“I would never have gone for screening if it hadn't arrived, this home kit”. Motivation, Capacity and Opportunities for Cervical Cancer Home-based Vaginal Self-sampling in Reunion Island: a qualitative study

“I would never have gone for screening if it hadn't arrived, this home kit”. 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Motivation, Capacity and Opportunities for Cervical Cancer Home-based Vaginal Self-sampling in Reunion Island: a qualitative study Dolorès POURETTE, Amber CRIPPS, Amir HASSINE, Eric OPIGEZ, Marc BARDOU, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4843003/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Jul, 2026 Read the published version in BMC Public Health → Version 1 posted 11 You are reading this latest preprint version Abstract Background: In 2022, RESISTE conducted a cluster-randomised trial to assess the feasibility and effectiveness of home delivery of HPV vaginal self-sampling kits. The trial targeted women living in deprived areas who were not up to date with their screening. This article presents the results of the post-intervention qualitative study conducted in Reunion Island. The study explores women's motivation and capacity to conduct home-based vaginal self-sampling and analyses the influence of providing a financial incentive (voucher upon return) and of returning the kit by post or to a health professional. Method: A total of 35 semi-structured interviews were conducted with women respondents who returned the kit (16), non-respondents (13) and health professionals contacted by women during the trial (6). Results: After receiving the kit, several women underwent screening either by self-sampling or by visiting a health professional. Ease of use, convenience and privacy were key factors in self-sampling uptake. Receiving the kit at home creates a sense of being targeted which reinforces the perceived relevance of screening and further encourages uptake. Relatives generally had a facilitating effect, encouraging self-sampling and follow-up. Amongst women respondents, a HPV positive result, was a strong motivator to undergo a follow-up smear test. Nevertheless, a lack of prior knowledge of vaginal self-sampling, led to a lack of trust in the programme amongst women sometimes likened by women to a scam. This and the perceived complexity of the procedure were the main demotivating factors. The financial incentive did not reverse this trend. On the contrary, it contributed to doubts regarding authenticity. In addition, the health professionals contacted rarely encouraged women to self-sample. Conclusions : Women appreciated receiving an HPV vaginal self-sampling kit at home. Motivation and capacity could however be improved by increasing prior communication – to both women and health professionals - on self-sampling in general, and more specifically on reliability, sample preservation and ease of use. User-friendliness could also be improved by providing HPV tests results more quickly. Providing the option of collecting and returning the kit to a health professional of women’s choice helps ensure they receive adapted information and support. Trial Registration: 6 February 2020 - "Sud-Ouest et Outre-Mer II" ethics committee - Version 04 dated 29 July 2023 is currently in force - ID-RCB no.: 2020-A0002237 (File 2-20-006 id6698) 2°HPs. cervical cancer human papilloma virus home-based HPV vaginal self-sampling qualitative study underprivileged women Reunion Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Context Potentially curable, cervical cancer (CC) was the fourth most common cancer in women in 2020, with 604,127 new cases and 341,931 deaths worldwide [1,2]. CC is strongly correlated to social inequality. In 2020, 90% of all CC cases and deaths occurred in low- and middle-income countries ( 1 ). In middle- to high-income countries, women from more disadvantaged socioeconomic backgrounds are also more likely to die from the illness ( 2 ). Inequitable access to preventive measures, to early detection and treatment explain such disparities, the 5-year survival rate being strongly linked to the stage at which the cancer is diagnosed ( 2 ). Reunion Island is a French overseas department in the southwest Indian Ocean. With a population of 870,000, the poverty rate is 2.5 times higher than in mainland France (36% compared to 14% in 2020), making it the department with the third highest poverty rate in France (after Mayotte and French Guiana). Poverty in Reunion Island is gender and age sensitive. Pensioners (with a high proportion of female-headed households) account for almost 23% of those living in poverty. More than 50% of young- (under 30) and single parent- (mostly female) families live in poverty. Among those in employment, single-parent families (again mostly headed by women) and larger families (with more than two children) are more impacted by poverty (representing 11% of poor households) ( 3 ). In Reunion Island, 45 cases of invasive cervical cancer are diagnosed each year, resulting in 16 deaths ( 4 ). Both incidence (13,9 versus 6,1/100 000 ) and mortality (4,8 versus 1,7/100 000) rates are two times higher than in mainland France ( 5 ). As elsewhere in France, prevention of CC is based on the vaccination of adolescent girls and boys aged 11 to 19 years old against the most common high-risk oncogenic types of human papillomavirus (HPV), followed by cervical screening of women aged 25 to 65. Since 2019, Pap smear testing is used to screen women aged 25 to 29, followed by HPV testing 3 years after the last normal cytological test and then every 5 years until the age of 65. In Reunion Island, the screening rate (65% amongst women aged 25–65) decreases with age (76% amongst women aged 30–34 and 46% amongst women aged 60–65) ( 6 ). Since 2009, women who have not screened in the past 3 years receive a reminded letter inviting them to be screened ( 7 ) but participation rates remain low (23–24%) ( 8 ). A survey conducted in 2017, on a representative sample of 1,000 women eligible for screening, identified low socio-economic status, low CC screening awareness, low literacy levels, and being a migrant from other Indian Ocean islands as key factors in non-participation ( 8 ). In July 2019, the French National Authority for Health recommended that women aged 30 and above be screened using HPV testing instead of cervical cytology, it also stated that "Vaginal self-sampling represents an alternative to cervical sampling by a health professional for women who have not been screened or who have been insufficiently screened". Study Background Fieldwork was conducted on Reunion Island between January and November 2022 as part of the RESISTE programme. The RESISTE trial is a "Combined incentive action, centred on primary care providers, to improve cervical cancer screening in socially disadvantaged unscreened women: evaluation of effectiveness and ethical and economic issues" ( 9 ). The RESISTE study involved a cluster-randomised trial targeting women living in low socioeconomic areas (number 4 and 5 IRISs, the smallest geographical subdivision in France) who are not up to date with their screening. On 5th January 2022, 2,564 self-sampling kits for high-risk oncogenic human papillomavirus (HPV-HR) were sent out by post to targeted women’s homes. Return and incentive arrangements were randomised under 4 trial groups: 1) simple postal return, 2) postal return with an economic incentive of €20 upon receipt of the collected sample, 3) return to a healthcare professional of the woman's choice (gynaecologist, general practitioner, midwife or pharmacist), 4) return to a healthcare professional of the woman’s choice with an economic incentive of €20. The kit contained a detailed presentation of the study, illustrated instructions, a self-sampling tube, a zip-lock bag and a pre-stamped return envelope. Prior to the trial, an introductory letter had been sent out to targeted women and to all health professionals in the department who might come into contact with them as part of the study (gynaecologists, general practitioners, midwifes and pharmacists). Women who returned a sample received their HPV results by text message and by post within 3 months. These documents are presented in additional files [see Additional files 1, 2, 3, 4, 5]. The current study was conducted post trial, amongst women who received the kit – both those who returned the kit and those who did not. A preliminary qualitative study had been conducted prior to the RESISTE trial to assess the acceptability of the scheme to both women and health professionals ( 10 ).The discussion section of this article compares the results of pre- and post-trial research data. Study Aims The objective of this anthropological study was to assess the feasibility and effectiveness of a cervical cancer screening strategy involving home delivery of HPV vaginal self-sampling kits. The study explores women's motivation, and capacity to conduct home-based vaginal self-sampling (HBVSS) while analysing external influences and opportunities. This article also weighs the respective impact of the economic incentive and of returning the kit to a health professional. Methods Rationale and methodology Social anthropology helps capture the positive and negative experiences and feelings of individuals and communities, without "false familiarity" or "false evidence" ( 11 ). The aim of this study was not to deliver statistical data, but rather to provide a comprehensive understanding of human logic, of how and why people act and react in one way rather than another. Semi-structured interviews based on pre-established open-ended anchor questions were used to create a framework for active listening ( 12 ) The interviewee is encouraged to steer the conversation towards what he or she considers most essential, thus moving away from the interviewer’s rationale and closer to the interviewee’s. This openness towards the interviewee helps build a relationship of trust and confidentiality that is particularly well-suited to exploring intimate and sensitive topics such as cervical cancer self-screening. Study Topics The interview guide explored women’s capacity (knowledge-levels and practices), motivation (perceptions and feelings) and opportunities (external factors) in chronological order from when they received the kit (their understanding of the kit’s use and usefulness, their appreciation for the screening format, their decision to self-test or not), to when they conducted the self-collection (ease of use, feelings, concerns and practices) and then returned the kit (including their interactions with health professionals), and later received their results (understanding of the results, practices of HPV-positive women, awareness of follow-up modalities for both HPV-positive and negative results. We identified specific research questions: did home-based vaginal self-sampling help overcome barriers to conventional screening ? What new barriers have emerged? How does women's experience of self-testing compare with their experience of clinician-assisted testing? How do women respond to receiving a kit compared to receiving the usual invitation letter? How does the financial incentive affect uptake? How do the different return modalities (postal or health professional) impact uptake? How did the fact that it was a trial affect the results? What questions do women have? How can the system be improved? Health professionals were interviewed about their knowledge, perceptions and experience of the RESISTE programme. Sampling The study targeted women on Reunion Island who had received an HPV-HR vaginal self-sampling kit under the RESISTE trial. Sampling aimed to select a wide range of women in terms firstly of individual characteristics based on their age group (3 age groups were defined − 30 to 39, 40 to 54 and over 55) and place of residence. For sampling purposes, the island was divided into 6 geographical areas: North, West, South, East, "les hauts" (literally "high places", a term used locally to refer to the centre of the island, which is at a higher altitude) and the "cirques" (literally natural “amphitheatres”, created by the collapse of an extinct volcano) (Fig. 1 ). Access to health care is more problematic in the latter two geographical areas due to their remoteness. Secondly, women were selected according to their interaction with the RESISTE trial : their assigned trial group (4 groups), whether they returned the kit or not (responders and non-responders), how long they took to return the kit ('normal' return within 2 months or 'late' return between 2 and 6 months), and, finally, their HPV test results (negative or positive). Health professional (HP) sampling targeted doctors and pharmacists who received women for the return of their samples. Interviews Women were contacted by telephone (using the details provided on the return form for responders and the Regional Cancer Screening Coordination Centre (RCSCC) details for non-responders). We contacted responders, with negative HPV results 1 month after sending out their results so as to allow for postal delivery from mainland France. This was the