Uptake and acceptability of human papillomavirus self-sampling in rural and remote Aboriginal communities: Evaluation of a nurse-led community engagement model

Uptake and acceptability of human papillomavirus self-sampling in rural and remote Aboriginal communities: Evaluation of a nurse-led community engagement model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Uptake and acceptability of human papillomavirus self-sampling in rural and remote Aboriginal communities: Evaluation of a nurse-led community engagement model Tegan Dutton, Jo Marjoram, Shellie Burgess, Laurinne Campbell, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.23841/v2 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 May, 2020 Read the published version in BMC Health Services Research → Version 2 posted 9 You are reading this latest preprint version Show more versions Abstract Background: Aboriginal women experience disproportionately higher rates of cervical cancer mortality yet are less likely to participate in screening for early detection. This study sought to determine whether a community-based HPV self-sampling service model can effectively recruit never-screened and under-screened Aboriginal women to participate in cervical cancer screening; assess the clinical outcomes; and explore the acceptability of the model from the perspective of the participants. Methods: Aboriginal women aged 25-69 years of age were recruited from eight rural and remote communities in New South Wales, Australia to participate in HPV self-sampling via a community-based service model. Outcome measures were: number of women screened by HPV self-sampling, their prior cervical screening status (under-screened or never-screened), clinical outcomes and participation in follow-up pathways of care, and satisfaction with the service model. Results: In total, 215 women conducted a HPV self-sampling test and 200 evaluation surveys were completed. One-fifth of participants (n=46) were never-screened and one-third (n=69) were under-screened. Many were unsure of their screening status. Nine women were HPV 16/18 positive and eight had completed all follow up by the conclusion of the study. A further 30 women tested positive for a high risk type other than HPV 16/18 (HPV other), of which 14 had completed follow up at the conclusion of the study. Satisfaction with the HPV self-sampling kit, the process of self-sampling and the service model was high (>92% satisfied on all items). Many women had difficulty understanding their official HPV results and placed high importance on the nurse explaining it to them. Conclusions: A community-based service model that respects Aboriginal Women’s Business can effectively recruit under-screened and never-screened Aboriginal women to complete cervical cancer screening. Furthermore, this service model supports them to complete recommended follow-up care and engage with their local existing health services. Health Policy Aboriginal women cervical screening program evaluation Aboriginal Women’s business cancer Figures Figure 1 Figure 2 Figure 3 Figure 4 Background In December 2017, the Australian National Cervical Screening Program (NCSP) was updated, with HPV testing replacing Pap tests. Other changes include an increase in entry age from 18 to 25 years, and recommended screening every five years (previously two years). Also, clinician-supervised, HPV self-sampling became available to eligible women. To be eligible for self-sampling, a woman must be aged 30 years or over and be overdue for screening by at least two years. 1 This change was based on extensive evidence demonstrating that HPV testing is a more sensitive screening test, providing better protection against cervical cancer through detection of HPV before cell changes occur in the cervix. 2-4 Key to the NCSP’s success however, is in effectively recruiting women to participate in screening. Never-screened or under-screened women are at higher risk of cervical cancer than those who regularly participate in screening programs. 5-7 This recent change to HPV testing and the ability to self-sample provides a unique opportunity to engage these women. National cervical screening rates for Aboriginal and Torres Strait Islander women is unknown as pathology forms do not record Indigenous status. However, several studies that have utilised community level and State/Territory data have indicated that the average screening rates for Indigenous women lies between 33.5% and 44%, compared to 55.7% - 59.1% for non-Indigenous women. . . 8-12 Aboriginal and Torres Strait Islander women also experience higher rates of cervical cancer incidence and mortality, 12-13 hence, increasing their participation in preventative screening is crucial. International research aimed at increasing the uptake of cervical screening was summarised in a recent meta-analysis. 14 The study found that door-to-door recruitment was most effective at increasing screening uptake as compared to clinician-collected samples. This was followed by community campaigns and mail-out to all, with the opt-in approach considered ineffective. However, the success of these recruitment techniques varied across populations and geographical regions, and thus techniques need to be tailored to specific regions. The best way to offer self-sampling to women who are disengaged from the health system and are under- or never-screened is also not yet known. To our knowledge, no other programs in Australia have offered face-to-face distribution and collection of HPV self-sampling kits within the home and community. One Australian study successfully recruited Aboriginal women from a regional Aboriginal Community Controlled Health Service to participate in self-sampling, 15 suggesting self-sampling is an acceptable option for Aboriginal and Torres Strait Islander women. No HPV self-collection studies have specifically targeted Aboriginal and Torres Strait Islander women in rural and remote communities. The option of clinician-supervised patient self-sampling under the new NCSP could positively impact screening practices of women who have never been screened or are under-screened. However, this pathway relies on existing patient engagement with a clinician and/or health service. If a woman does not routinely engage with a primary healthcare service, opportunities to actively encourage screening via this pathway are limited. This is particularly important in rural and remote communities where access to female health professionals can be limited and the proportion of under-screened and never-screened women increases . Innovative models of care are needed to engage these hard-to-reach women. This research sought to: determine whether a community based HPV self-sampling model effectively recruited never-screened and under-screened Aboriginal women to participate in cervical cancer screening; assess the clinical outcomes, including follow-up; and explore the acceptability of the model from the perspective of the participants. Methods Community consultation: Marathon Health Primary Health Care Nurses (PHCNs) consulted extensively with local organisations and community members across rural and remote New South Wales, Australia to establish the new service model for HPV self-sampling amongst Aboriginal women, including clinical governance processes. Pilot sites : Eight rural and remote communities participated in the pilot study. Notably, seven of these had minimal access to female General Practitioners (GPs). Our target sample size (n=266) was calculated based on the estimated number of Aboriginal women who were under-screened. Across the study region in 2011, the total female Aboriginal population was 596 and an estimated 45% of women (both Aboriginal and non-Aboriginal) were under-screened (data provided by the NSW Cancer Institute, 2011-13). Self-sampling pathway: PHCNs established partnerships with Local Aboriginal Land Councils (LALC) as the representative body for Aboriginal people in each community. Each LALC identified a female employee or community member to recruit as the Community Engagement Worker (CEW) for each site. Their primary role was to engage and recruit women to the program, and support them along the self-sampling pathway, with clinical support provided by the PHCN. Once the women completed the self-sample with the support of the PHCN and CEW, the PHCN sent the HPV samples to the VCS Foundation to be analysed. Pathology results were returned by mail to the participant, their nominated GP and the PHCN. A project GP was recruited to provide clinical oversight of those participants who did not have a regular GP. The PHCN followed up with all participants face-to-face or by phone to ensure they received their results and that they understood their meaning, including any follow-up that was required. Women who returned invalid results were provided the option to rescreen. See Figure 1 for a detailed flowchart of the self-sampling process. Recruitment of women: The CEWs were members of the local Aboriginal community themselves, and had existing links with the community to identify and engage with local women about the program. Whilst some women were recruited at local community events, the majority were recruited via home visits. Convenience sampling was used to recruit women, followed by snowballing (referred to as the “Koori Grapevine” by the local Aboriginal women) with the women identifying other family and friends for cervical screening. Whilst this inevitably would have resulted in bias, gaining trust with the community and having the women take on some ownership increased acceptance of the program. . Participants: The renewed NCSP recommends clinician-led HPV screening for women in the age range 25-69 years (inclusive), therefore our study included women in this age range. It is worth noting however, that the current NCSP only permits self-sampling to be completed at 30 years of age, when a woman is at least 5 years overdue for screening. Screening of women younger than 25 years was allowed at the discretion of the PHCN based on clinical indication (for example, sexual debut younger than 14 years of age and have not received the HPV vaccination). The NCSP recommends all women conduct an ‘exit-screen’ between 70-74 years of age. We elected not to include women in this age group so as to ensure they conducted their recommended exit screen outside of this pilot study under the guidance of their clinician. Whilst we sought to recruit women who were under-screened, the CEW and PHCN were able to decide whether they believed it was clinically and ethically appropriate to screen women who had been screened in the previous four years, particularly if they were due for a screen or were overdue. Data collection and management: An eligibility survey was conducted at the outset of the recruitment process. An evaluation survey was conducted during follow-up to elicit feedback on the service model and the participant’s experience of self-sampling using likert scale responses from 1 (very unsatisfied) to 5 (very satisfied). Clinical data were input into the client’s electronic medical record as per routine practice. All data were stored securely and confidentially so as to comply with both clinical governance requirements and research ethics requirements. All data were linked using a code number and then de-identified by the PHCN before analysis by the research team. Data were entered into Excel. IBM SPSS Statistics (version 22) was used for descriptive statistics on the quantitative dataset. Open-ended comments were combined and key themes then extracted by two researchers independently as part of the manifest content analysis process. 