2\u003e\u003cp\u003eOverall, 11.2% (n\u0026thinsp;=\u0026thinsp;394) of all participants with an HPV self-test result (n\u0026thinsp;=\u0026thinsp;3524) responded to the online survey (December 2011 - September 2023). The response rate was higher in those with an HPV detected result (33.4%; n\u0026thinsp;=\u0026thinsp;112 of 335) than in those with an HPV not detected result (8.9%; n\u0026thinsp;=\u0026thinsp;282 of 3159) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The respondents were reasonably diverse in terms of self-reported prioritised ethnicity: Māori (15%), Pacific (28%), Asian (38%), European/Other (13%) and not answered (7%). There was a similar number of respondents across each of three age bands from 30\u0026ndash;59 years (24% to 28% each), with fewer (16%) aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years (see Additional file 3). Compared to the self-tested participants, there was a lower proportion of Pacific and a higher proportion of European/Other ethnicity groups and lower proportion of the 30\u0026ndash;39-year age group in the survey respondents\u0026rsquo; sample (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, there was a lower proportion of HPV not detected, and a higher proportion of HPV detected participants in the survey sample compared to the self-tested participants (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (see Additional file 3).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eAmount of information on self-testing\u003c/h2\u003e\u003cp\u003eMost (93%, n\u0026thinsp;=\u0026thinsp;365) respondents stated that the amount of information they received about the HPV self-test was \u0026lsquo;about right\u0026rsquo;. Several participants also gave free text comments with a theme of \u003cem\u003e\u0026lsquo;Appreciation of the explanation\u0026rsquo;\u003c/em\u003e:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI was well informed of my choices\u003c/em\u003e [Pacific participant, 60\u0026ndash;69 years]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA small proportion of respondents (4%, n\u0026thinsp;=\u0026thinsp;14) wanted to know more, with a theme of \u003cem\u003e\u0026lsquo;Specifics about the test\u0026rsquo;\u003c/em\u003e, such as the accuracy or benefits of the HPV self-test.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eComfort level with decision to self-test\u003c/h2\u003e\u003cp\u003eThe majority (86%, n\u0026thinsp;=\u0026thinsp;337) of survey respondents were comfortable with their decision to do the self-test. Of the survey respondents who provided free text comments (n\u0026thinsp;=\u0026thinsp;131) most (84%, n\u0026thinsp;=\u0026thinsp;110) were highly favourable regarding their experience of the opportunistic self-test, with the main theme \u003cem\u003e\u0026lsquo;Ease and autonomy\u0026rsquo;\u003c/em\u003e:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eIt was easy, quick and private\u003c/em\u003e [Pacific participant, 50\u0026ndash;59 years]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eI was surprised with this such an easy self-test [European/Other participant, 40\u0026ndash;49 years]\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eDidn\u0026rsquo;t hesitate when the nurse told me about this self-test because I get to do it myself whereas before I don\u0026rsquo;t go to my cervical appointments\u003c/em\u003e [Pacific participant, 50\u0026ndash;59 years]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThemes from the more ambivalent comments were \u003cem\u003e\u0026lsquo;Uncertainties about the test\u0026rsquo;\u003c/em\u003e, such as concern about whether they had performed it correctly and the longer testing interval, and \u0026lsquo;location of testing\u0026rsquo;, several respondents expressing discomfort with testing in the clinic bathroom:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eAs an obese woman I did have a little trouble getting in a position to do the test, I couldn\u0026rsquo;t do it sitting as directed in the instructions\u003c/em\u003e [Māori participant, 50\u0026ndash;59 years]\u003c/p\u003e\u003cp\u003e\u003cem\u003ePlease provide a stretcher or bed while doing the self-test in the clinic\u003c/em\u003e [Pacific participant, 60\u0026ndash;69 years]\u003c/p\u003e\u003cp\u003e\u003cem\u003eDidn\u0026rsquo;t feel very confident. I hope I did it correctly as next is due in 5 years [Asian participant, 60\u0026ndash;69 years].\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFurthermore, free texts from participants who tested at home (n\u0026thinsp;=\u0026thinsp;30) were universally positive with dominant themes of \u0026lsquo;relief and dignity\u0026rsquo; and \u0026lsquo;convenience\u0026rsquo;:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI sincerely appreciated the option to \u0026lsquo;self-test\u0026rsquo; in the comfort and privacy of my own home\u0026hellip; I didn't have to go through the emotions of discomfort and feeling whakama of exposing my tinana (body), but rather proud that I was in control \u0026hellip; Mihi maioha (thankyou) for restoring my dignity and mana (power/spiritual power).\u003c/em\u003e [Māori 50\u0026ndash;59 years]\u003c/p\u003e\u003cp\u003e\u003cem\u003eSimple to do at home \u0026hellip;no time off work to go into a clinic and just drop off at the local lab on the way to work.\u003c/em\u003e [Māori participant, 50\u0026ndash;59 years]\u003c/p\u003e\u003cp\u003e\u003cem\u003eIt\u0026rsquo;s in my own comfort space.