case whether they were ‘normal’ or ‘late’ responders. Women with positive results were contacted 3 months after their results were posted out to them, to allow them time to see a doctor and undergo additional screening before the interview. Women were considered non-responders if a sample was not received within 6 months after home delivery, estimated at 2 weeks after posting. The interviews with women were mostly (25/29) conducted in their homes and a few (4/29) by telephone. It was the opposite for HP, 5 interviews (1 medical doctor (MD) and 4 pharmacists) were conducted by telephone and 1 in person, with an MD. Anthropologists conducted the semi-structured interviews based on target group specific interview guidelines (women, doctors and pharmacists - see Additional files 6 and 7). Before the interviews, participants were informed of the purpose of the study and of its non-binding and confidential nature. They were provided with an information sheet and a consent form. Interviews were conducted in French or Reunionese Creole, according to participant preference. They were recorded with participant prior consent. To ensure confidentiality, no names were mentioned or recorded at any time during the interviews. Each interview was then transcribed into French. Data Analysis Cross-sectional thematic analysis was used to contrast participants’ responses and to identify general trends and divergences ( 13 ). The results are presented according Michie et al’s Behaviour Change Wheel ( 14 ). The desired change was the uptake of CC screening (either through home-based self-sampling or by visiting a practitioner). This conceptual model highlights the drivers and barriers to change by grouping them into three dimensions: motivation (and demotivation), capabilities (as perceived by the individual), and 'opportunities' or external influence (encouraging and discouraging the adoption of change). Ethics The RESISTE protocol was approved for the first time by the "Sud-Ouest et Outre-Mer II" ethics committee on 6 February 2020 and is currently been conducted in accordance with the fourth version of June 10th, 2022 - ID-RCB no.: 2020-A0002237 (File 2-20-006 id6698) 2°HPs. Results Women Participants A total of 29 women participated in the study. In terms of their individual characteristics, fewer women above 55 participated in the study as displayed in Table 1 below. Table 1 : Women Participants’ Age Group Age Group Participants 30-39 10 40-54 14 55+ 5 TOTAL 29 Women interviewees came from the 6 study areas (see Figure 1 below). More women in the south, and les hauts participated than in other areas. Women’s socio-economic status varied considerably (see Figure 2). Most women (15) were unemployed, all of whom had access to National Health Insurance. Of these women, 10 lived in social housing and 7 considered that they had difficulties “making ends meet” at the end of the month. The other 13 women were employed or retired and had private health insurance. We documented 4 women living with a disability and 3 others caring for a disabled family member. In terms of their family situation, 15 women lived with a partner and their children, 4 families had 3 or more children (defined in France as a “large family”). Most of the other women (13) were single mothers, 7 of which had 3 or more children. The last woman was single and did not have children. In terms of their origin, most women were born in Reunion Island (25), 2 were born in France, 1 in Madagascar (of Mahoran parents), and the last was from Vietnam. Given the cultural diversity of Reunion Island, we asked the women to describe their cultural identity (see Figure 3 below). Most of them considered themselves to be of mixed cultural origin: either Creole - "Catholic [1] Creole" (8) or "Malbar [2] Creole " (6) - or "Reunionese" (9). The remaining 4 women identified themselves as Muslim (2), Tamil (1) and Hindu (1). In terms of how women interacted with the RESISTE study, we tried to have a representative sample in terms of trial groups, however only 2 women in group 1 participated. This was due mostly to difficulties in contacting non-respondents: several telephone numbers provided by the RCSCC were out of service (15/85), a higher proportion of women did not answer calls (47/85), while several of those who answered did not agree to partake in the study (25/38) often calming not to have received the kit (15/38). As displayed in Table 2, this impacted our ability to represent all arms of the randomised trial equally. Table 2 : Women Participant’s Trial Group Trial Group Participants 1 2 2 11 3 9 4 7 TOTAL 29 Of the 29 women participants, 16 were respondents, 8 with negative and 8 with positive HPV results, and 13 were non-respondents (see Table 3 below). Among the respondents, 10 women returned the sample within 2 months (normal return) and 6 within 2 to 6 months (late return). Of the 13 HBVSS non-respondents, 5 were screened under other Organised Cervical Cancer Screening (OCCS) services. Indeed, 1 had just been screened when she received the kit, 4 were screened by a health professional after receiving the kit, and 1 was waiting for an appointment to be screened. Another non-respondent was not eligible to screening due to a total hysterectomy. Thus, only 6 of the 13 non-respondents to home-based self-sampling can be considered as OCCS non-participants. Table 3 : Study Participants’ Interaction with HBVSS and with OCCS In terms of their screening history (see Figure 4 below), 12 study participants reported having been screened in the past 3 years. The majority of these women had a regular screening history, all those who did not consider themselves already up-to-date with their screening self-sampled (8) or screened with an HP (2) after receiving the kit. The other 16 women had not been screened in the previous 3 years. Almost two thirds of these women, including some who had not been screened in the past 5 or even 10 years, chose to self-sample (10/16). Health Professional Participants In this study, we interviewed health professionals who collected women’s self-samples and whose contact details were provided to the coordinating centre and those who refused to receive self-samples and who’s contact details were provided by women who called the RESISTE team to enquire about the programme (see table 5 Below). Table 5 : Health Professional Study Participants Geographical Area / Profession Doctor Pharmacist TOTAL North 2 2 4 East - 1 1 West - 1 1 TOTAL 2 4 6 Vaginal Self-sampling Motivating Factors Most of the women interviewed (20/29) appreciated receiving the kit at home. Eighteen of the women surveyed felt that self-sampling at home was more convenient than visiting a doctor. They mentioned the time gain, not having to wait for a doctor’s appointment, and not having to deal with Covid related restrictions or screening program changes. Several women (7) contrasted their experience using self-sampling with conventional screening which they presented as a violation of their privacy, they emphasised their discomfort during gynaecological examination. "Personally, I would never have gone for screening if it hadn't arrived, this home kit. I wouldn't have made an appointment to do it because we don't have time, and personally, it's true that I'm not concerned about my state of health." (Respondent, late returnee, age 44, tested 8 years earlier) Women described a sense of urgency and importance in receiving a kit at home. The kit’s provenance, from mainland France, and the Dijon University Hospital logo added to the perception that the kit was ”more serious”. Women interpreted being included in the study as a sign that they were more at risk of cervical cancer than others. They mentioned their fear of cancer, feeling "late for screening", being at an age where they considered themselves more vulnerable to CC (identified as around 50) or having gynaecological symptoms. Some women felt that if they had received the kit, they must “already be contaminated”. These perceptions motived women to self-sample or be screened by a professional. A feeling that "things could get worse" over time also encouraged screening – this feeling was shared both by those who returned the kit immediately and by those who initially put the kit aside and then undertook delayed self-sampling. "When it comes from over there (mainland France), it's not the same. If it comes from the other side, there's something wrong! The other side: outside Reunion! Because it's far away. How can they know? So, there's something wrong. They want in-depth results to make sure! (Respondent, aged 51, screened 4 years earlier) "It seems more serious because we're talking about mainland France. There may be great specialists over there who will analyse everything, whereas here it's routine (...) you get the impression that it's more serious" (Respondent, late returnee, aged 56, screened 1 month earlier). Two women who had recently had a cervical smear conducted returned the HBVSS sample, because they thought it was a more in-depth test aiming to investigate a suspicion of cancer found on the pap-smear test. "I said to myself, "Wasn't the test any good? Why are they sending me back for another one? Do I have cancer? I had a smear test in the hospital in September 2021". (Respondent, age 42, HPV positive, negative pap-smear test 6 months earlier) Having previously heard about self-sampling and being familiar with other self-screening programmes increase women’s motivation to return the kit. Some women said they “automatically” respond to all screening invitations (2). "Every time I receive something, I automatically go and do it. It's automatic! I'm really into all that stuff. You must do it...". (Respondent, late returnee, age 56, tested 1 month earlier) Several women (6) said the quality of the kit, and in particular of the swab, "reassures" and "makes you want" to take part. Doubts and Demotivating Factors The main emotions experienced by women upon receiving the kit were fear and surprise. While fear of cancer was a motivating factor, fear of pain and fear of discovering a disease were demotivating factors for 3 women. "You have to admit that you don't want to be screened and found with a disease... it's not a very pleasant thing to hear" (non-respondent, aged 30, screened "a long time ago"). Women's surprise was related to their unfamiliarity with cervical cancer self-screening, which they described as “bizarre”. The usefulness of the RESISTE program was questioned by women with a regular screening history - they felt that it was the role of their general practitioner (GP) to invite them to be screened. Other women were concerned about self-sampling reliability as compared to HP-led screening and in relation to kit shelf life, sample contamination or deterioration (over time or heat related), and sample damage or loss in the post. "It says it's not the same method as a smear test, but is it still reliable? I don't know, the [smear] it pinches, it goes right to the bottom." (respondent, age 46, screened more than 3 years earlier). Another concern voiced by women (8) related to how they had been selected and how their personal information (name and address) had been accessed, in particular given that the kit had been sent directly from mainland France rather than through the Reunion social security system. The unconventional circuit contributed to concerns regarding the program’s authenticity. A significant number of women (12) considered the intervention to be a "scam”. The financial incentive contributed to this perception (6/12 women). "I was surprised. I didn't expect to get this kit because I know that it's usually the doctor who takes the samples. But I was reluctant to do it! (...) Isn't it a scam? Did it exist and why did it come from mainland France? It was bizarre! How did they get my address? Why me? (...) I hesitated for at least two months, I think. (Respondent, late returnee, aged 38, tested 2 years earlier) Nonetheless, women displayed mixed reactions to the financial incentive: several appreciated receiving the incentive (9) but did not consider it to be a determining factor in their decision to self-test or not. They distinguished the incentive from a decision made "for the sake of their health". Another woman, with a positive HPV result after self-testing, felt that the approach was inappropriate, likening it to a "consolation prize". In addition, 2 women reported difficulties in using the vouchers they had received, as very few shops in Reunion Island would accept them. “[20€] is fine but I’m not interested either [in self-sampling], but if I do it, it's for my health and if they give it to me, I'll take it" (HBVSS non-respondent who made a gynaecological appointment after receiving the kit, age 43, screened 7 years earlier). Finally, the fact that the kit was sent out as part of a trial had an impact on how the objective of the intervention was perceived. Some women thought that the aim was to produce “statistics” rather than to improve women’s health. This demotivated them to take part. "It is a very personal thing! So, I prefer to keep it personal! Still, I can understand