16 Themes and sub-themes were compared and discussed until a consensus was reached. Ethics Approval: Ethics approval was granted by the Aboriginal Health and Medical Research Council Human Research Ethics Committee (reference 1188/16) and Western Sydney University Human Research Ethics Committee (reference H11837). Results Part 1: Clinical results HPV self-sampling kits were distributed from September 2016 to June 2018 (21 months). The 215 women (80.8% of the targeted sample) that agreed to participate were all eligible and completed the HPV self-sample. Participation was highest amongst women aged 25-29 years (Figure 2). One-fifth of participants (21.4%; 46) self-reported that they had never completed a Pap test and 32.1% (69) had previously completed a Pap test but more than 4 years ago, with the range since last Pap test being 4 to 20 years (Figure 3). A total of 26.0% (56) of participating women reported that they had been screened, but could not remember when, suggesting that it was more than 4 years ago. Of the 34 (15.8%) women that had been screened in the previous 4 years, all but thirteen (6%) had not been screened in the previous two years, and thus were due for screening. Last screen was not recorded or was unknown for 10 (4.7%) participants. Eighteen percent (18.1%; 39) of women had a positive result: 4.2% (9) were HPV Positive 16/18 and 14% (30) HPV Positive other (defined as a high risk HPV type other than 16 or 18). Seventy-eight percent (78%; 168) had a negative result (two of which were the results of a second screen as the initial result was invalid), and 3.7% (8) had invalid results and did not complete a rescreen. Stratification by age group showed that women who tested positive were distributed across all of the age groups (Table 1). Table 1: HPV test results stratified by age group HPV Test Result Negative Positive for HPV 16/18 type Positive for a type other than HPV 16/18 Age Group < 25 years 8 (4.8%) 0 5 (12.8%) 25-29 years 27 (16.1%) 1 (11.1%) 10 (25.6%) 30-34 years 27 (16.1%) 1 (11.1%) 4 (10.3%) 35-39 years 22 (13.1%) 2 (22.2%) 6 (15.4%) 40-44 years 20 (11.9%) 0 5 (12.8%) 45-49 years 19 (11.3%) 2 (22.2%) 3 (7.7%) 50-54 years 18 (10.7%) 1 (11.1%) 2 (5.1%) 55-59 years 11 (6.5%) 0 2 (5.1%) 60-64 years 12 (7.1%) 2 (22.2%) 2 (5.1%) 65 years and over 4 (2.4%) 0 0 Eight of the nine women (88.9%) with a HPV Positive 16/18 result had attended a colposcopy appointment by mid-July 2018. The other woman failed to attend her appointments due to documented clinical and other issues. Just under half (46.7%; 14) of the women with a HPV Positive other result had attended an appointment for a cervical screen by mid-July 2018 when this study ended. Attendance at follow-up appointments was relatively similar regardless of cervical screening history (Figure 4). Part 2: Women’s satisfaction and feedback Almost all women (92.6%; 199) completed the follow-up evaluation survey. One completed the survey twice as her initial result was invalid (200 total surveys). More than 90% of women were highly satisfied with the HPV self-sampling kit and the process involved (Table 2). In response to whether results were presented in an easy to understand format, 13.2% (23) were unsatisfied or very unsatisfied. Further, some women that were highly satisfied with the format of results commented that they were unable to interpret the paper copy independently, but the PHCN explained the results well: “The pathology made no sense to me but when the Nurse called and discussed I understood them” Table 2: Participating women’s level of satisfaction with the HPV self-sampling program Aspects of the self-sampling program (5) very satisfied (4) satisfied (3) neither satisfied/ dissatisfied (2) dissatisfied (1) very dissatisfied 1.1 HPV self-sampling kit The kit provided everything to complete the self-sampling test? (n=200) 199 (99.5%) 1 (0.5%) - - - Satisfaction with the self-sampling instructions (n=200) 196 (98.0%) 1 (0.5%) 1 (0.5%) - 2 (1%) 1.2 HPV self-sampling process Process clearly explained by the CEW (n=197) 188 (95.4%) 5 (2.5%) 3 (1.5%) 1 (0.5%) - Able to ask questions and receive answers in a timely manner? (n=186 a ) 183 (98.4%) 2 (1.1%) - 1 (0.5%) - The process was simple (n=197) 187 (94.9%) 4 (2%) 4 (2%) - 2 (1.0%) Provided with privacy and confidentiality (n=197) 182 (92.4%) 6 (3.0%) 7 (3.6%) 2 (1.0%) - 1.3 Results Results were provided in an easy to understand format (n=174 b ) 136 (78.2%) 6 (3.4%) 9 (5.2%) 3 (1.7%) 20 (11.5%) <2 weeks 3 weeks Unsure Not at time PHCN made contact c Mailed results returned within 2 weeks (n=195) 148 (75.9%) 13 (6.7%) 6 (3.1%) 13 (6.7%) 15 (7.7%) a Eight participants said they did not need to ask questions and six did not respond to this question. b Some participants had not yet received results and thus not applicable or did not respond to this question. c The hard copy paper results were not yet received by the participant at the time the PHCN provided the results verbally over the phone (this may have been within two weeks of the self-sampling test). <br. The majority of participants (96.0%; 192) would use the HPV self-sampling kit again. Of the six women who stated they would not use it again, four were referred to the GP for a pap test and would thus go directly to the GP next time, and two experienced difficulties completing the sample. Almost all women (98.5%; 197) would recommend the HPV self-sampling kit to other women. Women were grateful of, and highly satisfied with, the service (Table 3). There was overwhelming agreement that self-sampling removed the shame, intimidation, embarrassment, and pain that has historically been associated with clinician-collected Pap tests. Positive aspects included the ability to complete the test in the home, and thus the accessibility and privacy of cervical screening; the simplicity of the test; being in charge of Women’s business (an important consideration in Aboriginal culture where certain aspects of life are performed separately and termed Men’s and Women’s business 17 – cervical screening falls into this category); the appropriateness of the self-sampling kit contents, with the exception of there not being a non-transparent bag to return the swab in; and the professionalism of the PHCN. Women felt they would not have completed cervical screening had this service not been available. “I could do it myself. No pain. I ended up having to go to the GP for a Pap test but I would have never done that if I didn’t have a self-sample, may have saved my life. I recommend this to everyone. The government needs to give all women the choice to self-sample” Table 3: Participating women’s experiences with HPV self-sampling Themes Description Location of self-sample In the home: Women felt it was a more private, confidential and comfortable experience; they could complete it without embarrassment and shame. Out of the home: There was mixed feelings regarding privacy and confidentiality when completed out of the home (e.g. park, LALC, mother’s groups). Accessible Accessible (in the home) and free. No need to travel long distances for a female GP, or wait and pay at a General Practice. Privacy and confidentiality – shame and embarrassment Self-sampling was private and confidential, with no shame or embarrassment. Women did not feel violated or lose their dignity. Simplicity Self-sampling was described as simple, easy, convenient, quick, and not too daunting. Several women experienced some difficulty completing the test themselves. In charge of Aboriginal women’s business* Women felt a sense of control over their own women’s business, health and wellbeing. Women found it to be a positive and personal experience, and they felt comfortable and at ease. Comparison of HPV self-sampling to Pap test Pap test – uncomfortable, painful, humiliating, daunting, shameful, embarrassing, degrading, intimidating, not confidential. Women do not like going to the Doctor and do not want a man involved in women’s business. HPV self-sampling – easier, more private, discreet, comfortable, personal, dignified, appropriate, and quicker. Not as intrusive, evasive or awkward. Self-sampling kit contents High importance was place on the quality of the instruction cards: They were clear, easy to understand, straight forward – not having to sift through unnecessary readings. Illustrations for black women were good. In the case a woman could not read, the Nurse could clearly explain the process and the picture cards supported this. The women were happy they could keep the case the kit came in. A non-transparent bag needs to be included in the kit for the sample to be returned to improve privacy and remove any shame. The PHCN gave the women confidence in the service being professional Women placed high importance on a trained professional (i.e. the PHCN) being present throughout the program, giving them confidence that it was accurate and professional. Some women would have preferred the PHCN (instead of the CEW) to explain the kit/process and take the completed sample. Verbal communication of results Women appreciated the verbal communication of results from the PHCN, particularly as many women could not understand them. This was described as ‘caring’ and gave women confidence in the entire program. Unlikely that women would have completed a cervical screen had the HPV self-sampling test not been offered Women commented on: never having completed a cervical screen until participating in this study; being hesitant, reluctant, frightened, or scared to go to the Doctor to have a cervical screen, even in the case that one woman had a family history of cervical cancer and understood the risks; postponing Pap tests, with women suggesting anywhere between 1 and 20 years before they thought they would be screened again. Grateful of a potential lifesaving experience Women (irrelevant of results) were grateful and happy they had been offered the self-sampling kit, and that it could have saved their lives. Initial concerns with the Program Women were not always forthcoming to completing the self-sampling, describing that they were initially nervous (e.g. unsure of accuracy of the test; previous painful experience with a pap test; worried of a positive result). However, these comments were followed by positive feedback about the test and increased confidence to complete the test next time. * In Aboriginal culture, certain aspects of life are performed separately for men and women, and are termed Men’s business and Women’s business 17 ; cervical screening and related items fall into this category Discussion This program successfully recruited never- and under-screened Aboriginal women across rural and remote Australia to participate in HPV self-sampling in the home or community. Indeed, we were able to recruit 81% of our target sample size to participate in screening, a value much larger than the estimated 30-40% of Aboriginal women who have traditionally been recruited to participate in cervical screening. 8-12 Certainly, one-fifth of participating women had never been screened previously, one-third were overdue for screening, and a further quarter could not remember when they were last screened, suggesting it was a long time ago and they were therefore likely to be overdue for screening. Despite historically being disengaged from the health system, eight of the nine women with a HPV Positive 16/18 had attended a colposcopy appointment by the completion of the project. This is in line with other studies that also reported high follow-up rates for women who participated in self-sampling. 13, 15 The lower follow-up rates (46.7%) observed for women who tested HPV Positive Other (defined as a high risk HPV type other than HPV 16 or 18) may be the result of not tracking women for long enough as anecdotal evidence provided after the completion of this study reported that some women did attend a follow up GP appointment that occurred after the end date of this study. Long-term research is therefore needed to understand whether follow-up care is achieved and how women can best be supported. Given the target population was not actively engaged in cervical cancer screening or the health system, the timely and individual support the PHCN and CEW provided to each woman to ensure results and follow-up care were understood, and women remained engaged, was key to the model’s success. Women placed high importance on the verbal communication of results given by the PHCN, particularly as they did not understand the hard copy results. Ensuring women have maximum understanding of the next steps in their pathway of care decreases anxiety and assists with successful completion of the self-sampling pathway. 18 Flexibility in PHCN and CEW roles enabled innovative solutions to be adapted for each woman to support them at an individual level to access the follow-up care required. This included offering self-sampling in the home environment. The majority of self-sampling studies have not allowed for home-based self-collection so this study adds to the limited evidence base attesting to its effectiveness at engaging women to complete screening. There was overwhelming agreement that this method for cervical cancer screening is appropriate for Aboriginal women, ensuring Aboriginal Women’s Business is respected. In comparison to Pap tests it was seen as a positive experience which women were happy to repeat and recommend to others, also documented in numerous self-sampling trials. 