\u003c/em\u003e [Pacific participant, 40\u0026ndash;49 years]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eNext test preference\u003c/h2\u003e\u003cp\u003eWhen asked about their next cervical screening, most survey respondents (84%, n\u0026thinsp;=\u0026thinsp;329) stated a preference for the self-test. Overall, 37% (n\u0026thinsp;=\u0026thinsp;147) of respondents to this question specified a preference to do the self-test at a clinic, 32% (n\u0026thinsp;=\u0026thinsp;124) a mailed test kit to do at home, and 15% (n\u0026thinsp;=\u0026thinsp;58) to pick up a test kit from a clinic or pharmacy to do at home (see Additional file 4).\u003c/p\u003e\u003cp\u003eWhen restricted to participants' preferences for self-test at a clinic or home-based self-testing for their next test, a slightly higher proportion of Māori participants (51%, n\u0026thinsp;=\u0026thinsp;25 of 49) preferred a self-test at a clinic; while more European/Other participants (67%, n\u0026thinsp;=\u0026thinsp;30 of 45) preferred home-based self-testing; however, the differences were non-significant (p\u0026thinsp;=\u0026thinsp;0.515). While more participants with HPV not detected results (58%, n\u0026thinsp;=\u0026thinsp;141 of 243) showed a preference for home-based self-testing, a larger proportion of HPV detected participants (52%, n\u0026thinsp;=\u0026thinsp;45 of 86) preferred a self-test at a clinic (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e), these results were not statistically different (p\u0026thinsp;=\u0026thinsp;0.097).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eUnderstanding of HPV result\u003c/h2\u003e\u003cp\u003eOf the respondents to the survey with HPV detected results, 78% (n\u0026thinsp;=\u0026thinsp;87) reported having good understanding of their test result after a cervical screening nurse had discussed it with them, and 21% (n\u0026thinsp;=\u0026thinsp;23) were neutral (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eHPV human papillomavirus\u003c/p\u003e\u003cp\u003eTo protect participant confidentiality and privacy, values of less than 6 are combined with at least one other value.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Number of HPV detected survey participants responding to questions on \u0026lsquo;understanding of HPV result\u0026rsquo;, \u0026lsquo;worry about HPV results\u0026rsquo;, \u0026lsquo;clarity about next steps\u0026rsquo; and \u0026lsquo;comfort level to attend colposcopy\u0026rsquo; (Māori n\u0026thinsp;=\u0026thinsp;15, Pacific n\u0026thinsp;=\u0026thinsp;36, Asian n\u0026thinsp;=\u0026thinsp;33, European/Other n\u0026thinsp;=\u0026thinsp;14, Not stated n\u0026thinsp;=\u0026thinsp;14, Total n\u0026thinsp;=\u0026thinsp;112)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eWorry about HPV detected result\u003c/h2\u003e\u003cp\u003eRegarding their level of concern about the HPV detected result, of the 110 respondents to this question, 10% (n\u0026thinsp;=\u0026thinsp;11) reported being very worried, 33% (n\u0026thinsp;=\u0026thinsp;36) a bit worried, 13% (n\u0026thinsp;=\u0026thinsp;14) were neutral, 23% (n\u0026thinsp;=\u0026thinsp;25) were mostly OK, and 22% (n\u0026thinsp;=\u0026thinsp;24) were not at all worried (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The dominant theme from the reasons for worry about HPV detected results was \u0026rsquo;anxiety about cancer\u0026rsquo;, with a sub-theme relating to the additional burden of uncertainty and \u0026lsquo;having something else to worry about\u0026rsquo;:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI'm also glad that I have done the test and the outcome did get me worried a bit. As long as I follow through with all my tests, I can feel better about myself and choices I make. [Māori participant, 40\u0026ndash;49 yrs]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI'm thinking of my children.\u003c/em\u003e [Pacific participant, 50\u0026ndash;59 years]\u003c/p\u003e\u003cp\u003e\u003cem\u003eNot knowing how long I had the virus, how I got it and when will it go away.\u003c/em\u003e [Asian participant, 50\u0026ndash;59 years]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eClarity and comfort with follow-up testing\u003c/h2\u003e\u003cp\u003eMost respondents with HPV detected (81%, n\u0026thinsp;=\u0026thinsp;91 of 112) felt clear about \u0026lsquo;what happens next\u0026rsquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most (66%, n\u0026thinsp;=\u0026thinsp;74) felt comfortable about attending a colposcopy, with those who were less comfortable most commonly selecting \u0026lsquo;more information about what to expect\u0026rsquo; (n\u0026thinsp;=\u0026thinsp;19).\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e Our study explored clinician experiences of implementing opportunistic offer of HPV self-testing in GP clinics serving a diverse and under-screened population, with a centralised follow-up team, as well as the participant experience. The study was conducted prior to the New Zealand implementation of primary HPV screening with offer of self-testing and helped inform the decision to support this policy change. COVID-19 lockdowns took place during the study timeframe.