that studies might help and all that, but it didn't motivate me! I said to myself 'there are other women who will do it'" (woman screened by a professional after receiving the kit, aged 34, screened 1 year earlier). Capacity: knowledge and practice Most women understood that the kit was sent to them as part of the cervical cancer organised screening programme. They considered the self-test to be equivalent to a smear test (the same test, but done at home rather than by a professional). Some of those who had a positive self-test, and then had a smear test as part of their follow-up, understood the difference between the two. Several women (6) confused the test for other forms of self-testing. Three women understood the kit to be a colorectal cancer screening device. For 3 other women, the visual similarity of the kit to a covid test was confusing and not very reassuring given their unpleasant experiences with nasal swabs. Two women did not understand that the device provided was for self-testing. They thought they had to take the kit to a healthcare professional to have the sample taken, which they didn’t do. Self-sampling initially seemed complex to several women (13), many of whom (9/13) did not return the kit. Women said the accompanying documents gave the impression that “it's long, it's complicated”. Some women (5) had to read the letter several times and said that the terminology was “too medical”. Others (3) had a low level of education or were not used to reading “official documents”, while 1 was visually impaired. Most of these women (11/13) decided to put the kit aside until they had more time to read the documents and/or collect the sample and only just over half (6/11) later returned the kit (late return). "When I receive something like this, I put it on the table. But I wait before I go and do it! I have the impression that it's long, complicated and all that, so I don't read it, I don't look at it too much and then when I have really made up my mind, that's when I go back to it. (...) We get a bit confused... and sometimes we don't understand! an explanation, but it's short! That way you understand! If they shorten it and just say what's essential, that’s better" (respondent, late returnee, aged 56, tested 1 month earlier). Conversely, the illustrated instructions were considered clear (19) and user-friendly. However, even with the illustrated instructions, the procedure remained unclear to some non-respondents who were not used to self-sampling. "If it wasn't for the drawings, I would have needed to talk to someone, but with the drawings I didn't need to" (respondent, 46 years old, screened more than 3 years earlier). "The booklet was well designed for someone who is used to doing it alone, but for someone who is not used to it, it doesn't work" (non-respondent woman, aged 47, screened 12 years earlier). More than half of the responders expressed feeling at ease self-sampling (7). However, vaginal self-sampling for the first-time caused anxiety for both responders and non-responders. Twelve women felt the procedure was “too technical” and doubted their capacity to carryout self-sampling and produce a sample of sufficient quality. They were uncertain about how deep to insert le swab (the red mark did not seem to have been understood), where exactly they needed to touch (should they try to reach the cervix?), how long and in what position to use the swab. Some of the women (5) tried to imitate the position for undergoing a smear test and self-sampled in the morning believing this would provide a better sample. "I thought about how the doctor does it... the position and I tried to do it, reading the instructions carefully... I lay on my back, spread my legs apart, and I put the little stick in, turned and turned and looked to see if there was enough secretion on it to make sure it worked! That was in the morning. Because generally, when I go in with my GP, he tells me it's better to do it in the morning and avoid washing too much down there to make sure that the white discharge is really there. That's another way of finding out what's wrong. That's what I was thinking about.” (Respondent, late return, 38 years old, tested 2 years earlier) Because self-testing was considered the same as a smear test (a technical procedure), 7 women considered it unsuitable for home use. None of them returned the kit. Two of these women were afraid of hurting themselves. Another important factor in women’s capacity to self-sample was their availability. For some women (4) self-sampling and then returning the sample was an additional burden in an already busy schedule. Finding time at home was considered more difficult than attending a gynaecologist appointment. "When I received the test, and it has to be done, but after work... I put it off, I put it off... it's not easy. The doctor told me to go to the gynaecologist to have the test done. But it's really far away and I put it off each time because I've got other things to do too. I don't have time to read too much (non-respondent who made an appointment after receiving the kit, 43 years old, screened 7 years earlier) Finally, 2 women felt ashamed to carry out self-sampling, or even to consider doing so, one returned the kit, the other did not for this very reason. Opportunities: External Factors The women interviewed appreciated the HBVSS postal return modalities, they considered the process “simple”. They particularly appreciated the pre-stamped return envelopes (10) noting that it was “free” and “anonymous”. Ensuring that the sample arrived quickly and safely so it could be processed rapidly and their results sent out as fast as possible was a key concern. Several women (5) made sure to send off the sample quickly after self-collection. One did not return the kit because she was afraid she wouldn’t be able to post it off before sample deterioration. Some (5) preferred to return the sample to a HP where they felt it would be processed more rapidly. In terms of how the kit impacted motivation, several women (5) found the kit more encouraging than a reminder letter. This was also the case amongst women (4) who had not been screened in the past 4 to 8 years. Receiving the kit at home and having it "at hand" made screening easier. Another 2 said they had booked an appointment for a cervical smear test, whereas they had not done so after receiving a reminder letter. Women also appreciated the information provided with the kit and some (2) felt better informed after receiving the kit than after receiving a reminder letter, which encouraged them to be screened. "If I'd received a letter instead of the kit, it would have gone in the bin". (Respondent, late returnee, aged 44, tested 8 years earlier) "I often receive letters at home but you had to go to a gynaecologist to have the sample taken, which I didn't do, I always put the letter in the bin, so I thought it was a good thing to be able to do it myself (...) I think that after a week or two, I decided to take the sample. I said to myself, it's there anyway, I'll do it and then I'll see. (Respondent, age 50, tested 8 years earlier) Concerning how and when the results were sent out, participants appreciated receiving their results by text message and by post. Some of them said they had not received the text message, while others could not remember receiving a letter in the post. Receiving results by SMS is appreciated for its speed - a delay of several months is mentioned for receiving letters from mainland France - and for its familiarity since the Covid crisis. The text of the SMS, "You performed a self-test on the (date)…" reassures women that the information is genuine. Some women (3) preferred to receive the results by post which allows them to decide when to read the letter and provides more official documentation as well as a means of keeping record. Participants generally felt (10) the 3-month wait to be too long. One women did not participate specifically for this reason. A 15 day to a month wait was considered “normal”. Women who tested positive remarked that, in hindsight, they would have liked to have known earlier. A prolonged wait was understood to imply that “everything’s fine”. Indeed, several women (5) mentioned that their gynaecologist only contacts them if “something’s wrong”. "I received [the results] after two, two and a half months. It was a bit long, 15 days would be normal. We'd like to have the results as soon as possible. Waiting is stressful" (respondent, age 59, screened 3 years earlier). In terms of social opportunities, women’s relatives (husbands, mothers, sisters, daughters) and close friends with whom they discussed receiving the kit generally encouraged them to screen (18). Before self-sampling only two said they had looked the process up on the internet, the information they found reassured them. A lack of prior information on self-screening was a strong barrier to screening. Some non-respondents (3) would have participated if they had heard about the programme beforehand, from their GP or on the radio or television. After receiving the kit, 13 women contacted a health professional, either their GP (9) or the Dijon University Hospital who’s contact details were provided with the kit (4). None of the GPs contacted were aware of the intervention, and most discouraged them from self-testing. Women said the GPs they discussed the kit with had concerns regarding how the kits were sent and where they came from (4), the self-testing procedure and women's ability to perform it (2). Most of the women who received such feedback did not self-sample. The professionals' lack of prior knowledge about the study, and, in some cases, about HPV self-sampling, made the programme "less credible" to the women. Some of them were offered a smear test instead and chose this option (3). A total of 4 women went for alternative screening after meeting a HP, 3 with a GP and one asked a home care nurse to collect the sample for her as she did not feel comfortable doing it herself. She had previously taken the kit to her GP but her doctor had refused to collect the sample, saying she was not familiar with this screening “model”. "She [the doctor] said she didn't dare! Because now they've changed the model (...) Because they've done like the PCR test there, the rod. She said that she'd never seen it before. She said she'd never seen it come to your house, the doctor does it but it doesn't come to your house. She said it's not my problem because we don't know where it comes from, we don't know what it is. "If you can do it, do it, if you can't, don't do it. That's what she said. (respondent who asked a home nurse to take the sample, age 57, not tested for "a long time"). When the kit had to be returned to a health professional, as was the case for to 2 of the 4 randomised trial groups, the pharmacists and GPs they contacted (8/9) were not aware of the study and refused to take the sample. Some women visited several health professionals before returning the kit themselves by post (5), sometimes after calling the Dijon University Hospital for confirmation (2). "The fact that you arrive at the pharmacy and that the pharmacist discovers the scheme and says, 'What the hell is this?' And that he's taken the document to read it and all that, well that makes it a little less credible (respondent, late returnee, 44 years old, tested 8 years earlier). The pharmacists interviewed had not received the RESISTE information letter, they explained that letters are often received at management level. One of the GPs received the information leaflet and kept it; she also encouraged those woman who consulted her to practice HBVSS. The influence of health professionals on their decision to self-screen was highlighted by the women. Several women (6) would have self-sampled if a health professional had reassured them about the device: 4 would if they had received the kit in person from their GP, a pharmacist, a midwife or through a mobile outreach clinic and 2 if it had been possible to self-sample in front of the health professional. Following explanations at the end of interviews, 5 non-respondents would now like to self-sample . "I think the only person who would have reassured me would have been my GP (...) if my GP had known about it, if she had told me, it was normal, then yes, I would have had more confidence in it! I would have told my doctor to do it, or to do the smear test for me in fact. I don't think I would have done it myself. (Non-respondent, age 31, screened 2 years earlier) Eleven women (respondents and non-respondents) would nonetheless prefer to be screened by a doctor. “I put it away somewhere, but I can't remember where I put it. Maybe I'll use it, but not for the moment. I'll take it to the midwife for help.” (Non-respondent, 47 years old, screened 12 years earlier). Post-HBVSS monitoring Ability to Understand Test Results Many women thought that a positive HPV result was a cancer diagnosis (7). Receiving a positive result is a “shock”, even for women who don’t think a positive result necessarily means they have cancer. The need for medical follow-up and further testing