18-21 Importantly, women mentioned they would not have participated in screening had this not been available. This pilot highlighted how the model can provide an access point into the health system, demonstrated by the large proportion of women that entered the mainstream health system for follow-up care. Further, an unexpected outcome was that some women who attended a GP follow-up appointment, also sought after additional medical advice/treatment for other conditions. It provided a comfortable access point for these women, and therefore can have a net overall positive impact on health service engagement. Whilst the current NCSP supports never- and under-screened women to participate in self-sampling rather than clinician-led sampling, there are specific criteria and it must be facilitated and requested by a clinician who routinely performs cervical screening. Hence, it is reliant on existing engagement with a clinician/health service. The current community-based service model could serve as an effective adjunct to clinician-led NCSP services by engaging with those women who are currently not engaged with a health service or clinician. Significantly, data from this study shows that this service model can also facilitate health service engagement amongst women who were previously disengaged. For many women though, the barriers to engagement with cervical screening under the previous NCSP will not immediately be broken down by completing one self-sample HPV test. It is a key recommendation of this study that women who are eligible for self-sampling continue to remain eligible to screen via this pathway, should they decline clinician-led screening in the future. Limitations This study did not capture numbers of women who were approached and declined participation or were obviously ineligible, such as being pregnant. Screening history was self-reported and thus there may have been some error in this data. There was not a structured process in place to document the follow-up outcomes for women and support required, including a formal clinical record review to determine actual disease burden from biopsy results. When women completed the evaluation survey there was a feeling that using a scale of 1 to 5 was not always understood by the women, and that a yes/no response (or something similar) would be more appropriate. The data collection timeframe was longer than anticipated (21 months) and this was due to a number of external factors along with workforce challenges in retaining CEWs in some of the communities. For reasons unrelated to the project, a number of CEWs relocated to other regions and new CEWS had to be recruited. Nonetheless, these are important considerations when scaling up services such as this across the region, particularly in rural and remote areas where health workforce is already a challenge. Conclusions This pilot demonstrated how a community-based model that respects Aboriginal Women’s Business, is community-led, and has a clinical lead to maintain high clinical governance and professionalism within the program, can effectively recruit hard-to-reach under-screened and never-screened Aboriginal women to complete cervical cancer screening. This was evidenced through high screening participation rates, high levels of satisfaction amongst participating women and the high rates of women engaging with recommended follow-up care. It is extremely unlikely that these women would have engaged in the current NCSP via clinician-supervised self-sampling as they are not engaged in the health system (i.e. they do not visit GPs). Future research and evaluation is needed to explore translation of this best practice service model into other remote, rural and regional sites. Research that builds on the current pilot study data can inform the requirements of rolling out this service model to communities that differ by population size, remoteness, geography, health service access, and other aspects unique to that community. Long-term follow-up of HPV self-sampling participants can also shed light on the ongoing health service engagement and cervical screening practices of these women. List Of Abbreviations CEW = Community Engagement Worker GP = General Practitioner HPV = Human Papilloma Virus LALC = Local Aboriginal Lands Council NCSP = National Cervical Screening Program PHCN = Primary Health Care Nurse Declarations Ethics approval and consent to participate Ethics approval for this project was granted by the Aboriginal Health and Medical Research Council Human Research Ethics Committee (reference 1188/16) and Western Sydney University Human Research Ethics Committee (reference H11837). All participants signed a consent form. Consent for publication Not applicable. Availability of data and materials The datasets are available from the corresponding author upon request. Competing interests The authors declare that they have no competing interests. Funding This service was initially funded by the Western NSW Primary Health Network. An early funding contribution was also received from the Murdi Paaki Regional Enterprise Corporation. The completion of the project was enabled through funding provided by the Australian Government Department of Health. Research costs were partially funded through a Western Sydney University Partnerships Grant. Authors' contributions All authors satisfy the four criteria to authorship as outlined by the International Committee of Medical Journal Editors. LC conceived the project idea, and AV, NC, SJ, JM, SB, DH, MS, and JB all contributed to designing the project and evaluation. LC, AV, NC, and JM undertook data collection. TD and JB completed data analysis. All authors contributed to the interpretation of data. TD, JB, JM and SB drafted the paper, and the remaining authors revised the manuscript and provided feedback. All authors have read and approved the final manuscript and agree to being accountable for all aspects of the work. Acknowledgements We wish to acknowledge and thank all of the organisations that funded this project: The Western NSW Primary Health Network; the Murdi Paaki Regional Enterprise Corporation; the Australian Government Department of Health; and the Western Sydney University (Partnerships Grant). We would also like to acknowledge the Community Engagement Workers who were instrumental in recruiting women to the project. References Australian Government Department of Health. National Cervical Screening Program. Updated 28 Aug 2019. http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/cervical-screening-1 (viewed Aug 2019). Elfstrom KM, Smelov V, Johansson AL, et al. Long term duration of protective effect for HPV negative women: follow-up of primary HPV screening randomised controlled trial. BMJ . 2014; 348:g130. Ronco G, Dillner J, Elfstrom KM, et al. 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Cite Share Download PDF Status: Published Journal Publication published 11 May, 2020 Read the published version in BMC Health Services Research → Version 2 posted Editorial decision: Accept 10 Apr, 2020 Reviewers invited by journal 07 Apr, 2020 Reviewer # 1 agreed at journal 07 Apr, 2020 Reviewer # 2 agreed at journal 07 Apr, 2020 Review # 1 received at journal 07 Apr, 2020 Review # 2 received at journal 07 Apr, 2020 Editor assigned by journal 06 Apr, 2020 Submission checks completed at journal 05 Apr, 2020 Editor invited by journal 05 Apr, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-14404","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":475105,"identity":"40250632-4972-40c1-84be-a002a138a240","order_by":1,"name":"Tegan Dutton","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0003-2260-9004","institution":"Western Sydney University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Tegan","middleName":"","lastName":"Dutton","suffix":""},{"id":475106,"identity":"7b002ebb-c5cc-4d56-8b00-c0bcc155f987","order_by":2,"name":"Jo Marjoram","email":"","orcid":"","institution":"Marathon Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jo","middleName":"","lastName":"Marjoram","suffix":""},{"id":475107,"identity":"baa8ee36-55cd-4284-9560-92057b6d2ec1","order_by":3,"name":"Shellie Burgess","email":"","orcid":"","institution":"Marathon Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shellie","middleName":"","lastName":"Burgess","suffix":""},{"id":475108,"identity":"50161228-9f25-42eb-90ff-590a82105e6e","order_by":4,"name":"Laurinne Campbell","email":"","orcid":"","institution":"Marathon Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Laurinne","middleName":"","lastName":"Campbell","suffix":""},{"id":475109,"identity":"e115e1d8-1ff0-47f8-a5ee-a0ea30ed8b67","order_by":5,"name":"Anne Vail","email":"","orcid":"","institution":"Marathon Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Anne","middleName":"","lastName":"Vail","suffix":""},{"id":475110,"identity":"a6bbe1b7-ffb4-44a6-99df-6d8a0ba6705f","order_by":6,"name":"Nichole Callan","email":"","orcid":"","institution":"Marathon Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nichole","middleName":"","lastName":"Callan","suffix":""},{"id":475111,"identity":"91fb9ea8-00e8-4482-8aec-e517e4971d18","order_by":7,"name":"Sunil Jacob","email":"","orcid":"","institution":"Dubbo Medical and Allied Health Group","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sunil","middleName":"","lastName":"Jacob","suffix":""},{"id":475112,"identity":"ae4c3b41-0ab9-4fab-b97e-3e8facd17631","order_by":8,"name":"David Hawkes","email":"","orcid":"","institution":"Victorian Cytology 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15:27:43","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.2.23841/v2","doiUrl":"https://doi.org/10.21203/rs.2.23841/v2","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-020-05214-5","type":"published","date":"2020-05-11T21:01:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":890411,"identity":"cf4736d5-c8b7-48b3-80b4-01459f2053a3","added_by":"auto","created_at":"2020-04-13 19:12:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":342512,"visible":true,"origin":"","legend":"Study flowchart","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-14404/v2/1.png"},{"id":890412,"identity":"6367eff8-b2cc-4923-91af-732778c3388f","added_by":"auto","created_at":"2020-04-13 19:12:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":19022,"visible":true,"origin":"","legend":"Age distribution of women that participated in HPV self-sampling","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-14404/v2/2.png"},{"id":890413,"identity":"846627c5-b4c8-436f-a5ae-15117d5b1b8b","added_by":"auto","created_at":"2020-04-13 19:12:44","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":31188,"visible":true,"origin":"","legend":"Cervical screening history of women who participated in HPV self-sampling","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-14404/v2/3.png"},{"id":890414,"identity":"daa0be30-4bde-4403-bd72-a3a69088a34d","added_by":"auto","created_at":"2020-04-13 19:12:44","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":20852,"visible":true,"origin":"","legend":"Follow-up rate of women who tested positive for HPV by cervical screening status","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-14404/v2/4.png"},{"id":13498178,"identity":"0d096418-6d09-409e-ad95-58b310625765","added_by":"auto","created_at":"2021-09-16 22:56:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":658276,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-14404/v2/092c6af9-a80f-4802-b53c-85c5ca0ffacb.pdf"}],"financialInterests":"","formattedTitle":"Uptake and acceptability of human papillomavirus self-sampling in rural and remote Aboriginal communities: Evaluation of a nurse-led community engagement model","fulltext":[{"header":"Background","content":"\u003cp\u003eIn December 2017, the Australian National Cervical Screening Program (NCSP) was updated, with HPV testing replacing Pap tests. Other changes include an increase in entry age from 18 to 25 years, and recommended screening every five years (previously two years). Also, clinician-supervised, HPV self-sampling became available to eligible women. To be eligible for self-sampling, a woman must be aged 30 years or over and be overdue for screening by at least two years.\u003csup\u003e1\u003c/sup\u003e This change was based on extensive evidence demonstrating that HPV testing is a more sensitive screening test, providing better protection against cervical cancer through detection of HPV before cell changes occur in the cervix.\u003csup\u003e2-4\u003c/sup\u003e Key to the NCSP\u0026rsquo;s success however, is in effectively recruiting women to participate in screening. Never-screened or under-screened women are at higher risk of cervical cancer than those who regularly participate in screening programs.\u003csup\u003e5-7\u003c/sup\u003eThis recent change to HPV testing and the ability to self-sample provides a unique opportunity to engage these women.\u003c/p\u003e\n\u003cp\u003eNational cervical screening rates for Aboriginal and Torres Strait Islander women is unknown as pathology forms do not record Indigenous status. However, several studies that have utilised community level and State/Territory data have indicated that the average screening rates for Indigenous women lies between 33.5% and 44%, compared to 55.7% - 59.1% for non-Indigenous women. . .\u003csup\u003e8-12\u003c/sup\u003e Aboriginal and Torres Strait Islander women also experience higher rates of cervical cancer incidence and mortality,\u003csup\u003e12-13\u003c/sup\u003e hence, increasing their participation in preventative screening is crucial.\u003c/p\u003e\n\u003cp\u003eInternational research aimed at increasing the uptake of cervical screening was summarised in a recent meta-analysis.