\u003c/p\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eReceptivity\u003c/h2\u003e\u003cp\u003eAccording to clinicians, most participants were very receptive to being offered the self-test when they attended the GP clinic for any reason. This finding, together with positive reports about the offer from most survey respondents, supports quantitative findings from the main study indicating that HPV self-testing offered opportunistically was broadly acceptable (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Recent international reviews and meta-analyses have reported on the relative success of HPV self-test invitation strategies involving a face-to-face invitation (\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Compared to other approaches, direct offer of the HPV self-test in primary care clinics has the benefit of an in-person explanation in a generally trusted setting that can support uptake of the offer. However, receptivity must be considered within the overall context of known systemic access barriers to primary care that disproportionately impact Māori wāhine (women) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003ePatient-centred barriers and enablers\u003c/h2\u003e\u003cp\u003eThe clinicians reported that clear, unhurried, \u003cem\u003ekanohi ki te kanohi\u003c/em\u003e (face-to-face) discussion was a key factor supporting understanding and participation in the self-test, and that putting the self-test offer in the context of other screening and prevention discussions was helpful. Survey participants also reported a good understanding of self-testing including clear follow-up steps from nurse communication which likely supported their comfort level with self-testing (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The importance of the clinician-patient relationship, good communication and adequate information are similar themes found in other qualitative studies of HPV self-testing in Australian and NZ primary care settings (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Clinicians in our study attended in-depth training on offering the HPV self-test, including scenarios of difficult or uncertain situations. Communication challenges reported by the clinicians often related to the diversity of background health knowledge and languages of the clinic population, suggesting that \u0026lsquo;layered\u0026rsquo; communications in a range of formats and level of detail are needed. Clinician cultural safety and competence\u003csup\u003ea\u003c/sup\u003e have been identified as significant barriers in primary health care (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). A previous study on the acceptability of self-testing among never/under screened Māori wāhine found culturally competent engagement was an important factor influencing uptake (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Continuing to strive for alignment with \u003cem\u003etikanga\u003c/em\u003e (cultural protocols and processes) in mainstream primary health services as well as workforce diversity, representing the population being served, and culturally safe health interactions to reduce trauma are key ways of addressing inequity (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNotable among barriers reported by clinicians regarding uptake of the self-test was the fact that many were not comfortable with the time and place for doing the test at the clinic, or the available facilities for comfort or accessibility. Participants in this and similar studies have commented on clinic bathrooms being cramped, feeling \u0026lsquo;unhygienic\u0026rsquo;, not sufficiently private, or culturally not feeling like a safe place for self-sampling (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). For Māori, the womb (te whare tangata, the house in which human life grows), can have particular significance and sacredness (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Research among Māori wāhine and Indigenous Australian women has shown that self-testing increased body autonomy (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). This and other cultural factors including connections to the body and whenua (land) for Māori wāhine together with cultural safety are likely impacting the safety and comfort of the testing environment and overall trust and willingness to participate in cervical screening (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). These aspects need to be considered within the wider context of structural barriers to health care impacting Māori including colonisation and breaches of Te Tiriti o Waitangi (the founding agreement of Aotearoa New Zealand) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Similar considerations arise for many Pacific women (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Furthermore, personal or situational circumstances made self-testing onsite difficult for some participants. The possibility of taking a self-test kit home mitigated these barriers for many. Despite the initial offer to test in the clinic, clinicians reported that the option to take kits home supported participation, providing a greater sense of comfort, safety or convenience. While all were offered the self-test in a clinic, nearly half of our survey respondents preferred to do a home-based sample when they are next due screening. This result supports our previous study findings (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and other studies that have found \u0026lsquo;home\u0026rsquo; to be the preferred setting for cervical self-sampling, including for wāhine Māori (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Additionally, non-speculum clinician collected samples could be an option for those who fear incorrectly administering the self-test or have difficulty collecting a self-sample due to physical impairments or disabilities (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eClinician implementation barriers and enablers\u003c/h2\u003e\u003cp\u003eFrom the clinician interviewee accounts, the opportunistic offer of self-test was feasible to integrate into the clinic workflow. Nevertheless, they encountered some implementation challenges. There