was recognised, although the participants did not always understand why. Some women (3) thought their partner had been unfaithful when they tested positive. One woman, who had prior suspicions, split up with her partner after receiving a positive test result. Another woman wondered if her HPV result was positive because she had Covid when she self-sampled. “Even if they say no, I immediately think of cancer, it makes you think of difficult treatment, and of death. Injections, chemotherapy, and more (...) I’ll have to see a gynaecologist again, I want to find a woman, she's going to take a sample and maybe do an operation. It has to be done. I've already made an appointment for Monday. I'll ask her if it hurts. I don't know exactly why I need to go and see a gynaecologist.” (Respondent, HPV positive, age 44, screened 5 years earlier) Regarding the CC screening calendar, women knew that screening has to be done regularly, but there was a lot of confusion about the interval between screenings. More than half of the participants (16) said they could not remember what was in the letter and did not know exactly when they needed to be screened again. This was also the case for 2 HPV-positive women who still needed to have a follow-up test. Eleven women knew that smear tests are conducted every 2 to 3 years, 2 mentioned the 5-year interval for HPV testing, and 3 thought that screening should be done every year. There was also some confusion about the age at which screening should be done, it was considered more important after the age of 40 or 50, and sometimes less important after 60 when sexual activity was considered less regular. Motivation to Undergo Additional Screening Receiving a positive result is a "scary" experience for women. All 8 HPV positive respondents went to a doctor for a smear test. Many (6/8) went straight to their GP or immediately made an “urgent” appointment with a gynaecologist. The other two women with positive HPV results consulted a month after receiving their initial results by text message, one because she wanted to be screened by a woman (and she had to wait before having an appointment with a woman), and the other because she was waiting for more official confirmation of the results by post and she did not trust the text message (see below). "I saw the gynaecologist quickly, I said it was an emergency and I got an appointment quickly" (respondent, HPV positive, age 42, screened 6 months earlier). Women with positive results discussed them with friends and family, who encouraged them to have further tests. Others looked for information on the internet, which generally reassured them. Opportunities for Post-HBVSS Monitoring Half of the HPV positive respondents (4/8) would have preferred to receive their results by phone, so as to be able to be able to ask questions and receive more in-depth information right away. One HPV-positive woman deleted the text message as soon as she received it because she was shocked and did not want her adult children to find out "without really knowing what [she] had". After receiving the letter, she informed her family and then consulted a doctor. "I received the results after two months, by text message, saying that my test was positive (...) For me it was a normal, run-of-the-mill test. I was really, really surprised when I got the text message (...) I found it really bizarre, being told that my test was positive and it was also a high-risk test. I didn't think it was a good idea to receive this kind of result by text message. I was shocked. Receiving it by text message. Afterwards, of course, I deleted the text message, I didn't want my children to see, not really knowing what was wrong with me. (...) A month later, I told my children about it because I'd received a letter at home saying that I should contact a health professional as soon as possible. It's easier to read than to receive a text message. For me, a text message is more familiar". (Respondent, HPV positive, aged 50, screened 8 years earlier) In some cases, there was some confusion between the trial HPV results and organised screening pap-smear results. One woman who received a positive HPV result from a self-sample immediately went to a gynaecologist for a smear test. She had not yet received the results of this smear test when her GP, to whom she had returned the self-sample, phoned to tell her about the positive results, without specifying that it was the HPV test. She thought it was the result of the smear test and became concerned. Another woman received the kit when she had just had a smear test, the results of which she had not yet received. She thought this meant her results must be positive and she needed further screening. She was very concerned and went straight to her GP. "When I received the kit, I was worried, because I already had the sample taken by my GP. And I thought there was a problem! That's why I went back to see my GP, and he said "No, it's not the same". " (Non-respondent, 42 years old, screened 1 month earlier). Discussion After receiving the kit, women who had not been screened for several years screened either by self-sampling or with a practitioner. Women said they were more motivated to screen after receiving a kit than after receiving a simple reminder letter. Sending a kit to women's homes does more to encourage screening than a simple reminder. Another randomised trial has also shown increased participation amongst women who receive a HBVSS kit by post compared to those who receive a reminder letter or a HBVSS kit order form [19]. We found that ease of use, convenience and privacy are key factors in self-sampling uptake. Previous studies also identified these factors as promoting HBVSS ( 16 – 18 ). Receiving results directly and quickly, identified by both respondents and non-respondents as an important factor in uptake, has also previously been identified as being highly valued by women ( 17 ). Feeling that screening is relevant is another essential determinant of uptake. As in our pre-intervention study ( 10 ) and in other prior research, we found that having symptoms ( 19 ), being over 50 years of age ( 20 ), or engaging in risky sexual behaviour, defined in Reunion Island as having multiple partners, ( 10 ) meant that women considered screening to be more relevant to their personal circumstances. Our results show that receiving the kit at home also creates a sense that one is being targeted and thus that screening is relevant. This is an important motivational factor that, to our knowledge, has not been previously documented in HBVSS research. However, it is important to note that the resulting sense of urgency may lead to undue anxiety (about having cancer) and duplicate screening. Furthermore, duplicate screening can lead to cross-communication of results. This was particularly the case when the women’s GP was not involved in the screening process from the beginning. One of the respondents in our study said she had self-sampled despite having had a negative past experience with screening. HBVSS could provide an alternative for women, enabling them to overcome past painful screening experiences, a factor identified in the pre-intervention study ( 10 ) as a strong barrier to OCCS. This contrasts with other studies which identify a previous painful gynaecological examination as inducing a fear of all screening objects, including the VSS stick ( 17 ). Further investigation is needed to confirm the potential of HBVSS in overcoming past negative screening experiences. Relatives generally have a facilitating effect, encouraging the practice of self-sampling at home. Other studies have highlighted the influence of pairs ( 17 ) and husbands ( 21 – 23 ), particularly in cultural contexts of close family proximity. In one study, women with friends or family members to discuss screening with were three times more likely to participate in screening than those who did not ( 24 ). The suggestion of several women that the opinions of women who have carried out HBVSS should be shared (so-called "community champions") ( 25 ) seems justified. Conversely, misconception about the screening programme especially by close relatives could be a major barrier to home screening ( 19 ). In our study, some husbands reinforced women's fears that the study was a scam or the procedure too technical to completed at home. This highlights the need for prior communication targeting women as well as the general public. A lack of prior information about vaginal self-collection and the perceived complexity of the procedure (likened to a smear test) were the main demotivating factors for women in Reunion Island. Both non-respondents and respondents did not feel entirely apt to perform a self-sample, they were concerned that they would not be able to collect a sample of sufficient quality or that they would hurt themselves. A few felt ashamed. A lack of self-confidence in sample collection has been observed in other contexts ( 16 – 18 , 26 , 27 ) and can lead to low uptake and poorer quality self-collection ( 19 ). As in our preintervention study, women emphasised their need for support ( 17 ). Lack of motivation to self-sample is also related to a lack of trust in the programme. Insufficient information about vaginal self-sampling may lead to misinterpretation of home-based screening programme and to non-participation. In Reunion Island, the barriers to optimal understanding were: a lack of HBVSS media coverage, low levels of health literacy, and a lack of availability coupled with the perceived complexity of the letter and kit (seen as requiring sufficient dedicated time to read and then complete). The pre-intervention study ( 10 ) and other studies conducted in mainland France ( 28 ) also identify the lack of prior information as one of the reasons women do not consider HBVSS a viable option, highlighting the direct (on the woman) and indirect impact (on next of kin) on uptake ( 19 ). The lack of information at the level of health professionals, particularly doctors and pharmacists, represents a missed opportunity and a major barrier to HBVSS as most of them discouraged uptake. In addition, the impact of returning the sample to a professional could not be fully explored as very few accepted to take the samples. Nonetheless, women emphasised their need and wish to be accompanied by a practitioner ( 10 , 28 ). The financial incentive does not seem to reverse non-response; on the contrary, it sometimes contributes to doubts about the authenticity of the programme. To our knowledge, there has been no qualitative study of a programme that included a financial incentive for screening. The importance of free screening has been documented in women of low socioeconomic status ( 27 ). The fact that this was a trial also influenced the results of this study by giving the impression that the programme was not solely about women's health. Finally, a positive result provided a strong motivation for women to seek advice and have a smear test. The concerns expressed by health professionals during the pre-intervention study regarding the loss of HPV positive women after self-testing ( 10 ) do not appear to be founded. Conclusions Participants in our study appreciated receiving a VSS kit at home and would like to do so in the future. Some women even wanted the kit to be sent out at initial screening (not just with the a reminder letter). However, to improve awareness, ease of use and support from health professionals, the system needs to be adapted. Increased and diversified coverage (radio, television, social networks, events) before introducing the system would help improve awareness levels and contribute to motivation. Women suggested media coverage should include guidance from health professionals and share the experience of women who have self-sampled. A video could be made available in health centres and pharmacies, as well as on social security websites and social networks. Mass media communication should also be addressed to husbands, who can play a key role in encouraging participation. The planned takeover of the programme by the National Health Insurance Scheme in 2024 should provide reassurance about the provenance of kits. Financial incentives do not seem to be a key factor in motivating women to participate and can be dropped. To ensure that women feel confident to perform the HBVSS, the information provided with the kit should be brief, clear, accurate and written in non-medical language. Clear information about the reliability of the results, the preservation of the sample and the ease of the procedure is also important. A QR code to access a short explanatory video could be included to accompany the written instructions. The illustrated instructions were considered clear but the position for self-sampling and the depth of penetration needs to be better specified – that there’s no need to imitate the position used for a pap-smear or to touch the cervix. All messages on cervical cancer should include all available screening options and provide the screening schedule. User-friendliness would also be enhanced by a shorter time frame for receiving results (to be indicated in the information letter). This will help to reduce anxiety and maintain enthusiasm for the programme. Results should be emailed to women’s GP for speed and convenience and a link to access results sent directly to women via text message and email - so they can view them at their convenience. In the case of positive results, immediate feedback to the GP by email, followed by a phone call to the women, would provide optimal communication, reducing anxiety and ensuring optimal follow-up. Many women prefer to receive and return the kit by post. Others appreciate the support of a health professional. Healthcare professionals can play an important role in the implementation of HBVSS. Offering the option of receiving the kit at home or of picking it up then returning it to a GP or pharmacy could help build confidence in the programme and allow women to access more personalised support. It would also provide greater opportunity to discuss alternative screening options with women choose not to self-test. Healthcare professionals requested more information and learning materials on HBVSS so they are better able to guide women. Particular attention should be paid to GPs and pharmacists, who play an important role in patient education on Reunion Island. Pharmacists are the only health professionals that women can see without an appointment. Women and professionals requested outreach activities in more geographically and socially isolated neighbourhoods. A mobile caravan conducted by midwives, health mediators and translators (Creole, Shimaoré, Malagasy) would help reassure women about HBVSS and other cervical cancer screening alternatives. Abbreviations CC Cervical cancer CCOS Cervical cancer organised screening CSS Supplementary health insurance FCU Cervico-uterine smear GP General practitioner HBVSS Home-based vaginal self-sampling HPV Human papillomavirus HPV-HR High-risk oncogenic human papillomavirus RCSCC Regional cancer screening coordination centre VSS Vaginal self-sampling Declarations Ethics approval The RESISTE protocol was the subject of an initial favourable opinion on 6 February 2020 by the "Sud-Ouest et Outre-Mer II" ethics committee. Version 04 dated 29 July 2023 is currently in force - ID-RCB no.: 2020-A0002237 (File 2-20-006 id6698) 2°HPs. Consent to participate and consent for publication Before taking part in the interviews, participants were informed about the purpose of the study, the publication of results and the study’ non-binding and confidential nature. An information sheet and consent form were provided prior to each interview. To ensure confidentiality, women and health professionals names were not mentioned or recorded at any time during the interviews. All interviews were recorded with the prior consent of the participants. Availability of data and materials The datasets analysed during the current study are not publicly available due to their confidential nature but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding This research was funded by the French Ministry of Solidarity and Health (PREPS-19-0008) and by the French Institute of Cancer (INCa-AAP DEPISTAGE 2019-Projet DEP19-003-BARDOU). Authors' contributions AC and DP carried out the interviews and subsequent analysis and writing. The English version was revised by AC. AD and MB supervised the study and were the main reviewers of the article. AH selected potential women to be contacted based on the selection criteria and reviewed the content of the article. E.O. prepared Figure 1. Acknowledgements We would like to thank the women and health professionals who gave so generously of their time, answering sometimes sensitive questions, sharing their experiences, views and suggestions to improve screening. References Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021 May;71(3):209–49. Singh GK, Jemal A. 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Perspectives of women participating in a cervical cancer screening campaign with community-based HPV self-sampling in rural western Kenya: a qualitative study. BMC Women’s Health. 2019 Jun 13;19(1):75. Sewali B, Okuyemi KS, Askhir A, Belinson J, Vogel RI, Joseph A, et al. Cervical cancer screening with clinic-based Pap test versus home HPV test among Somali immigrant women in Minnesota: a pilot randomized controlled trial. Cancer Med. 2015 Apr;4(4):620–31. Lofters A, Prakash V, Devotta K, Vahabi M. The potential benefits of “community champions” in the healthcare system. Healthc Manage Forum. 2023 Nov 1;36(6):382–7. Teng FF, Mitchell SM, Sekikubo M, Biryabarema C, Byamugisha JK, Steinberg M, et al. Understanding the role of embarrassment in gynaecological screening: a qualitative study from the ASPIRE cervical cancer screening project in Uganda. BMJ Open. 2014 Apr 1;4(4):e004783. Camara H, Zhang Y, Lafferty L, Vallely AJ, Guy R, Kelly-Hanku A. Self-collection for HPV-based cervical screening: a qualitative evidence meta-synthesis. BMC Public Health. 2021 Aug 4;21(1):1503. Le Goff J, Le Duc-Banaszuk AS, Lefeuvre C, Pivert A, Ducancelle A, De Pauw H, et al. Acceptability to Healthcare Professionals of Home-Based HPV Self-Sampling for Cervical Screening: A French Qualitative Study Conducted in an Area with Low Access to Health Services. Cancers. 2023 Jan;15(21):5163. Footnotes The term "Catholic Creole" refers to the practice of the Catholic religion by women who identify themselves as being of mixed cultural origin and predominantly African (especially Malagasy). The term "Malbar Creole" refers to the practice of Hinduism and/or mixed cultural origins, which are predominantly Indian and Hindu. The term "Malbar" refers to the inhabitants of the Malabar Coast in India who came to Reunion Island as indentured labourers. On Reunion Island, this term is used to refer to people considered to be of Indian descent ( 15 ). Additional Declarations No competing interests reported. Supplementary Files ADDITIONALFILE1.pdf Additional Files Additional file 1 ADDITIONAL FILE 1.pdf Introductory letter for women ADDITIONALFILE2.pdf Additional file 2 ADDITIONAL FILE 2.pdf Introductory letter for health professionals ADDITIONALFILE3.pdf Additional file 3 ADDITIONAL FILE 3.pdf Presentation of the study ADDITIONALFILE4.pdf Additional file 4 ADDITIONAL FILE 4.pdf Illustrated instructions ADDITIONALFILE5.pdf Additional file 5 ADDITIONAL FILE 5.pdf Result letter ADDITIONALFILE6.pdf Additional file 6 ADDITIONAL FILE 6.pdf Interview guide for women ADDITIONALFILE7.pdf Additional file 7 ADDITIONAL FILE 7.pdf Interview guide for health professional Cite Share Download PDF Status: Published Journal Publication published 11 Jul, 2026 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 26 Sep, 2025 Reviews received at journal 03 Oct, 2024 Reviewers agreed at journal 23 Sep, 2024 Reviewers agreed at journal 20 Sep, 2024 Reviews received at journal 14 Aug, 2024 Reviewers agreed at journal 07 Aug, 2024 Reviewers invited by journal 07 Aug, 2024 Editor invited by journal 05 Aug, 2024 Editor assigned by journal 02 Aug, 2024 Submission checks completed at journal 02 Aug, 2024 First submitted to journal 01 Aug, 2024 You are reading this latest preprint version 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. 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BARDOU","email":"","orcid":"","institution":"Centre d’investigation clinique INSERM 1432, Centre Hospitalier Universitaire de Dijon, Dijon, Bourgogne, France","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Marc","middleName":"","lastName":"BARDOU","suffix":""},{"id":346129982,"identity":"271c5c25-9ca5-4aa1-9266-9f59a61d8747","order_by":5,"name":"Alexandre DUMONT","email":"","orcid":"","institution":"French National Institute for Sustainable Development, UMR Ceped, Université Paris Cité","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alexandre","middleName":"","lastName":"DUMONT","suffix":""}],"badges":[],"createdAt":"2024-08-01 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letter\u003c/p\u003e","description":"","filename":"ADDITIONALFILE5.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4843003/v1/234cb4acc1188391ec3825de.pdf"},{"id":63551261,"identity":"ecc7d7ed-c35b-4d29-bffb-27d195c1a153","added_by":"auto","created_at":"2024-08-29 12:29:14","extension":"pdf","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":109492,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional file 6\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eADDITIONAL FILE 6.pdf\u003c/p\u003e\n\u003cp\u003eInterview guide for women\u003c/p\u003e","description":"","filename":"ADDITIONALFILE6.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4843003/v1/6fa4c23c21b8e752d264eb7d.pdf"},{"id":63551912,"identity":"69f9662e-997f-4cfe-80f6-274753609ded","added_by":"auto","created_at":"2024-08-29 12:37:14","extension":"pdf","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":56931,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional file 7\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eADDITIONAL FILE 7.pdf\u003c/p\u003e\n\u003cp\u003eInterview guide for health professional\u003c/p\u003e","description":"","filename":"ADDITIONALFILE7.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4843003/v1/21f751b79214a94439415074.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“I would never have gone for screening if it hadn't arrived, this home kit”. Motivation, Capacity and Opportunities for Cervical Cancer Home-based Vaginal Self-sampling in Reunion Island: a qualitative study","fulltext":[{"header":"Background","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eContext\u003c/h2\u003e \u003cp\u003ePotentially curable, cervical cancer (CC) was the fourth most common cancer in women in 2020, with 604,127 new cases and 341,931 deaths worldwide [1,2]. CC is strongly correlated to social inequality. In 2020, 90% of all CC cases and deaths occurred in low- and middle-income countries (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In middle- to high-income countries, women from more disadvantaged socioeconomic backgrounds are also more likely to die from the illness (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Inequitable access to preventive measures, to early detection and treatment explain such disparities, the 5-year survival rate being strongly linked to the stage at which the cancer is diagnosed (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eReunion Island is a French overseas department in the southwest Indian Ocean. With a population of 870,000, the poverty rate is 2.5 times higher than in mainland France (36% compared to 14% in 2020), making it the department with the third highest poverty rate in France (after Mayotte and French Guiana). Poverty in Reunion Island is gender and age sensitive. Pensioners (with a high proportion of female-headed households) account for almost 23% of those living in poverty. More than 50% of young- (under 30) and single parent- (mostly female) families live in poverty. Among those in employment, single-parent families (again mostly headed by women) and larger families (with more than two children) are more impacted by poverty (representing 11% of poor households) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Reunion Island, 45 cases of invasive cervical cancer are diagnosed each year, resulting in 16 deaths (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Both incidence (13,9 versus 6,1/100 000 ) and mortality (4,8 versus 1,7/100 000) rates are two times higher than in mainland France (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). As elsewhere in France, prevention of CC is based on the vaccination of adolescent girls and boys aged 11 to 19 years old against the most common high-risk oncogenic types of human papillomavirus (HPV), followed by cervical screening of women aged 25 to 65. Since 2019, Pap smear testing is used to screen women aged 25 to 29, followed by HPV testing 3 years after the last normal cytological test and then every 5 years until the age of 65.\u003c/p\u003e \u003cp\u003eIn Reunion Island, the screening rate (65% amongst women aged 25\u0026ndash;65) decreases with age (76% amongst women aged 30\u0026ndash;34 and 46% amongst women aged 60\u0026ndash;65) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Since 2009, women who have not screened in the past 3 years receive a reminded letter inviting them to be screened (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) but participation rates remain low (23\u0026ndash;24%) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). A survey conducted in 2017, on a representative sample of 1,000 women eligible for screening, identified low socio-economic status, low CC screening awareness, low literacy levels, and being a migrant from other Indian Ocean islands as key factors in non-participation (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn July 2019, the French National Authority for Health recommended that women aged 30 and above be screened using HPV testing instead of cervical cytology, it also stated that \"Vaginal self-sampling represents an alternative to cervical sampling by a health professional for women who have not been screened or who have been insufficiently screened\".