\u003csup\u003e14\u003c/sup\u003e The study found that door-to-door recruitment was most effective at increasing screening uptake as compared to clinician-collected samples. This was followed by community campaigns and mail-out to all, with the opt-in approach considered ineffective. However, the success of these recruitment techniques varied across populations and geographical regions, and thus techniques need to be tailored to specific regions. The best way to offer self-sampling to women who are disengaged from the health system and are under- or never-screened is also not yet known. To our knowledge, no other programs in Australia have offered face-to-face distribution and collection of HPV self-sampling kits within the home and community. One Australian study successfully recruited Aboriginal women from a regional Aboriginal Community Controlled Health Service to participate in self-sampling,\u003csup\u003e15\u003c/sup\u003e suggesting self-sampling is an acceptable option for Aboriginal and Torres Strait Islander women. No HPV self-collection studies have specifically targeted Aboriginal and Torres Strait Islander women in rural and remote communities.\u003c/p\u003e\n\u003cp\u003eThe option of clinician-supervised patient self-sampling under the new NCSP could positively impact screening practices of women who have never been screened or are under-screened. However, this pathway relies on existing patient engagement with a clinician and/or health service. If a woman does not routinely engage with a primary healthcare service, opportunities to actively encourage screening via this pathway are limited. This is particularly important \u0026nbsp;in rural and remote communities where access to female health professionals can be limited and the proportion of under-screened and never-screened women increases . Innovative models of care are needed to engage these hard-to-reach women. This research sought to: determine whether a community based HPV self-sampling model effectively recruited never-screened and under-screened Aboriginal women to participate in cervical cancer screening; assess the clinical outcomes, including follow-up; and explore the acceptability of the model from the perspective of the participants.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eCommunity consultation: \u003c/em\u003eMarathon Health Primary Health Care Nurses (PHCNs) consulted extensively with local organisations and community members across rural and remote New South Wales, Australia to establish the new service model for HPV self-sampling amongst Aboriginal women, including clinical governance processes.\u003c/p\u003e\n\u003cp\u003e\u003ca name=\"_Toc528314674\"\u003e\u003c/a\u003e\u003cem\u003ePilot sites\u003c/em\u003e\u003cem\u003e: \u003c/em\u003eEight rural and remote communities participated in the pilot study. Notably, seven of these had minimal access to female General Practitioners (GPs). Our target sample size (n=266) was calculated based on the estimated number of Aboriginal women who were under-screened. Across the study region in 2011, the total female Aboriginal population was 596 and an estimated 45% of women (both Aboriginal and non-Aboriginal) were under-screened (data provided by the NSW Cancer Institute, 2011-13). \u0026nbsp;\u003cem\u003eSelf-sampling pathway: \u003c/em\u003ePHCNs established partnerships with Local Aboriginal Land Councils (LALC) as the representative body for Aboriginal people in each community. Each LALC identified a female employee or community member to recruit as the Community Engagement Worker (CEW) for each site. Their primary role was to engage and recruit women to the program, and support them along the self-sampling pathway, with clinical support provided by the PHCN. Once the women completed the self-sample with the support of the PHCN and CEW, the PHCN sent the HPV samples to the VCS Foundation to be analysed. Pathology results were returned by mail to the participant, their nominated GP and the PHCN. A project GP was recruited to provide clinical oversight of those participants who did not have a regular GP. The PHCN followed up with all participants face-to-face or by phone to ensure they received their results and that they understood their meaning, including any follow-up that was required. Women who returned invalid results were provided the option to rescreen. See Figure 1 for a detailed flowchart of the self-sampling process.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRecruitment of women: \u003c/em\u003eThe CEWs were members of the local Aboriginal community themselves, and had existing links with the community to identify and engage with local women about the program. Whilst some women were recruited at local community events, the majority were recruited via home visits. Convenience sampling was used to recruit women, followed by snowballing (referred to as the \u0026ldquo;Koori Grapevine\u0026rdquo; by the local Aboriginal women) with the women identifying other family and friends for cervical screening. Whilst this inevitably would have resulted in bias, gaining trust with the community and having the women take on some ownership increased acceptance of the program. .\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipants: \u003c/em\u003eThe renewed NCSP recommends clinician-led HPV screening for women in the age range 25-69 years (inclusive), therefore our study included women in this age range. It is worth noting however, that the current NCSP only permits self-sampling to be completed at 30 years of age, when a woman is at least 5 years overdue for screening. Screening of women younger than 25 years was allowed at the discretion of the PHCN based on clinical indication (for example, sexual debut younger than 14 years of age and have not received the HPV vaccination). The NCSP recommends all women conduct an \u0026lsquo;exit-screen\u0026rsquo; between 70-74 years of age. We elected not to include women in this age group so as to ensure they conducted their recommended exit screen outside of this pilot study under the guidance of their clinician.\u003c/p\u003e\n\u003cp\u003eWhilst we sought to recruit women who were under-screened, the CEW and PHCN were able to decide whether they believed it was clinically and ethically appropriate to screen women who had been screened in the previous four years, particularly if they were due for a screen or were overdue.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData collection and management:\u003c/em\u003e An eligibility survey was conducted at the outset of the recruitment process. An evaluation survey was conducted during follow-up to elicit feedback on the service model and the participant\u0026rsquo;s experience of self-sampling using likert scale responses from 1 (very unsatisfied) to 5 (very satisfied). Clinical data were input into the client\u0026rsquo;s electronic medical record as per routine practice. All data were stored securely and confidentially so as to comply with both clinical governance requirements and research ethics requirements.\u003c/p\u003e\n\u003cp\u003eAll data were linked using a code number and then de-identified by the PHCN before analysis by the research team. Data were entered into Excel. IBM SPSS Statistics (version 22) was used for descriptive statistics on the quantitative dataset. Open-ended comments were combined and key themes then extracted by two researchers independently as part of the manifest content analysis process.\u003csup\u003e16\u003c/sup\u003e Themes and sub-themes were compared and discussed until a consensus was reached.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics Approval: \u003c/em\u003eEthics approval was granted by the Aboriginal Health and Medical Research Council Human Research Ethics Committee (reference 1188/16) and Western Sydney University Human Research Ethics Committee (reference H11837).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003ca name=\"_Toc528314681\"\u003e\u003c/a\u003e\u003cem\u003e\u003cu\u003ePart 1: Clinical results\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHPV self-sampling kits were distributed from September 2016 to June 2018 (21 months). The 215 women (80.8% of the targeted sample) that agreed to participate were all eligible and completed the HPV self-sample. Participation was highest amongst women aged 25-29 years (Figure 2).\u003c/p\u003e\n\u003cp\u003eOne-fifth of participants (21.4%; 46) self-reported that they had never completed a Pap test and 32.1% (69) had previously completed a Pap test but more than 4 years ago, with the range since last Pap test being 4 to 20 years (Figure 3). A total of 26.0% (56) of participating women reported that they had been screened, but could not remember when, suggesting that it was more than 4 years ago. Of the 34 (15.8%) women that had been screened in the previous 4 years, all but thirteen (6%) had not been screened in the previous two years, and thus were due for screening. Last screen was not recorded or was unknown for 10 (4.7%) participants.\u003c/p\u003e\n\u003cp\u003eEighteen percent (18.1%; 39) of women had a positive result: 4.2% (9) were HPV Positive 16/18 and 14% (30) HPV Positive other (defined as a high risk HPV type other than 16 or 18). Seventy-eight percent (78%; 168) had a negative result (two of which were the results of a second screen as the initial result was invalid), and 3.7% (8) had invalid results \u003cem\u003eand \u003c/em\u003edid not complete a rescreen. Stratification by age group showed that women who tested positive were distributed across all of the age groups (Table 1).\u003c/p\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:12.0pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: 12px; line-height: 200%; font-family: Helvetica;\"\u003eTable 1: HPV test results stratified by age group\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"width: 4.7e+2pt;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.5pt;border-top: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eHPV Test Result\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eNegative\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.5pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePositive for HPV 16/18 type\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePositive for a type other than HPV 16/18\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.5pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cem\u003e\u003cspan style=\"line-height: 200%;\"\u003eAge Group\u003c/span\u003e\u003c/em\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border: none;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.5pt;border: none;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.5pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026lt; 25 years\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border: none;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e8 (4.8%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.5pt;border: none;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e0\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e5 (12.8%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.5pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 18.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e25-29 years\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border: none;padding: 0in 5.4pt;height: 18.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e27 (16.1%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.5pt;border: none;padding: 0in 5.4pt;height: 18.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e1 (11.1%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 18.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e10 (25.6%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.5pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:7.1pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e30-34 years\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e27 (16.1%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e1 (11.1%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e4 (10.3%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.5pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 17.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e35-39 years\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border: none;padding: 0in 5.4pt;height: 17.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e22 (13.1%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.5pt;border: none;padding: 0in 5.4pt;height: 17.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e2 (22.2%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 17.