was a strong theme of competing demands on clinicians, not least from requirements to undertake opportunistic screening for other conditions, and these time constraints in busy clinics are likely to have made the offer to all potentially eligible patients challenging. This finding aligns with other studies that reported or anticipated competing priorities within consultations as a barrier to implementing opportunistic offer of the self-test (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). In contrast, other clinician implementation barriers reported were gaps in knowledge and understanding and mixed attitudes to self-testing, specifically two thirds of GPs and nurses were either neutral or preferred sample collection by clinicians, in a study among primary healthcare staff (GPs, nurses and other health care workers) in Australia (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). In our study, the self-test was mostly delivered by nurse cervical screen takers, either before or after the consultation with the doctor, countering some concern that opportunistic self-sampling might cause workflow disruptions or shorten the patient-doctor encounter time (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The interviews in our study also indicated that well-designed technological aids and supportive staff management processes can be employed to support opportunistic offer and uptake of the test. These included a PMS dashboard identifier of those eligible for a self-test and the text message icebreakers.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eCentralised support team\u003c/h2\u003e\u003cp\u003eClinicians appreciated the support and management of results by the central specialist nurse research team. Our survey finding that an HPV detected result is worrying for many participants is consistent with other studies finding anxiety, shame, or fear of cancer associated with a HPV detected test result (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Support for a centralised team as an ongoing service model was partly based on its advantages as an experienced team of cervical screening specialists offering safe, consistent and proactive results management. Participant experience of results communication and follow-up appeared to support this perception, and a high level of results follow-up achieved in our study (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnother key service role of the central team was follow-up of kits taken home. Follow-up of samples not returned has been anticipated as a challenging area in the new self-test era and there is an identified need for robust support systems (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) that could have benefits for both clinicians and patients.\u003c/p\u003e\u003cp\u003eOverall, next test preference was for self-testing at home in our study and a previous New Zealand study (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), however, HPV detected participants most frequently preferred self-testing at a clinic whereas self-testing at home was preferred by HPV non-detected participants in our study, although, these were not significantly different.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eStrengths\u003c/h2\u003e\u003cp\u003eThis investigation into the experiences of clinicians and participants enriches the quantitative findings from our study of opportunistic HPV self-testing. We identified real-world challenges and enablers for clinicians working in busy clinics with culturally and linguistically diverse populations. Many of those presenting to the practice were overdue for cervical screening and are the priority group for increasing participation. We were able to explore their receptiveness to opportunistic offer, some of the barriers to uptake of the test in clinic and some pragmatic enablers.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eSeveral factors may limit the generalisability of our study to other primary care clinics. The ethnicity and socioeconomic status of the patient population in the participating clinics does not reflect all populations in New Zealand and the response from participants and challenges faced by nurses may be different in other regions. The clinicians were predominantly non-New Zealand trained nurses, and their age and ethnic group was not systematically collected therefore we were not able to present comparable information for clinician perspectives as for participant perspectives. This PHO already incorporates opportunistic interventions into their patient consultation model, whereas this way of working may be less readily accommodated in clinics with more traditional general practice models. The study was conducted during the COVID-19 pandemic, which is likely to have exacerbated staffing shortages and pressures. Despite measures taken to support survey participation, the response rate was low (11.2% of participants with a test result), particularly for those with HPV not detected results who comprised 90% of participants sent the survey. Finally, the study took place prior to the national roll-out of HPV self-testing, with the intent of informing programme change, along with additional studies from our research programme and other groups. Testing for HPV with a self-swab was a significant departure from previous experience of cervical screening, requiring in-depth first-time explanations. It was also offered as a research study. The response from patients may be different once the test is more established as usual care.