\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Background\u003c/h2\u003e \u003cp\u003eFieldwork was conducted on Reunion Island between January and November 2022 as part of the RESISTE programme. The RESISTE trial is a \"Combined incentive action, centred on primary care providers, to improve cervical cancer screening in socially disadvantaged unscreened women: evaluation of effectiveness and ethical and economic issues\" (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe RESISTE study involved a cluster-randomised trial targeting women living in low socioeconomic areas (number 4 and 5 IRISs, the smallest geographical subdivision in France) who are not up to date with their screening. On 5th January 2022, 2,564 self-sampling kits for high-risk oncogenic human papillomavirus (HPV-HR) were sent out by post to targeted women\u0026rsquo;s homes. Return and incentive arrangements were randomised under 4 trial groups: 1) simple postal return, 2) postal return with an economic incentive of \u0026euro;20 upon receipt of the collected sample, 3) return to a healthcare professional of the woman's choice (gynaecologist, general practitioner, midwife or pharmacist), 4) return to a healthcare professional of the woman\u0026rsquo;s choice with an economic incentive of \u0026euro;20.\u003c/p\u003e \u003cp\u003eThe kit contained a detailed presentation of the study, illustrated instructions, a self-sampling tube, a zip-lock bag and a pre-stamped return envelope. Prior to the trial, an introductory letter had been sent out to targeted women and to all health professionals in the department who might come into contact with them as part of the study (gynaecologists, general practitioners, midwifes and pharmacists). Women who returned a sample received their HPV results by text message and by post within 3 months. These documents are presented in additional files [see Additional files 1, 2, 3, 4, 5].\u003c/p\u003e \u003cp\u003eThe current study was conducted post trial, amongst women who received the kit \u0026ndash; both those who returned the kit and those who did not. A preliminary qualitative study had been conducted prior to the RESISTE trial to assess the acceptability of the scheme to both women and health professionals (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).The \u003cspan refid=\"Sec24\" class=\"InternalRef\"\u003ediscussion\u003c/span\u003e section of this article compares the results of pre- and post-trial research data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Aims\u003c/h2\u003e \u003cp\u003eThe objective of this anthropological study was to assess the feasibility and effectiveness of a cervical cancer screening strategy involving home delivery of HPV vaginal self-sampling kits. The study explores women's motivation, and capacity to conduct home-based vaginal self-sampling (HBVSS) while analysing external influences and opportunities. This article also weighs the respective impact of the economic incentive and of returning the kit to a health professional.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eRationale and methodology\u003c/h2\u003e \u003cp\u003eSocial anthropology helps capture the positive and negative experiences and feelings of individuals and communities, without \"false familiarity\" or \"false evidence\" (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The aim of this study was not to deliver statistical data, but rather to provide a comprehensive understanding of human logic, of \u003cem\u003ehow\u003c/em\u003e and \u003cem\u003ewhy\u003c/em\u003e people act and react in one way rather than another.\u003c/p\u003e \u003cp\u003eSemi-structured interviews based on pre-established open-ended anchor questions were used to create a framework for active listening (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) The interviewee is encouraged to steer the conversation towards what he or she considers most essential, thus moving away from the interviewer\u0026rsquo;s rationale and closer to the interviewee\u0026rsquo;s. This openness towards the interviewee helps build a relationship of trust and confidentiality that is particularly well-suited to exploring intimate and sensitive topics such as cervical cancer self-screening.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStudy Topics\u003c/h2\u003e \u003cp\u003eThe interview guide explored women\u0026rsquo;s capacity (knowledge-levels and practices), motivation (perceptions and feelings) and opportunities (external factors) in chronological order from when they received the kit (their understanding of the kit\u0026rsquo;s use and usefulness, their appreciation for the screening format, their decision to self-test or not), to when they conducted the self-collection (ease of use, feelings, concerns and practices) and then returned the kit (including their interactions with health professionals), and later received their results (understanding of the results, practices of HPV-positive women, awareness of follow-up modalities for both HPV-positive and negative results.\u003c/p\u003e \u003cp\u003eWe identified specific research questions: did home-based vaginal self-sampling help overcome barriers to conventional screening ? What new barriers have emerged? How does women's experience of self-testing compare with their experience of clinician-assisted testing? How do women respond to receiving a kit compared to receiving the usual invitation letter? How does the financial incentive affect uptake? How do the different return modalities (postal or health professional) impact uptake? How did the fact that it was a trial affect the results? What questions do women have? How can the system be improved?\u003c/p\u003e \u003cp\u003eHealth professionals were interviewed about their knowledge, perceptions and experience of the RESISTE programme.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eSampling\u003c/h2\u003e \u003cp\u003eThe study targeted women on Reunion Island who had received an HPV-HR vaginal self-sampling kit under the RESISTE trial. Sampling aimed to select a wide range of women in terms firstly of individual characteristics based on their age group (3 age groups were defined \u0026minus;\u0026thinsp;30 to 39, 40 to 54 and over 55) and place of residence. For sampling purposes, the island was divided into 6 geographical areas: North, West, South, East, \"les hauts\" (literally \"high places\", a term used locally to refer to the centre of the island, which is at a higher altitude) and the \"cirques\" (literally natural \u0026ldquo;amphitheatres\u0026rdquo;, created by the collapse of an extinct volcano) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Access to health care is more problematic in the latter two geographical areas due to their remoteness.\u003c/p\u003e \u003cp\u003eSecondly, women were selected according to their interaction with the RESISTE trial : their assigned trial group (4 groups), whether they returned the kit or not (responders and non-responders), how long they took to return the kit ('normal' return within 2 months or 'late' return between 2 and 6 months), and, finally, their HPV test results (negative or positive).\u003c/p\u003e \u003cp\u003eHealth professional (HP) sampling targeted doctors and pharmacists who received women for the return of their samples.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eInterviews\u003c/h2\u003e \u003cp\u003eWomen were contacted by telephone (using the details provided on the return form for responders and the Regional Cancer Screening Coordination Centre (RCSCC) details for non-responders). We contacted responders, with negative HPV results 1 month after sending out their results so as to allow for postal delivery from mainland France. This was the case whether they were \u0026lsquo;normal\u0026rsquo; or \u0026lsquo;late\u0026rsquo; responders. Women with positive results were contacted 3 months after their results were posted out to them, to allow them time to see a doctor and undergo additional screening before the interview. Women were considered non-responders if a sample was not received within 6 months after home delivery, estimated at 2 weeks after posting. The interviews with women were mostly (25/29) conducted in their homes and a few (4/29) by telephone. It was the opposite for HP, 5 interviews (1 medical doctor (MD) and 4 pharmacists) were conducted by telephone and 1 in person, with an MD.\u003c/p\u003e \u003cp\u003e Anthropologists conducted the semi-structured interviews based on target group specific interview guidelines (women, doctors and pharmacists - see Additional files 6 and 7). Before the interviews, participants were informed of the purpose of the study and of its non-binding and confidential nature. They were provided with an information sheet and a consent form. Interviews were conducted in French or Reunionese Creole, according to participant preference. They were recorded with participant prior consent. To ensure confidentiality, no names were mentioned or recorded at any time during the interviews. Each interview was then transcribed into French.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eCross-sectional thematic analysis was used to contrast participants\u0026rsquo; responses and to identify general trends and divergences (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The results are presented according Michie et al\u0026rsquo;s Behaviour Change Wheel (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The desired change was the uptake of CC screening (either through home-based self-sampling or by visiting a practitioner). This conceptual model highlights the drivers and barriers to change by grouping them into three dimensions: motivation (and demotivation), capabilities (as perceived by the individual), and 'opportunities' or external influence (encouraging and discouraging the adoption of change).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e The RESISTE protocol was approved for the first time by the \"Sud-Ouest et Outre-Mer II\" ethics committee on 6 February 2020 and is currently been conducted in accordance with the fourth version of June 10th, 2022 - ID-RCB no.: 2020-A0002237 (File 2-20-006 id6698) 2\u0026deg;HPs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003ch4\u003eWomen\u0026nbsp;Participants\u003c/h4\u003e\n\u003cp\u003eA total of 29 women participated in the study. In terms of their individual characteristics, fewer women above 55 participated in the study as displayed in Table 1 below. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eTable 1\u003c/u\u003e\u003c/em\u003e: Women Participants\u0026rsquo; Age Group\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e30-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e40-54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e55+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eTOTAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWomen interviewees came from the 6 study areas (see Figure 1 below). More women in the south, and \u003cem\u003eles hauts\u003c/em\u003e participated than in other areas.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWomen\u0026rsquo;s socio-economic status varied considerably (see Figure 2). Most women (15) \u0026nbsp; were unemployed, all of whom had access to National Health Insurance. Of these women, 10 lived in social housing and 7 considered that they had difficulties \u0026ldquo;making ends meet\u0026rdquo; at the end of the month. The other 13 women were employed or retired and had private health insurance. We documented 4 women living with a disability and 3 others caring for a disabled family member.\u003c/p\u003e\n\u003cp\u003eIn terms of their family situation, 15 women lived with a partner and their children, 4 families had 3 or more children (defined in France as a \u0026ldquo;large family\u0026rdquo;). Most of the other women (13) were single mothers, 7 of which had 3 or more children. The last woman was single and did not have children.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn terms of their origin, most women were born in Reunion Island (25), 2 were born in France, 1 in Madagascar (of Mahoran parents), and the last was from Vietnam. Given the cultural diversity of Reunion Island, we asked the women to describe their cultural identity (see Figure 3 below). Most of them considered themselves to be of mixed cultural origin: either Creole - \u0026quot;Catholic\u003csup\u003e[1]\u0026nbsp;\u003c/sup\u003eCreole\u0026quot; (8) or \u0026quot;Malbar\u003csup\u003e[2]\u0026nbsp;\u003c/sup\u003eCreole \u0026quot; (6) - or \u0026quot;Reunionese\u0026quot; (9). The remaining 4 women identified themselves as Muslim (2), Tamil (1) and Hindu (1).\u003c/p\u003e\n\u003cp\u003eIn terms of how women interacted with the RESISTE study, we tried to have a representative sample in terms of trial groups, however only 2 women in group 1 participated. This was due mostly to difficulties in contacting non-respondents: several telephone numbers provided by the RCSCC were out of service (15/85), a higher proportion of women did not answer calls (47/85), while several of those who answered did not agree to partake in the study (25/38) often calming not to have received the kit (15/38). As displayed in Table 2, this impacted our ability to represent all arms of the randomised trial equally.