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e6 (15.4%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.5pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e40-44 years\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20 (11.9%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.5pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e0\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e5 (12.8%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.5pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e45-49 years\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e19 (11.3%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.5pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e2 (22.2%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e3 (7.7%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.5pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e50-54 years\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e18 (10.7%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.5pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e1 (11.1%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e2 (5.1%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.5pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e55-59 years\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e11 (6.5%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.5pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e0\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e2 (5.1%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.5pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e60-64 years\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e12 (7.1%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.5pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e2 (22.2%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e2 (5.1%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.5pt;border-top: none;border-left: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e65 years and over\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e4 (2.4%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.5pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e0\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116.55pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e0\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:12.0pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: 12px; line-height: 200%; font-family: Helvetica;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\u003cbr\u003e\u003cbr\u003e\n\u003cp\u003eEight of the nine women (88.9%) with a HPV Positive 16/18 result had attended a colposcopy appointment by mid-July 2018. The other woman failed to attend her appointments due to documented clinical and other issues. Just under half (46.7%; 14) of the women with a HPV Positive other result had attended an appointment for a cervical screen by mid-July 2018 when this study ended. Attendance at follow-up appointments was relatively similar regardless of cervical screening history (Figure 4).\u003c/p\u003e\n\u003cp\u003e\u003ca name=\"_Toc528314685\"\u003e\u003c/a\u003e\u003cem\u003e\u003cu\u003ePart 2: Women\u0026rsquo;s satisfaction and feedback\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAlmost all women (92.6%; 199) completed the follow-up evaluation survey. One completed the survey twice as her initial result was invalid (200 total surveys). More than 90% of women were highly satisfied with the HPV self-sampling kit and the process involved (Table 2). In response to whether results were presented in an easy to understand format, 13.2% (23) were unsatisfied or very unsatisfied. Further, some women that were highly satisfied with the format of results commented that they were unable to interpret the paper copy independently, but the PHCN explained the results well:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The pathology made no sense to me but when the Nurse called and discussed I understood them\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:12.0pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: 12px; line-height: 200%; font-family: Helvetica;\"\u003eTable 2: Participating women\u0026rsquo;s level of satisfaction with the HPV self-sampling program\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"width: 4.6e+2pt;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.1pt;border-top: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eAspects of the self-sampling program\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.75pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e(5) very satisfied\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.2pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e(4) satisfied\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e(3) neither satisfied/ dissatisfied\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e(2) dissatisfied\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e(1) very dissatisfied\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.1pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cem\u003e\u003cspan style=\"line-height: 200%;\"\u003e1.1 HPV self-sampling kit\u003c/span\u003e\u003c/em\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.75pt;border: none;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.2pt;border: none;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border: none;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.1pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eThe kit provided everything to complete the self-sampling test? (n=200)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.75pt;border: none;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e199 (99.5%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.2pt;border: none;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e1 (0.5%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e-\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border: none;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e-\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e-\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.1pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 18.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eSatisfaction with the self-sampling \u0026nbsp;instructions (n=200)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.75pt;border: none;padding: 0in 5.4pt;height: 18.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e196 (98.0%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.2pt;border: none;padding: 0in 5.4pt;height: 18.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e1 (0.5%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;height: 18.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e1 (0.5%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border: none;padding: 0in 5.4pt;height: 18.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e-\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 18.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e2 (1%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.1pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cem\u003e\u003cspan style=\"line-height: 200%;\"\u003e1.2 HPV self-sampling process\u003c/span\u003e\u003c/em\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.2pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.1pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 17.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eProcess clearly explained by the CEW (n=197)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.75pt;border: none;padding: 0in 5.4pt;height: 17.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e188 (95.4%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.2pt;border: none;padding: 0in 5.4pt;height: 17.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e5 (2.5%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;height: 17.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e3 (1.5%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border: none;padding: 0in 5.4pt;height: 17.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e1 (0.5%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 17.15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e-\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.1pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eAble to ask questions and receive answers in a timely manner? \u0026nbsp;(n=186\u003c/span\u003e\u003csup\u003e\u003cspan style=\"line-height: 200%;\"\u003ea\u003c/span\u003e\u003c/sup\u003e\u003cspan style=\"line-height: 200%;\"\u003e)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.75pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e183 (98.4%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.2pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e2 (1.1%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e-\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e1 (0.5%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e-\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.1pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eThe process was simple (n=197)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.75pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e187 (94.9%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.2pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e4 (2%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e4 (2%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border: none;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e-\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 16.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e2 (1.0%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.1pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 17.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eProvided with privacy and confidentiality (n=197)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.75pt;border: none;padding: 0in 5.4pt;height: 17.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e182 (92.4%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.2pt;border: none;padding: 0in 5.4pt;height: 17.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e6 (3.0%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;height: 17.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e7 (3.6%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border: none;padding: 0in 5.4pt;height: 17.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e2 (1.0%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 17.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e-\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.1pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 12.2pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cem\u003e\u003cspan style=\"line-height: 200%;\"\u003e1.3 Results\u003c/span\u003e\u003c/em\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.75pt;border: none;padding: 0in 5.4pt;height: 12.2pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.2pt;border: none;padding: 0in 5.4pt;height: 12.2pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;height: 12.2pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border: none;padding: 0in 5.4pt;height: 12.2pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 12.2pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.1pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 19.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eResults were provided in an easy to understand format (n=174\u003csup\u003eb\u003c/sup\u003e)\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.75pt;border: none;padding: 0in 5.4pt;height: 19.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e136 (78.2%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.2pt;border: none;padding: 0in 5.4pt;height: 19.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e6 (3.4%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;height: 19.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e9 (5.2%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border: none;padding: 0in 5.4pt;height: 19.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e3 (1.7%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 19.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20 (11.5%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.1pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;height: 11.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.75pt;border: none;padding: 0in 5.4pt;height: 11.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026lt;2 weeks\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.2pt;border: none;padding: 0in 5.4pt;height: 11.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026lt;3 weeks\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;height: 11.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026gt;3 weeks\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border: none;padding: 0in 5.4pt;height: 11.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eUnsure\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 11.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eNot at time PHCN made contact\u003csup\u003ec\u003c/sup\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.1pt;border-top: none;border-left: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;height: 19.