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe insights from clinicians and participants involved in a study of opportunistic offer of the HPV self-test in GP clinics support the acceptability of this approach and its feasibility for clinic staff. Most participants were comfortable with communication about self-testing and follow-up and decision to self-test. There were some indications of preference at the next test for home-testing by HPV non-detected and clinic testing by HPV detected participants. Wider implementation of the opportunistic offer of HPV self-testing in New Zealand primary care could increase screening coverage among those not currently accessing screening. Flexibility in the choice of taking kits home for sampling is an important enabler to participation. The study highlights the importance of resources and systems to support clinicians in primary care to offer the HPV self-test opportunistically. Further investigation of a centralised specialist team model to provide support and follow-up of those who take a kit home and potentially overseeing HPV results management, could be useful for future programme planning.\u003c/p\u003e"},{"header":"List of abbreviations","content":"\u003cp\u003eGP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;General Practitioner\u003c/p\u003e\n\u003cp\u003eHDEC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;NZ Health and Disability Ethics Committee\u003c/p\u003e\n\u003cp\u003eHPV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Human papillomavirus\u003c/p\u003e\n\u003cp\u003eNCSP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;National Cervical Screening Programme\u003c/p\u003e\n\u003cp\u003eNZ\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;New Zealand\u003c/p\u003e\n\u003cp\u003ePHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Primary healthcare organisation\u003c/p\u003e\n\u003cp\u003ePMS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Practice management system\u003c/p\u003e\n\u003cp\u003eUS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;United States\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eThis study was approved by the New Zealand Health and Disability Ethics Committee (HDEC), reference number 21/STH/141. Data access was approved by the NCSP programme and by the National Kaitiaki Group, which oversees the use of data from wāhine Māori (Māori women) from the NCSP Register. The study was approved through localities research office approvals in the three Auckland districts where the study was conducted. A Māori data sovereignty assessment was conducted and approved as part of ethics and localities approval. A privacy and security assessment was conducted and approved. All individuals in the study provided informed consent. This study adhered to the Declaration of Helsinki.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis study was funded by Health New Zealand | Te Whatu Ora\u0026rsquo;s Te Toka Tumai Auckland District, Waitematā District, and Counties Manukau District, Tamaki Health, and Health New Zealand | Te Whatu Ora\u0026rsquo;s National Screening Unit (formerly the Ministry of Health, New Zealand).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualisation \u0026ndash; KB, AM, CB, JG, KMMethodology - KB, AM, CB, JG, SSSoftware \u0026ndash; AM, JG, CN, LYaValidation \u0026ndash; CN, LYaFormal analysis \u0026ndash; AM, LYa, CN, PSAInvestigation \u0026ndash; SC, CB, GM, JK, DF, RM, JGResources - KBData curation \u0026ndash; LYa, CNWriting - original draft \u0026ndash; AM, LYo, LYa, SS, KB, CN, CBWriting - review and editing \u0026ndash; all authorsVisualisation \u0026ndash; CN, LYa, CB, PSA, LYoSupervision \u0026ndash; JG, SC, KB, PC, WB, CB, GM, RM, AM, DF, JK, KM, SSProject administration \u0026ndash; KB, AM, JGFunding acquisition \u0026ndash; KB\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank the study participants for their contribution to informing the roll out of HPV primary screening with a primary choice of self-test in Aotearoa New Zealand. We acknowledge the leadership and dedication of the nurse-led co-ordination team (Seshnee Pillay, Fiona Gillet, Frances Kendall, Isha Gaikwad, Natacha Toledo Yanez), the HPV call centre and mail-out staff (Melissa Murray, Awhina Brockbank, Paris Fale, Eden Wharerau, Faenza Williams-Fonohema, Brooke Crawford, Louise Swann, Angelina Taungahihifo) and kaiawhina (cultural support; Marara Metekingi). We thank the Group Manager of the Māori Health Pipeline team Scott Abbot and the Māori engagement manager Erin Stirling for their ongoing support. We thank Dr Mahesh Patel (Clinical Director), Rachael Sculley (Nurse Leader), and Reshmi Lata Chand (senior nurse) at Tamaki Health for support with results management and troubleshooting in clinics, all the staff at the participating primary care clinics, and Rodney Burger for technical data support. We acknowledge the support of a range of laboratory staff at Pathlab. We thank the National Kaitiaki Group and National Cervical Screening Programme for their feedback on the initial proposal, the project in flight and this manuscript. We thank the Procon team, Ken Leech and Arthur Mate for their support with the bespoke IT software. We thank the colposcopy teams in the Auckland region who participated in this study. We thank the Equity, Scientific and Technical team for their support with data processes, including Group Manager Wendy Bennett, analysts Michael Walsh and Jean Wignall, and technical data specialist Malcolm Fletcher.