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eTable 2\u003c/u\u003e\u003c/em\u003e: Women Participant\u0026rsquo;s Trial Group\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrial Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eTOTAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOf the 29 women participants, 16 were respondents, 8 with negative and 8 with positive HPV results, and 13 were non-respondents (see Table 3 below). Among the respondents, 10 women returned the sample within 2 months (normal return) and 6 within 2 to 6 months (late return). Of the 13 HBVSS non-respondents, 5 were screened under other Organised Cervical Cancer Screening (OCCS) services. Indeed, 1 had just been screened when she received the kit, 4 were screened by a health professional after receiving the kit, and 1 was waiting for an appointment to be screened. Another non-respondent was not eligible to screening due to a total hysterectomy. Thus, only 6 of the 13 non-respondents to home-based self-sampling can be considered as OCCS non-participants.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eTable 3\u003c/u\u003e\u003c/em\u003e: Study Participants\u0026rsquo; Interaction with HBVSS and with OCCS\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\" width=\"767\" height=\"314\"\u003e\u003c/p\u003e\n\u003cp\u003eIn terms of their screening history (see Figure 4 below), 12 study participants reported having been screened in the past 3 years. The majority of these women had a regular screening history, all those who did not consider themselves already up-to-date with their screening self-sampled (8) or screened with an HP (2) after receiving the kit. The other 16 women had not been screened in the previous 3 years. Almost two thirds of these women, including some who had not been screened in the past 5 or even 10 years, chose to self-sample (10/16).\u003c/p\u003e\n\u003ch4\u003eHealth Professional\u0026nbsp;Participants\u003c/h4\u003e\n\u003cp\u003eIn this study, we interviewed health professionals who collected women\u0026rsquo;s self-samples and whose contact details were provided to the coordinating centre and those who refused to receive self-samples and who\u0026rsquo;s contact details were provided by women who called the RESISTE team to enquire about the programme (see table 5 Below).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eTable 5\u003c/u\u003e\u003c/em\u003e : Health Professional Study Participants\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.23943661971831%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeographical Area / Profession\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDoctor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.725352112676056%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePharmacist\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.725352112676056%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOTAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.23943661971831%\"\u003e\n \u003cp\u003eNorth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.725352112676056%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.725352112676056%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.23943661971831%\"\u003e\n \u003cp\u003eEast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.725352112676056%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.725352112676056%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.23943661971831%\"\u003e\n \u003cp\u003eWest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.725352112676056%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.725352112676056%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.23943661971831%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOTAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.725352112676056%\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.725352112676056%\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch4\u003eVaginal Self-sampling\u0026nbsp;\u003c/h4\u003e\n\u003ch5\u003eMotivating Factors\u003c/h5\u003e\n\u003cp\u003eMost of the women interviewed (20/29) appreciated receiving the kit at home. Eighteen of the women surveyed felt that self-sampling at home was more convenient than visiting a doctor. They mentioned the time gain, not having to wait for a doctor\u0026rsquo;s appointment, and not having to deal with Covid related restrictions or screening program changes. Several women (7) contrasted their experience using self-sampling with conventional screening which they presented as a violation of their privacy, they emphasised their discomfort during gynaecological examination. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Personally, I would never have gone for screening if it hadn\u0026apos;t arrived, this home kit. I wouldn\u0026apos;t have made an appointment to do it because we don\u0026apos;t have time, and personally, it\u0026apos;s true that I\u0026apos;m not concerned about my state of health.\u0026quot; (Respondent, late returnee, age 44, tested 8 years earlier)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWomen described a sense of urgency and importance in receiving a kit at home. The kit\u0026rsquo;s provenance, from mainland France, and the Dijon University Hospital logo added to the perception that the kit was \u0026rdquo;more serious\u0026rdquo;. Women interpreted being included in the study as a sign that they were more at risk of cervical cancer than others. They mentioned their fear of cancer, feeling \u0026quot;late for screening\u0026quot;, being at an age where they considered themselves more vulnerable to CC \u0026nbsp;(identified as around 50) or having gynaecological symptoms. Some women felt that if they had received the kit, they must \u0026ldquo;already be contaminated\u0026rdquo;. These perceptions motived women to self-sample or be screened by a professional. A feeling that \u0026quot;things could get worse\u0026quot; over time also encouraged screening \u0026ndash; this feeling was shared both by those who returned the kit immediately and by those who initially put the kit aside and then undertook delayed self-sampling.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;When it comes from over there (mainland France), it\u0026apos;s not the same. If it comes from the other side, there\u0026apos;s something wrong! The other side: outside Reunion! Because it\u0026apos;s far away. How can they know? So, there\u0026apos;s something wrong. They want in-depth results to make sure! (Respondent, aged 51, screened 4 years earlier)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;It seems more serious because we\u0026apos;re talking about mainland France. There may be great specialists over there who will analyse everything, whereas here it\u0026apos;s routine (...) you get the impression that it\u0026apos;s more serious\u0026quot; (Respondent, late returnee, aged 56, screened 1 month earlier).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwo women who had recently had a cervical smear conducted returned the HBVSS sample, because they thought it was a more in-depth test aiming to investigate a suspicion of cancer found on the pap-smear test. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I said to myself, \u0026quot;Wasn\u0026apos;t the test any good? Why are they sending me back for another one? Do I have cancer? I had a smear test in the hospital in September 2021\u0026quot;. (Respondent, age 42, HPV positive, negative pap-smear test 6 months earlier)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHaving previously heard about self-sampling and being familiar with other self-screening programmes\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eincrease women\u0026rsquo;s motivation to return the kit. Some women said they \u0026ldquo;automatically\u0026rdquo; respond to all screening invitations (2).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Every time I receive something, I automatically go and do it. It\u0026apos;s automatic! I\u0026apos;m really into all that stuff. You must do it...\u0026quot;. (Respondent, late returnee, age 56, tested 1 month earlier)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral women (6) said the quality of the kit, and in particular of the\u0026nbsp;swab, \u0026quot;reassures\u0026quot; and \u0026quot;makes you want\u0026quot; to take part.\u0026nbsp;\u003c/p\u003e\n\u003ch5\u003eDoubts and Demotivating Factors\u003c/h5\u003e\n\u003cp\u003eThe main emotions experienced by women upon receiving the kit were fear and surprise. While fear of cancer was a motivating factor, fear of pain and fear of discovering a disease\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ewere demotivating factors for 3 women.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;You have to admit that you don\u0026apos;t want to be screened and found with a disease... it\u0026apos;s not a very pleasant thing to hear\u0026quot; (non-respondent, aged 30, screened \u0026quot;a long time ago\u0026quot;).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWomen\u0026apos;s surprise was related to their unfamiliarity with cervical cancer self-screening, which they described as \u0026ldquo;bizarre\u0026rdquo;. The usefulness of the RESISTE program was questioned by women with a regular screening history - they felt that it was the role of their general practitioner (GP) to invite them to be screened. Other women were concerned about self-sampling reliability as compared to HP-led screening and in relation to kit shelf life, sample contamination or deterioration (over time or heat related), and sample damage or loss in the post.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;It says it\u0026apos;s not the same method as a smear test, but is it still reliable? I don\u0026apos;t know, the [smear] it pinches, it goes right to the bottom.\u0026quot; (respondent, age 46, screened more than 3 years earlier).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnother concern voiced by women (8) related to how they had been selected and how their personal information (name and address) had been accessed, in particular given that the kit had been sent directly from mainland France rather than through the Reunion social security system. The unconventional circuit contributed to concerns regarding the program\u0026rsquo;s authenticity. A\u0026nbsp;significant number of women (12) considered the intervention to be a \u0026quot;scam\u0026rdquo;. The financial incentive contributed to this perception (6/12 women).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I was surprised. I didn\u0026apos;t expect to get this kit because I know that it\u0026apos;s usually the doctor who takes the samples. But I was reluctant to do it! (...) Isn\u0026apos;t it a scam? Did it exist and why did it come from mainland France? It was bizarre! How did they get my address? Why me? (...) I hesitated for at least two months, I think. (Respondent, late returnee, aged 38, tested 2 years earlier)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNonetheless,\u0026nbsp;women displayed mixed reactions to the financial incentive: several\u0026nbsp;appreciated receiving the incentive (9) but did not consider it to be a determining factor in their decision to self-test or not. They distinguished the incentive from a decision made \u0026quot;for the sake of their health\u0026quot;. Another woman, with a positive HPV result after self-testing, felt that the approach was inappropriate, likening it to a \u0026quot;consolation prize\u0026quot;. In addition, 2 women reported difficulties in using the vouchers they had received, as very few shops in Reunion Island would accept them.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[20\u0026euro;] is fine but I\u0026rsquo;m not interested either [in self-sampling], but if I do it, it\u0026apos;s for my health and if they give it to me, I\u0026apos;ll take it\u0026quot; (HBVSS non-respondent who made a gynaecological appointment after receiving the kit, age 43, screened 7 years earlier).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFinally, the fact that the kit was sent out as part of a trial had an impact on how the objective of the intervention was perceived.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eSome women thought that the aim was to produce \u0026ldquo;statistics\u0026rdquo; rather than to improve women\u0026rsquo;s health. This demotivated them to take part. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;It is a very personal thing! So, I prefer to keep it personal! Still, I can understand that studies might help and all that, but it didn\u0026apos;t motivate me! I said to myself \u0026apos;there are other women who will do it\u0026apos;\u0026quot; (woman screened by a professional after receiving the kit, aged 34, screened 1 year earlier).