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:5.65pt;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eMailed results returned within 2 weeks (n=195)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.75pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 19.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e148 (75.9%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.2pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 19.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e13 (6.7%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 19.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e6 (3.1%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.8pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 19.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e13 (6.7%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 19.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e15 (7.7%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003csup\u003e\u003cspan style=\"line-height: 200%;\"\u003ea\u0026nbsp;\u003c/span\u003e\u003c/sup\u003e\u003cspan style=\"line-height: 200%;\"\u003eEight participants said they did not need to ask questions and six did not respond to this question.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003csup\u003e\u003cspan style=\"line-height: 200%;\"\u003eb\u0026nbsp;\u003c/span\u003e\u003c/sup\u003e\u003cspan style=\"line-height: 200%;\"\u003eSome participants had not yet received results and thus not applicable or did not respond to this question.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003csup\u003e\u003cspan style=\"line-height: 200%;\"\u003ec\u0026nbsp;\u003c/span\u003e\u003c/sup\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan style=\"font-size: 12px; line-height: 200%; font-family: Helvetica;\"\u003eThe hard copy paper results were not yet received by the participant at the time the PHCN provided the results verbally over the phone (this may have been within two weeks of the self-sampling test).\u003c/span\u003e\u003c/p\u003e\u003cbr.\u003cbr\u003e\u003cbr\u003e\n\u003cp\u003eThe majority of participants (96.0%; 192) would use the HPV self-sampling kit again. Of the six women who stated they would not use it again, four were referred to the GP for a pap test and would thus go directly to the GP next time, and two experienced difficulties completing the sample. Almost all women (98.5%; 197) would recommend the HPV self-sampling kit to other women.\u003c/p\u003e\n\u003cp\u003eWomen were grateful of, and highly satisfied with, the service (Table 3). There was overwhelming agreement that self-sampling removed the shame, intimidation, embarrassment, and pain that has historically been associated with clinician-collected Pap tests. Positive aspects included the ability to complete the test in the home, and thus the accessibility and privacy of cervical screening; the simplicity of the test; being in charge of Women\u0026rsquo;s business (an important consideration in Aboriginal culture where certain aspects of life are performed separately and termed Men\u0026rsquo;s and Women\u0026rsquo;s business\u003csup\u003e17\u003c/sup\u003e \u0026ndash; cervical screening falls into this category); the appropriateness of the self-sampling kit contents, with the exception of there not being a non-transparent bag to return the swab in; and the professionalism of the PHCN. Women felt they would not have completed cervical screening had this service not been available.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I could do it myself. No pain. I ended up having to go to the GP for a Pap test but I would have never done that if I didn\u0026rsquo;t have a self-sample, may have saved my life. I recommend this to everyone. The government needs to give all women the choice to self-sample\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: 12px; line-height: 200%; font-family: Helvetica;\"\u003eTable 3: Participating women\u0026rsquo;s experiences with HPV self-sampling\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border: none;border-collapse:collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eThemes\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eDescription\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eLocation of self-sample\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eIn the home: Women felt it was a more private, confidential and comfortable experience; they could complete it without embarrassment and shame.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOut of the home: There was mixed feelings regarding privacy and confidentiality when completed out of the home (e.g. park, LALC, mother\u0026rsquo;s groups).\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eAccessible\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eAccessible (in the home) and free. No need to travel long distances for a female GP, or wait and pay at a General Practice.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePrivacy and confidentiality \u0026ndash; shame and embarrassment\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eSelf-sampling was private and confidential, with no shame or embarrassment. Women did not feel violated or lose their dignity.\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eSimplicity\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eSelf-sampling was described as simple, easy, convenient, quick, and not too daunting.\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eSeveral women experienced some difficulty completing the test themselves.\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eIn charge of Aboriginal women\u0026rsquo;s business*\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eWomen felt a sense of control over their own women\u0026rsquo;s business, health and wellbeing. Women found it to be a positive and personal experience, and they felt comfortable and at ease.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eComparison of HPV self-sampling to Pap test\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cem\u003e\u003cspan style=\"line-height: 200%;\"\u003ePap test\u003c/span\u003e\u003c/em\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u0026ndash; uncomfortable, painful, humiliating, daunting, shameful, embarrassing, degrading, intimidating, not confidential. Women do not like going to the Doctor and do not want a man involved in women\u0026rsquo;s business.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cem\u003e\u003cspan style=\"line-height: 200%;\"\u003eHPV self-sampling\u003c/span\u003e\u003c/em\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u0026ndash; easier, more private, discreet, comfortable, personal, dignified, appropriate, and quicker. Not as intrusive, evasive or awkward.\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eSelf-sampling kit contents\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eHigh importance was place on the quality of the instruction cards:\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin-top:0in;margin-right:0in;margin-bottom:12.0pt;margin-left:0in;line-height:14.0pt;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: undefined;margin-left:0in;\"\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:12.0pt;margin-left:0in;line-height:14.0pt;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eThey were clear, easy to understand, straight forward \u0026ndash; not having to sift through unnecessary readings.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:12.0pt;margin-left:0in;line-height:14.0pt;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eIllustrations for black women were good.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eIn the case a woman could not read, the Nurse could clearly explain the process and the picture cards supported this.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eThe women were happy they could keep the case the kit came in.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eA non-transparent bag needs to be included in the kit for the sample to be returned to improve privacy and remove any shame.\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eThe PHCN gave the women confidence in the service being professional\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eWomen placed high importance on a trained professional (i.e. the PHCN) being present throughout the program, giving them confidence that it was accurate and professional. Some women would have preferred the PHCN (instead of the CEW) to explain the kit/process and take the completed sample.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eVerbal communication of results\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eWomen appreciated the verbal communication of results from the PHCN, particularly as many women could not understand them. This was described as \u0026lsquo;caring\u0026rsquo; and gave women confidence in the entire program.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eUnlikely that women would have completed a cervical screen had the HPV self-sampling test not been offered\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eWomen commented on: never having completed a cervical screen until participating in this study; being hesitant, reluctant, frightened, or scared to go to the Doctor to have a cervical screen, even in the case that one woman had a family history of cervical cancer and understood the risks; postponing Pap tests, with women suggesting anywhere between 1 and 20 years before they thought they would be screened again.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-right: none;border-bottom: none;border-image: initial;border-left: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eGrateful of a potential lifesaving experience\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-bottom: none;border-left: none;border-image: initial;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eWomen (irrelevant of results) were grateful and happy they had been offered the self-sampling kit, and that it could have saved their lives.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127.35pt;border-top: none;border-left: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eInitial concerns with the Program\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 323.45pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;line-height: 200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eWomen were not always forthcoming to completing the self-sampling, describing that they were initially nervous (e.g. unsure of accuracy of the test; previous painful experience with a pap test; worried of a positive result). \u0026nbsp;However, these comments were followed by positive feedback about the test and increased confidence to complete the test next time.\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:12.0pt;margin-left:0in;line-height:200%;font-size:13px;font-family:\"Arial\",sans-serif;'\u003e\u003cspan style=\"font-size: 12px; line-height: 200%; font-family: Helvetica;\"\u003e* In Aboriginal culture, certain aspects of life are performed separately for men and women, and are termed Men\u0026rsquo;s business and Women\u0026rsquo;s business\u003csup\u003e17\u003c/sup\u003e; cervical screening and related items fall into this category\u003c/span\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis program successfully recruited never- and under-screened Aboriginal women across rural and remote Australia to participate in HPV self-sampling in the home or community. Indeed, we were able to recruit 81% of our target sample size to participate in screening, a value much larger than the estimated 30-40% of Aboriginal women who have traditionally been recruited to participate in cervical screening.\u003csup\u003e8-12\u003c/sup\u003e Certainly, one-fifth of participating women had never been screened previously, one-third were overdue for screening, and a further quarter could not remember when they were last screened, suggesting it was a long time ago and they were therefore likely to be overdue for screening.\u003c/p\u003e\n\u003cp\u003eDespite historically being disengaged from the health system, eight of the nine women with a HPV Positive 16/18 had attended a colposcopy appointment by the completion of the project. This is in line with other studies that also reported high follow-up rates for women who participated in self-sampling.\u003csup\u003e13, 15\u003c/sup\u003e The lower follow-up rates (46.7%) observed for women who tested HPV Positive Other (defined as a high risk HPV type other than HPV 16 or 18) may be the result of not tracking women for long enough as anecdotal evidence provided after the completion of this study reported that some women did attend a follow up GP appointment that occurred after the end date of this study. Long-term research is therefore needed to understand whether follow-up care is achieved and how women can best be supported.