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data used and analysed during the current study contain identifiable individual patient information, including that of Māori. The data are not publicly available due to the data confidentiality and privacy restrictions and Māori data sovereignty considerations but are available from the corresponding author on reasonable request and corresponding approvals.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health. Wai 2575 Māori Health Trends Report. Wellington: Ministry of Health; 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChandrakumar A, Hoon E, Benson J, Stocks N. Barriers and facilitators to cervical cancer screening for women from culturally and linguistically diverse backgrounds; a qualitative study of GPs. BMJ Open. 2022;12(11):e062823.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePratt R, Barsness CB, Lin J, Desai J, Fordyce K, Ghebre R, et al. Integrating HPV self-collect into primary care to address cervical cancer screening disparities. Prev Med Rep. 2024;38:102599.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZammit C, Creagh N, Nightingale C, McDermott T, Saville M, Brotherton J, et al. I'm a bit of a champion for it actually': qualitative insights into practitioner-supported self-collection cervical screening among early adopting Victorian practitioners in Australia. Prim Health Care Res Dev. 2023;24:e31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIngamells S, Bell R, Nip J, Innes C, Te Whaiti S, Tino A, et al. Perceived barriers to self-collected HPV testing for cervical cancer screening, and knowledge of HPV: a survey of primary healthcare smear-takers across Aotearoa New Zealand. N Z Med J. 2024;137(1590):57\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLe A, Rohweder C, Wheeler SB, Lafata JE, Teal R, Giannone K, et al. Self-Collection for Primary HPV Testing: Perspectives on Implementation from Federally Qualified Health Centers. Prev Chronic Dis. 2023;20:E93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLim AWW, Deats K, Gambell J, Lawrence A, Lei J, Lyons M et al. Opportunistic offering of self-sampling to non-attenders within the English cervical screening programme: a pragmatic, multicentre, implementation feasibility trial with randomly allocated cluster intervention start dates (YouScreen). eClinicalMedicine. 2024:102672.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcBride E, Tatar O, Rosberger Z, Rockliffe L, Marlow LAV, Moss-Morris R, et al. Emotional response to testing positive for human papillomavirus at cervical cancer screening: a mixed method systematic review with meta-analysis. Health Psychol Rev. 2021;15(3):395\u0026ndash;429.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcLachlan E, Anderson S, Hawkes D, Saville M, Arabena K. Completing the cervical screening pathway: Factors that facilitate the increase of self-collection uptake among under-screened and never-screened women, an Australian pilot study. Curr Oncol. 2018;25(1):e17\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBartholomew K, Yang LPH, Neville C, Maxwell A, Aye PS, Grant J et al. Opportunistic offer of human papillomavirus (HPV) self-testing in ethnically diverse primary care clinics in Aotearoa New Zealand: an implementation study [pre-print available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchsquare.com/article/rs-6858056/v1]\u003c/span\u003e\u003cspan address=\"https://www.researchsquare.com/article/rs-6858056/v1]\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTerry GHN, Clarke V, Braun V. The SAGE handbook of qualitative research in psychology. London: Sage; 2017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSherman SM, Brewer N, Bartholomew K, Bromhead C, Crengle S, Cunningham C, et al. Human papillomavirus self-testing among unscreened and under-screened Māori, Pasifika and Asian women in Aotearoa New Zealand: A preference survey among responders and interviews with clinical-trial nonresponders. Health Expect. 2022;25(6):2914\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBartholomew K, Grant J, Maxwell A, Bromhead C, Gillett F, Saraf R, et al. Feasibility and acceptability of telehealth and contactless delivery of human papillomavirus (HPV) self-testing for cervical screening with Māori and Pacific women in a COVID-19 outbreak in Aotearoa New Zealand. N Z Med J. 2022;135(1565):83\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health. HISO 100001 2017 Ethnicity data protocols. Wellington: Ministry of Health; 2017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMicrosoft. Excel (Microsoft 365 subscription). Microsoft Corporation; 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStataCorp. Stata statistical software: release 18 [software]. StataCorp LLC; 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYeh PT, Kennedy CE, de Vuyst H, Narasimhan M. Self-sampling for human papillomavirus (HPV) testing: a systematic review and meta-analysis. BMJ Glob Health. 2019;4(3):e001351.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNgu SF, Lau LS, Chan CY, Ngan HY, Cheung AN, Chan KK. Acceptability of self-collected vaginal samples for human papillomavirus testing for primary cervical cancer screening: comparison of face-to-face and online recruitment modes. BMC Public Health. 2024;24(1):1104.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRose SB, McBain L, Garrett SM, Bell R, Innes C, Te Whaiti S, Tino A, Sykes P. I felt so empowered, respected and shame free.' Let's test for HPV participants' experience of HPV primary screening. J Prim Care. 2024;17(2):134\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCosta S, Verberckmoes B, Castle PE, Arbyn M. Offering HPV self-sampling kits: an updated meta-analysis of the effectiveness of strategies to increase participation in cervical cancer screening. Br J Cancer. 2023;128(5):805\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWaitangi Tribunal. Hauora: Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry Wai 2575. Lower Hutt. New Zealand: Waitangi Tribunal; 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRose SB, McBain L, Garrett SM, Bell R, Innes C, Te Whaiti S, Tino A, Sykes P. I felt so empowered, respected and shame free.\u0026rsquo; Let\u0026rsquo;s test for HPV participants\u0026rsquo; experience of HPV primary screening. J Prim Health Care. 2024;17(2):134\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGraham RM-AB. Experiences of Māori of Aotearoa New Zealand\u0026rsquo;s public health system: a systematic review of two decades of published qualitative research. Aust N Z J Public Health. 2020;44(3):193\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCurtis E, Loring B, Jones R, Tipene-Leach D, Walker C, Paine SJ, et al. Refining the definitions of cultural safety, cultural competency and Indigenous health: lessons from Aotearoa New Zealand. Int J Equity Health. 2025;24(1):130.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAdcock A, Cram F, Lawton B, Geller S, Hibma M, Sykes P, et al. Acceptability of self-taken vaginal HPV sample for cervical screening among an under-screened Indigenous population. Aust NZ J Obstet Gynaecol. 2019;59(2):301\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePalmer SC, Gray H, Huria T, Lacey C, Beckert L, Pitama SG. Reported Māori consumer experiences of health systems and programs in qualitative research: a systematic review with meta-synthesis. Int J Equity Health. 2019;18(1):163.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAdcock A, Stevenson K, Cram F, MacDonald EJ, Geller S, Hermens J, et al. He Tapu Te Whare Tangata (sacred house of humanity): Under-screened Māori women talk about HPV self-testing cervical screening clinical pathways. Int J Gynaecol Obstet. 2021;155(2):275\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilson D, Moloney E, Parr JM, Aspinall C, Slark J. Creating an Indigenous Māori-centred model of relational health: a literature review of Māori models of health. J Clin Nurs. 2021;30(23\u0026ndash;24):3539\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCook C, Clark T, Brunton M. Optimising cultural safety and comfort during gynaecological examinations: Accounts of Indigenous Māori women. Nurs Prax NZ. 2014;30(3):19\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarques B, Freeman C, Carter L. Adapting traditional healing values and beliefs into therapeutic cultural environments for health and well-being. Int J Environ Res Public Health. 2021;19(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFoliaki S, Matheson A. Barriers to cervical screening among Pacific women in a New Zealand urban population. Asian Pac J Cancer Prev. 2015;16(4):1565\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCamara H, Zhang Y, Lafferty L, Vallely AJ, Guy R, Kelly-Hanku A. Self-collection for HPV-based cervical screening: a qualitative evidence meta-synthesis. BMC Public Health. 2021;21(1):1503.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNishimura H, Yeh PT, Oguntade H, Kennedy CE, Narasimhan M. HPV self-sampling for cervical cancer screening: a systematic review of values and preferences. BMJ Glob Health. 2021;6(5).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRose SB, McBain L, Bell R, Innes C, Te Whaiti S, Tino A, et al. Experience of HPV primary screening: a cross-sectional survey of 'Let's test for HPV' study participants in Aotearoa New Zealand. J Prim Health Care. 2025;17(2):123\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLandy R, Hollingworth T, Waller J, Marlow LA, Rigney J, Round T, et al. Non-speculum sampling approaches for cervical screening in older women: randomised controlled trial. Br J Gen Pract. 2022;72(714):e26\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCreagh NS, Saunders T, Brotherton J, Hocking J, Karahalios A, Saville M, et al. Practitioners support and intention to adopt universal access to self-collection in Australia's National Cervical Screening Program. Cancer Med. 2024;13(10):e7254.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLim AW, Hollingworth A, Kalwij S, Curran G, Sasieni P. Offering self-sampling to cervical screening non-attenders in primary care. J Med Screen. 2017;24(1):43\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCheng E, Stubbs JM, Achat HM. Self-collection for HPV-based cervical screening: knowledge and attitudes of Australian health care workers in an area with low screening rates, July-November 2023. Public Health Rep. 2024:333549241299272.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRose SB, McBain L, Bell R, Innes C, Te Whaiti S, Tino A, Sykes P. 'Kind of scared but happy something was detected.' Cross-sectional survey of Let's Test for HPV participants to understand perspectives on an HPV detected result. Aust N Z J Obstet Gynaecol. 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBorchowsky K, Rush M, Mullally T, McBain L, Hudson B, McMenamin J, et al. Primary care experiences in the 'Let's test for HPV' study: a qualitative analysis. J Prim Health Care. 2023;15(2):147\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col style=\"list-style-type:lower-alpha;\"\u003e\u003cli\u003e\u003cspan\u003eWe utilise the Curtis et al (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) definitions of cultural safety and cultural competence in use in NZ. Cultural safety refers to the ongoing responsibility that healthcare professionals and healthcare organisations have to critically examine and address the influence of their own culture - including power, privileges, biases, attitudes and prejudices - and the potential impact these may have on patient interactions and delivery of health services with the goal of developing culturally safe care as defined by patients and the community. Cultural competence describes the cultural knowledge, skills and ways of working that health professionals need to provide high quality healthcare that is equitable for all populations.