\u003c/p\u003e\n\u003cp\u003eGiven the target population was not actively engaged in cervical cancer screening or the health system, the timely and individual support the PHCN and CEW provided to each woman to ensure results and follow-up care were understood, and women remained engaged, was key to the model\u0026rsquo;s success. Women placed high importance on the verbal communication of results given by the PHCN, particularly as they did not understand the hard copy results. Ensuring women have maximum understanding of the next steps in their pathway of care decreases anxiety and assists with successful completion of the self-sampling pathway.\u003csup\u003e18\u003c/sup\u003e Flexibility in PHCN and CEW roles enabled innovative solutions to be adapted for each woman to support them at an individual level to access the follow-up care required. This included offering self-sampling in the home environment. The majority of self-sampling studies have not allowed for home-based self-collection so this study adds to the limited evidence base attesting to its effectiveness at engaging women to complete screening.\u003c/p\u003e\n\u003cp\u003eThere was overwhelming agreement that this method for cervical cancer screening is appropriate for Aboriginal women, ensuring Aboriginal Women\u0026rsquo;s Business is respected. In comparison to Pap tests it was seen as a positive experience which women were happy to repeat and recommend to others, also documented in numerous self-sampling trials.\u003csup\u003e18-21\u003c/sup\u003e Importantly, women mentioned they would not have participated in screening had this not been available.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis pilot highlighted how the model can provide an access point into the health system, demonstrated by the large proportion of women that entered the mainstream health system for follow-up care. Further, an unexpected outcome was that some women who attended a GP follow-up appointment, also sought after additional medical advice/treatment for other conditions.\u0026nbsp; It provided a comfortable access point for these women, and therefore can have a net overall positive impact on health service engagement.\u003c/p\u003e\n\u003cp\u003eWhilst the current NCSP supports never- and under-screened women to participate in self-sampling rather than clinician-led sampling, there are specific criteria and it must be facilitated and requested by a clinician who routinely performs cervical screening. Hence, it is reliant on existing engagement with a clinician/health service. The current community-based service model could serve as an effective adjunct to clinician-led NCSP services by engaging with those women who are currently not engaged with a health service or clinician. Significantly, data from this study shows that this service model can also facilitate health service engagement amongst women who were previously disengaged. For many women though, the barriers to engagement with cervical screening under the previous NCSP will not immediately be broken down by completing one self-sample HPV test. It is a key recommendation of this study that women who are eligible for self-sampling continue to remain eligible to screen via this pathway, should they decline clinician-led screening in the future.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study did not capture numbers of women who were approached and declined participation or were obviously ineligible, such as being pregnant. Screening history was self-reported and thus there may have been some error in this data. There was not a structured process in place to document the follow-up outcomes for women and support required, including a formal clinical record review to determine actual disease burden from biopsy results. When women completed the evaluation survey there was a feeling that using a scale of 1 to 5 was not always understood by the women, and that a yes/no response (or something similar) would be more appropriate. The data collection timeframe was longer than anticipated (21 months) and this was due to a number of external factors along with workforce challenges in retaining CEWs in some of the communities. For reasons unrelated to the project, a number of CEWs relocated to other regions and new CEWS had to be recruited. Nonetheless, these are important considerations when scaling up services such as this across the region, particularly in rural and remote areas where health workforce is already a challenge.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis pilot demonstrated how a community-based model that respects Aboriginal Women\u0026rsquo;s Business, is community-led, and has a clinical lead to maintain high clinical governance and professionalism within the program, can effectively recruit hard-to-reach under-screened and never-screened Aboriginal women to complete cervical cancer screening. This was evidenced through high screening participation rates, high levels of satisfaction amongst participating women and the high rates of women engaging with recommended follow-up care. It is extremely unlikely that these women would have engaged in the current NCSP via clinician-supervised self-sampling as they are not engaged in the health system (i.e. they do not visit GPs). Future research and evaluation is needed to explore translation of this best practice service model into other remote, rural and regional sites. Research that builds on the current pilot study data can inform the requirements of rolling out this service model to communities that differ by population size, remoteness, geography, health service access, and other aspects unique to that community. Long-term follow-up of HPV self-sampling participants can also shed light on the ongoing health service engagement and cervical screening practices of these women.\u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cp\u003eCEW = Community Engagement Worker\u003c/p\u003e\n\u003cp\u003eGP = General Practitioner\u003c/p\u003e\n\u003cp\u003eHPV = Human Papilloma Virus\u003c/p\u003e\n\u003cp\u003eLALC = Local Aboriginal Lands Council\u003c/p\u003e\n\u003cp\u003eNCSP = National Cervical Screening Program\u003c/p\u003e\n\u003cp\u003ePHCN = Primary Health Care Nurse\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval for this project was granted by the Aboriginal Health and Medical Research Council Human Research Ethics Committee (reference 1188/16) and Western Sydney University Human Research Ethics Committee (reference H11837). All participants signed a consent form.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets are available from the corresponding author upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis service was initially funded by the Western NSW Primary Health Network. An early funding contribution was also received from the Murdi Paaki Regional Enterprise Corporation. The completion of the project was enabled through funding provided by the Australian Government Department of Health. Research costs were partially funded through a Western Sydney University Partnerships Grant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors satisfy the four criteria to authorship as outlined by the International Committee of Medical Journal Editors. LC conceived the project idea, and AV, NC, SJ, JM, SB, DH, MS, and JB all contributed to designing the project and evaluation. LC, AV, NC, and JM undertook data collection. TD and JB completed data analysis. All authors contributed to the interpretation of data. TD, JB, JM and SB drafted the paper, and the remaining authors revised the manuscript and provided feedback. All authors have read and approved the final manuscript and agree to being accountable for all aspects of the work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe wish to acknowledge and thank all of the organisations that funded this project: The Western NSW Primary Health Network; the Murdi Paaki Regional Enterprise Corporation; the Australian Government Department of Health; and the Western Sydney University (Partnerships Grant). We would also like to acknowledge the Community Engagement Workers who were instrumental in recruiting women to the project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAustralian Government Department of Health. National Cervical Screening Program. Updated 28 Aug 2019. \u003ca href=\"http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/cervical-screening-1\"\u003ehttp://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/cervical-screening-1\u003c/a\u003e (viewed Aug 2019).\u003c/li\u003e\n\u003cli\u003eElfstrom KM, Smelov V, Johansson AL, et al. Long term duration of protective effect for HPV negative women: follow-up of primary HPV screening randomised controlled trial. \u003cem\u003eBMJ\u003c/em\u003e. 2014; 348:g130.\u003c/li\u003e\n\u003cli\u003eRonco G, Dillner J, Elfstrom KM, et al. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. \u003cem\u003eLancet\u003c/em\u003e. 2014; 383:524-32.\u003c/li\u003e\n\u003cli\u003eCanfell K, Saville M, Caruana M, et al. Protocol for Compass: a randomised controlled trial of primary HPV testing versus cytology screening for cervical cancer in HPV-unvaccinated and vaccinated women aged 25\u0026ndash;69 years living in Australia. \u003cem\u003eBMJ open\u003c/em\u003e. 2018; 8:e016700.\u003c/li\u003e\n\u003cli\u003eVCS Foundation. Statistical Report 2015. 2017. \u003ca href=\"https://www.vcs.org.au/population-health/statistical-reports/annual-statistical-reports/\"\u003ehttps://www.vcs.org.au/population-health/statistical-reports/annual-statistical-reports/\u003c/a\u003e (viewed Aug 2019).\u003c/li\u003e\n\u003cli\u003eBos AB, Rebolj M, Habbema JD, et al. Nonattendance is still the main limitation for the effectiveness of screening for cervical cancer in the Netherlands. \u003cem\u003eInt. J. Cancer\u003c/em\u003e. 2006; 119(10):2372-5.\u003c/li\u003e\n\u003cli\u003eSasieni PD, Cuzick J, Lynch-Farmery E, et al. The National co-ordinating network for cervical screening working group. Estimating the efficacy of screening by auditing smear histories of women with and without cervical cancer.\u003cem\u003e Br J Cancer\u003c/em\u003e. 1996; 73:1001-1005.\u003c/li\u003e\n\u003cli\u003eAustralian Institute of Health and Welfare. Cervical Screening in Australia 2018. Canberra, AIHW;2018 Contract No.: Cat. no. CAN 111.\u003c/li\u003e\n\u003cli\u003eAustralian Institute of Health and Welfare. National Key Performance Indicators for Aboriginal and Torres Strait Islander primary health care: results from June 2016. 2017.\u003c/li\u003e\n\u003cli\u003eBinns PL, Condon JR. Participation in cervical screening by Indigenous women in the Northern Territory: a longitudinal study. \u003cem\u003eMJA\u003c/em\u003e. 2006; 185:490-4.\u003c/li\u003e\n\u003cli\u003eCoory MD, Fagan PS, Muller JM, et al. Participation in cervical cancer screening by women in rural and remote Aboriginal and Torres Strait Islander communities in Queensland. \u003cem\u003eMJA\u003c/em\u003e. 2002; 177:544-7.\u003c/li\u003e\n\u003cli\u003eWhop LJ, Garvey G, Baade P, et al. The first comprehensive report on Indigenous Australian women's inequalities in cervical screening: A retrospective registry cohort study in Queensland, Australia (2000-2011). \u003cem\u003eCancer\u003c/em\u003e. 2016; 122:1560-9.\u003c/li\u003e\n\u003cli\u003eAustralian Institute of Health and Welfare. Australian Cancer Incidence and Mortality (ACIM) books: cervical cancer. 2017. \u003ca href=\"https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia/acim-books\"\u003ehttps://www.aihw.gov.au/reports/cancer/cancer-data-in-australia/acim-books\u003c/a\u003e (viewed Aug 2019).\u003c/li\u003e\n\u003cli\u003eArbyn M, Smith SB, Temin S, et al. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. \u003cem\u003eBMJ\u003c/em\u003e. 2018; 363:k4823.\u003c/li\u003e\n\u003cli\u003eSaville M, Hawkes D, McLachlan E, et al. Self-collection for under-screened women in a National Cervical Screening Program: pilot study. \u003cem\u003eCurr Oncol (Toronto, Ont)\u003c/em\u003e. 2018; 25:e27-e32.\u003c/li\u003e\n\u003cli\u003eBengtsson M. How to plan and perform a qualitative study using content analysis. \u003cem\u003eNursingPlus Open\u003c/em\u003e. 2016; 2:8-14.\u003c/li\u003e\n\u003cli\u003eBarclay L, Andre CA, Glover PA. Women\u0026rsquo;s Business: the challenge of childbirth. \u003cem\u003eMidwifery\u003c/em\u003e. 1989; 5(3):122-33.\u003c/li\u003e\n\u003cli\u003eGupta S, Palmer C, Bik EM, et al. Self-Sampling for Human Papillomavirus Testing: Increased Cervical Cancer Screening Participation and Incorporation in International Screening Programs. \u003cem\u003eFront Public Health\u003c/em\u003e. 2018; 6:77.\u003c/li\u003e\n\u003cli\u003eMadzima TR, Vahabi M, Lofters A. Emerging role of HPV self-sampling in cervical cancer screening for hard-to-reach women: Focused literature review.\u003cem\u003e Canadian Family Physician Medecin de famille canadien\u003c/em\u003e. 2017; 63:597-601.\u003c/li\u003e\n\u003cli\u003eSultana F, Mullins R, English DR, et al. Women\u0026rsquo;s experience with home-based self-sampling for human papillomavirus testing. \u003cem\u003eBMC Cancer\u003c/em\u003e. 2015; 15:849.\u003c/li\u003e\n\u003cli\u003eWiner RL, Gonzales AA, Noonan CJ, et al. Assessing Acceptability of Self-Sampling Kits, Prevalence, and Risk Factors for Human Papillomavirus Infection in American Indian Women. \u003cem\u003eJournal of Community Health\u003c/em\u003e. 2016; 41:1049-61.\u003c/li\u003e\n\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-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Aboriginal women; cervical screening; program evaluation; Aboriginal Women’s business; cancer","lastPublishedDoi":"10.21203/rs.2.23841/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.23841/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Aboriginal women experience disproportionately higher rates of cervical cancer mortality yet are less likely to participate in screening for early detection. This study sought to determine whether a community-based HPV self-sampling service model can effectively recruit never-screened and under-screened Aboriginal women to participate in cervical cancer screening; assess the clinical outcomes; and explore the acceptability of the model from the perspective of the participants.\u003c/p\u003e\u003cp\u003eMethods: Aboriginal women aged 25-69 years of age were recruited from eight rural and remote communities in New South Wales, Australia to participate in HPV self-sampling via a community-based service model. Outcome measures were: number of women screened by HPV self-sampling, their prior cervical screening status (under-screened or never-screened), clinical outcomes and participation in follow-up pathways of care, and satisfaction with the service model.\u003c/p\u003e\u003cp\u003eResults: In total, 215 women conducted a HPV self-sampling test and 200 evaluation surveys were completed. One-fifth of participants (n=46) were never-screened and one-third (n=69) were under-screened. Many were unsure of their screening status. Nine women were HPV 16/18 positive and eight had completed all follow up by the conclusion of the study. A further 30 women tested positive for a high risk type other than HPV 16/18 (HPV other), of which 14 had completed follow up at the conclusion of the study. Satisfaction with the HPV self-sampling kit, the process of self-sampling and the service model was high (\u0026gt;92% satisfied on all items). Many women had difficulty understanding their official HPV results and placed high importance on the nurse explaining it to them.\u003c/p\u003e\u003cp\u003eConclusions: A community-based service model that respects Aboriginal Women’s Business can effectively recruit under-screened and never-screened Aboriginal women to complete cervical cancer screening. Furthermore, this service model supports them to complete recommended follow-up care and engage with their local existing health services.\u003c/p\u003e","manuscriptTitle":"Uptake and acceptability of human papillomavirus self-sampling in rural and remote Aboriginal communities: Evaluation of a nurse-led community engagement model","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2020-04-13 19:12:40","doi":"10.21203/rs.2.23841/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-04-10T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-04-07T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-04-07T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-04-07T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-04-07T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **Not relevant to this manuscript**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I have nothing to disclose**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"editorInvitedReview","content":"","date":"2020-04-07T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nThe revised manuscript is much improved.* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **Not relevant to this manuscript**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"editorAssigned","content":"","date":"2020-04-06T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-04-05T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-04-05T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-02-18 16:53:37","doi":"10.21203/rs.2.23841/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-03-03T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-03-02T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nFirst, I want to commend the authors for working on this article.\n\nI have divided my comments by sections:\n\nTITLE\n\nNo observations\n\nABSTRACT\n\nNo observations\n\nBACKGROUND\n\n\"In December 2017, the Australian National Cervical Screening Program (NCSP) was updated, with HPV testing replacing Pap tests, and clinician-supervised, HPV self-sampling becoming available to eligible under-screened women. To be eligible for self-sampling, a woman must be aged 30 years or over and be overdue for screening by at least two years. Other changes include an increase in entry age from 18 to 25 years, and recommended screening every five years (previously two years) \"\n\nSuggestion:\n\nIn December 2017, the Australian National Cervical Screening Program (NCSP) was updated, with HPV testing replacing Pap tests. Other changes include an increase in entry age from 18 to 25 years, and recommended screening every five years (previously two years). Also, clinician-supervised, HPV self-sampling became available to eligible under-screened women. To be eligible for self-sampling, a woman must be aged 30 years or over and be overdue for screening by at least two years.\n\n\nMETHODS\n\n\"A target sample size was calculated based on the aggregate population size of all eight communities and average current estimated screening rates across these eight communities (data kindly provided by the NSW Cancer Institute).\n\nRemove word \"kindly\"\n\nSuggestion:\n\nA target sample size was calculated based on the aggregate population size of all eight communities and average current estimated screening rates across these eight communities (data provided by the NSW Cancer Institute).\n\n\n\"screening of women younger than 25 years was allowed at the discretion of the PHCN based on clinical indication.\"\n\nCould you please elaborate what a clinical indication would be for screening under 25?\n\nRESULTS\n\n\"HPV self-sampling kits were distributed from September 2016 to June 2018 (21 months).\"\n\nPlease elaborate why it took so long for such a small sample size, this could potentially also be a reflection of limitations/challenges the program might have as it scales up\n\n\"One-fifth of participants (21.4%; 46) had never completed a Pap test and 32.1% (69) had\npreviously completed a Pap test but more than 4 years ago, with the range since last Pap test being 4 to 20 years (Figure 3).\n\nSo only 54.5% of women met criteria. The other percentages of women that were unsure of when their last screen was done, could they be potentially being over screen or is it more likely that it had been such a long time that they don't recall? Maybe elaborate more on why you could not show time of last screen. Not in their medical records? No proper system set in place?\n\n\"Eighteen percent (18.1%; 39) of women had a positive result: 4.2% (9) were HPV Positive\n16/18 and 14% (30) HPV Positive other.\"\n\nHPV prevalence is high, could you please elaborate on this. Is this due to the high percentage of younger women in sample size? I think it would be helpful to age stratify the HPV positivity rate.\n\n\"Further, some women that were highly satisfied with the format of results commented that they were unable to interpret the paper copy independently, but the PHCN explained the results well: \"The pathology made no sense to me but when the Nurse called and discussed I understood them\"\n\nSuggestion: I would delete this part\n\n\nDISCUSSION\n\nModify as needed based on previous comments\n\n\nLIMITATIONS\n\nPlease include:\nWhy most of women were young.\nBecause there are no results of biopsies from colposcopy, we don't know actual disease burden in population.\nLimitations of not having proper follow up of HPV positive women.\n\nConclusions\nModify as needed based on previous comments\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"editorInvitedReview","content":"","date":"2020-02-22T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nThe authors present a nicely designed study of participation in self-collected HPV screening in rural Aboriginal communities. The topic itself is very important to address women at highest risk of developing cervical cancer and increasing access.\n\nThe manuscript could be improved if authors emphasize the 2/3 major take away points from the study - which it seems are increased participation of women hard to reach (this should be emphasized, as well as explicitly compared to the presumed participation in the same community or control if these women did not participate in self-collection), the satisfaction in the program, and the relatively high percentage of women who presented for follow-up care.\n\nLine 18, page 2 - it is confusing for those not accustomed to HPV literature to call the result \"HPV other\". Explain that this is any high risk type other than HPV 16/18 for the readers\nLines 21-22, page 3 - phrased as a double negative. Consider stating that indigenous women are xx % less likely than non- to be screened?\nLines 4-8, page 4 - since this is not your research, the percentages aren't all necessary, but summarizing the point of the paper is important for the reader as an intro to the other studies that have found community models effective\nLines 20-24, page 4 - this is really two sentences and concepts that should be explained separately\n\nMethods:\nHow was the target sample of 20% of the assumed 45% of underscreened women selected? Randomly? Was bias introduced? What percentage participated (in results)\n\nIt is confusing why the inclusion of 25-29 year olds was made - I see it explained, but be more clear such as: \"the 2017 guidelines includes ____ age range, therefore our study included these women.\n\nDiscussion:\nThe information on follow-up of women in lines 17-22 of page 9 should be included in the results section before discussed.\n\nA point that comes up a few times is \"respect of Women's Business\". I have never heard this term or know of a commonly accepted definition of what this means. Where it is used in the manuscript, it seems that respecting their time could replace the phrase, but I don't know the true meaning or what is intended to be said with Women's Business.\n\nAnother point in the discussion would be to compare participation in the similar populations vs. the participation in your study. While there is no formal control group in the study (which would have made the point stronger), I still think the comparison would help the reader understand how much more participation can be had in self-collection models.\n\n\nFigures:\nThe Age of participation figures include women \u003c25, but these women should not have been included in the study, correct?\n\nThe figure on screening status shows 32% of women were previously screened - were any of these women treated, had follow-up care? This wasn't included in the exclusion criterion\n\n\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **No**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **Not relevant to this manuscript**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **None**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"reviewerAgreed","content":"","date":"2020-02-21T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-02-17T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-02-15T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-02-14T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-02-13T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-02-13T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-01-28T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0b0bc66f-7ce6-4086-92a0-d184a50e655b","owner":[],"postedDate":"April 13th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":82846,"name":"Health Policy"}],"tags":[],"updatedAt":"2021-07-27T21:01:53+00:00","versionOfRecord":{"articleIdentity":"rs-14404","link":"https://doi.org/10.1186/s12913-020-05214-5","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2020-05-11 21:01:53","publishedOnDateReadable":"May 11th, 2020"},"versionCreatedAt":"2020-04-13 19:12:40","video":"","vorDoi":"10.1186/s12913-020-05214-5","vorDoiUrl":"https://doi.org/10.1186/s12913-020-05214-5","workflowStages":[]},"version":"v2","identity":"rs-14404","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-14404","version":["v2"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}