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cervical screening, human papillomavirus (HPV), self-sampling, at-home testing, primary care, clinician perspectives, participant perspectives, Māori health, Pacific health, health inequity, implementation science","lastPublishedDoi":"10.21203/rs.3.rs-8092746/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8092746/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo support the introduction of human papillomavirus (HPV) self-testing in the New Zealand National Cervical Screening Programme, an implementation study of opportunistic self-test offer was undertaken in primary care clinics, with a home testing option and centralised follow-up. We aimed to explore the experience of study clinicians and participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrimary care clinicians trained to offer the self-test were invited to semi-structured interviews exploring their perception of receptivity to the opportunistic offer of self-testing, and challenges and enablers to implementation. Thematic analysis was undertaken on transcripts. Participants (aged 30-69 years) were sent a link to an online follow-up survey after HPV result notification. Survey results were analysed using descriptive statistics with thematic analysis of free text responses. Participant recruitment and data collection occurred between November 2021 and January 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 40 clinicians trained to offer self-testing, 12 primary care clinicians from six Auckland ethnically diverse primary care sites completed an interview. ‘Positive reception’ was the strongest theme with clinicians reporting that overwhelmingly, participants were receptive to the HPV self-test offer. The four enabler themes were: ‘supportive practice systems’, ‘importance of the discussion’, ‘testing options for women’ and ‘specialised support and consistency’. \u0026nbsp;Key challenge themes in implementing opportunistic self-testing were ‘competing demands’and ‘communicating what it’s all about’.\u003c/p\u003e\n\u003cp\u003eOf the 3524 study participants, 394 responded to the online survey. Most (93%) found the amount of information they received about HPV self-testing ‘about right’ and were comfortable about doing the self-test opportunistically (86%). Considering their next cervical screening, more respondents preferred home-based self-testing options than self-testing at a clinic (46% versus 37%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOffering the HPV self-test opportunistically to people due for screening when they visited their GP for another reason was generally well received and feasible for clinic staff. \u0026nbsp;The choice to take kits home for sampling was an enabler of participation. Supportive systems and resources for clinicians will be important if opportunistic HPV self-testing is offered more widely in primary care, including further consideration of a central specialist team to provide follow-up and support for home testing, and potentially for participants with HPV detected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not reach the ICJME or WHO criteria for clinical trial registration.\u003c/p\u003e","manuscriptTitle":"Clinician and patient experiences with opportunistic offer of HPV self-testing in Aotearoa New Zealand primary care clinics: interview and survey findings","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-01 06:53:30","doi":"10.21203/rs.3.rs-8092746/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-20T17:41:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-15T02:38:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-21T03:20:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136370993056672835890537745266034585734","date":"2025-12-19T21:24:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-17T15:14:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"28631225061253119639207986804376987926","date":"2025-12-16T23:25:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128000548651955705805704527064316807161","date":"2025-11-25T17:40:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-19T18:19:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-13T08:43:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-13T08:42:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-11-12T06:24:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"39d88929-f822-427b-9cf5-43b5b440fcf5","owner":[],"postedDate":"December 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:16:05+00:00","versionOfRecord":{"articleIdentity":"rs-8092746","link":"https://doi.org/10.1186/s12875-026-03247-z","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2026-03-03 15:57:12","publishedOnDateReadable":"March 3rd, 2026"},"versionCreatedAt":"2025-12-01 06:53:30","video":"","vorDoi":"10.1186/s12875-026-03247-z","vorDoiUrl":"https://doi.org/10.1186/s12875-026-03247-z","workflowStages":[]},"version":"v1","identity":"rs-8092746","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8092746","identity":"rs-8092746","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}