\u003c/em\u003e\u003c/p\u003e\n\u003ch5\u003eCapacity: knowledge and practice\u003c/h5\u003e\n\u003cp\u003eMost women understood that the kit was sent to them as part of the cervical cancer organised screening programme. They considered the self-test to be equivalent to a smear test (the same test, but done at home rather than by a professional). Some of those who had a positive self-test, and then had a smear test as part of their follow-up, understood the difference between the two. Several women (6) confused the test for other forms of self-testing. Three women understood the kit to be a colorectal cancer screening device. For 3 other women, the visual similarity of the kit to a covid test was confusing and not very reassuring given their unpleasant experiences with nasal swabs. Two women did not understand that the device provided was for self-testing. They thought they had to take the kit to a healthcare professional to have the sample taken, which they didn\u0026rsquo;t do.\u003c/p\u003e\n\u003cp\u003eSelf-sampling initially seemed complex to several women (13), many of whom (9/13) did not return the kit.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eWomen said\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ethe accompanying documents gave the impression that \u0026ldquo;it\u0026apos;s long, it\u0026apos;s complicated\u0026rdquo;. Some women (5) had to read the letter several times and said that the terminology was \u0026ldquo;too medical\u0026rdquo;. Others (3) had a low level of education or were not used to reading \u0026ldquo;official documents\u0026rdquo;, while 1 was visually impaired. Most of these women (11/13) decided to put the kit aside until they had more time to read the documents and/or collect the sample and only just over half (6/11) later returned the kit (late return).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;When I receive something like this, I put it on the table. But I wait before I go and do it! \u0026nbsp; I have the impression that it\u0026apos;s long, complicated and all that, so I don\u0026apos;t read it, I don\u0026apos;t look at it too much and then when I have really made up my mind, that\u0026apos;s when I go back to it. (...) We get a bit confused... and sometimes we don\u0026apos;t understand! an explanation, but it\u0026apos;s short! That way you understand! If they shorten it and just say what\u0026apos;s essential, that\u0026rsquo;s better\u0026quot; (respondent, late returnee, aged 56, tested 1 month earlier).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConversely, the illustrated instructions were considered clear (19) and user-friendly. However, even with the illustrated instructions, the procedure remained unclear to some non-respondents who were not used to self-sampling.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;If it wasn\u0026apos;t for the drawings, I would have needed to talk to someone, but with the drawings I didn\u0026apos;t need to\u0026quot; (respondent, 46 years old, screened more than 3 years earlier).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The booklet was well designed for someone who is used to doing it alone, but for someone who is not used to it, it doesn\u0026apos;t work\u0026quot; (non-respondent woman, aged 47, screened 12 years earlier).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMore than half of the responders expressed feeling at ease self-sampling\u0026nbsp;(7). However, vaginal self-sampling for the\u0026nbsp;first-time caused anxiety for both responders and non-responders. Twelve women felt the procedure was \u0026ldquo;too technical\u0026rdquo; and doubted their capacity to carryout self-sampling and produce a sample of sufficient quality. They were uncertain about how deep to insert le swab (the red mark did not seem to have been understood), where exactly they needed to touch (should they try to reach the cervix?), how long and in what position to use the swab. Some of the women (5) tried to imitate the position for undergoing a smear test and self-sampled in the morning believing this would provide a better sample.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I thought about how the doctor does it... the position and I tried to do it, reading the instructions carefully... I lay on my back, spread my legs apart, and I put the little stick in, turned and turned and looked to see if there was enough secretion on it to make sure it worked! That was in the morning. Because generally, when I go in with my GP, he tells me it\u0026apos;s better to do it in the morning and avoid washing too much down there to make sure that the white discharge is really there. That\u0026apos;s another way of finding out what\u0026apos;s wrong. That\u0026apos;s what I was thinking about.\u0026rdquo; (Respondent, late return, 38 years old, tested 2 years earlier)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBecause self-testing was considered the same as a smear test (a technical procedure), 7 women considered it unsuitable for home use. None of them returned the kit. Two of these women were afraid of hurting themselves.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother important factor in women\u0026rsquo;s capacity to self-sample was their availability. For some women (4) self-sampling and then returning the sample was an additional burden in an already busy schedule. Finding time at home was considered more difficult than attending a gynaecologist appointment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;When I received the test, and it has to be done, but after work... I put it off, I put it off... it\u0026apos;s not easy. The doctor told me to go to the gynaecologist to have the test done. But it\u0026apos;s really far away and I put it off each time because I\u0026apos;ve got other things to do too. I don\u0026apos;t have time to read too much (non-respondent who made an appointment after receiving the kit, 43 years old, screened 7 years earlier)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFinally, 2 women felt ashamed to carry out self-sampling, or even to consider doing so, one returned the kit, the other did not for this very reason.\u003c/p\u003e\n\u003ch5\u003eOpportunities: External Factors\u003c/h5\u003e\n\u003cp\u003eThe women interviewed appreciated the HBVSS postal return modalities, they considered the process \u0026ldquo;simple\u0026rdquo;.\u0026nbsp;They particularly appreciated the pre-stamped return envelopes (10) noting that it was \u0026ldquo;free\u0026rdquo; and \u0026ldquo;anonymous\u0026rdquo;. Ensuring that the sample arrived quickly and safely so it could be processed rapidly and their results sent out as fast as possible was a key concern. Several women (5) made sure to send off the sample quickly after self-collection. One did not return the kit because she was afraid she wouldn\u0026rsquo;t be able to post it off before sample deterioration. Some (5) preferred to return the sample to a HP where they felt it would be processed more rapidly.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn terms of how the kit impacted motivation, several women (5) found the kit more encouraging than a reminder letter. This was also the case amongst women (4) who had not been screened in the past 4 to 8 years. Receiving the kit at home and having it \u0026quot;at hand\u0026quot; made screening easier. Another 2 said they had booked an appointment for a cervical smear test, whereas they had not done so after receiving a reminder letter. Women also appreciated the information provided with the kit and some (2) felt better informed after receiving the kit than after receiving a reminder letter, which encouraged them to be screened.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;If I\u0026apos;d received a letter instead of the kit, it would have gone in the bin\u0026quot;. (Respondent, late returnee, aged 44, tested 8 years earlier)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I often receive letters at home but you had to go to a gynaecologist to have the sample taken, which I didn\u0026apos;t do, I always put the letter in the bin, so I thought it was a good thing to be able to do it myself (...) I think that after a week or two, I decided to take the sample. I said to myself, it\u0026apos;s there anyway, I\u0026apos;ll do it and then I\u0026apos;ll see. (Respondent, age 50, tested 8 years earlier)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConcerning how and when the results were sent out, participants appreciated receiving their results by text message and by post.\u0026nbsp;Some of them said they had not received the text message, while others could not remember receiving a letter in the post. Receiving results by SMS is appreciated for its speed - a delay of several months is mentioned for receiving letters from mainland France - and for its familiarity since the Covid crisis. The text of the SMS, \u0026quot;You performed a self-test on the (date)\u0026hellip;\u0026quot; reassures women that the information is genuine. Some women (3) preferred to receive the results by post which allows them to decide when to read the letter and provides more official documentation as well as a means of keeping record.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants generally felt (10) the 3-month wait to be too long. One women did not participate specifically for this reason. A 15 day to a month wait was considered \u0026ldquo;normal\u0026rdquo;. Women who tested positive remarked that, in hindsight, they would have liked to have known earlier. A prolonged wait was understood to imply that \u0026ldquo;everything\u0026rsquo;s fine\u0026rdquo;. Indeed, several women (5) mentioned that their gynaecologist only contacts them if \u0026ldquo;something\u0026rsquo;s wrong\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I received [the results] after two, two and a half months. It was a bit long, 15 days would be normal. We\u0026apos;d like to have the results as soon as possible. Waiting is stressful\u0026quot; (respondent, age 59, screened 3 years earlier).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn terms of social opportunities,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ewomen\u0026rsquo;s relatives (husbands, mothers, sisters, daughters) and close friends\u0026nbsp;with whom they discussed receiving the kit generally encouraged them to screen\u0026nbsp;(18). Before self-sampling only two said they had looked the process up on the internet, the information they found reassured them. A lack of prior information on self-screening was a strong barrier to screening. Some non-respondents (3) would have participated if they had heard about the programme\u0026nbsp;beforehand, \u0026nbsp;from their GP or on the radio or television.\u003c/p\u003e\n\u003cp\u003eAfter receiving the kit, 13 women contacted a health professional, either their GP (9) or the Dijon University Hospital who\u0026rsquo;s contact details were provided with the kit (4). None of \u0026nbsp;the GPs\u0026nbsp;contacted were aware of the intervention, and most discouraged them from self-testing. Women said the GPs they discussed the kit with had concerns regarding how the kits were sent and where they came from (4), the self-testing procedure and women\u0026apos;s ability to perform it (2). Most of the women who received such feedback did not self-sample. The professionals\u0026apos; lack of prior knowledge about the study, and, in some cases, about HPV self-sampling, made the programme \u0026quot;less credible\u0026quot; to the women. Some of them were offered a smear test instead and chose this option (3). A total of 4 women went for alternative screening after meeting a HP, 3 with a GP and one asked a home care nurse to collect the sample for her as she did not feel comfortable doing it herself. She had previously taken the kit to her GP but her doctor had refused to collect the sample, saying she was not familiar with this screening \u0026ldquo;model\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;She [the doctor] said she didn\u0026apos;t dare! Because now they\u0026apos;ve changed the model (...) Because they\u0026apos;ve done like the PCR test there, the rod. She said that she\u0026apos;d never seen it before. She said she\u0026apos;d never seen it come to your house, the doctor does it but it doesn\u0026apos;t come to your house. She said it\u0026apos;s not my problem because we don\u0026apos;t know where it comes from, we don\u0026apos;t know what it is. \u0026quot;If you can do it, do it, if you can\u0026apos;t, don\u0026apos;t do it. That\u0026apos;s what she said. (respondent who asked a home nurse to take the sample, age 57, not tested for \u0026quot;a long time\u0026quot;).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhen the kit had to be returned to a health professional, as was the case for to 2 of the 4 randomised trial groups, the pharmacists and GPs they contacted (8/9) were not aware of the study and refused to take the sample.\u0026nbsp;Some women visited several health professionals before returning the kit themselves by post (5), sometimes after calling the Dijon University Hospital for confirmation \u0026nbsp;(2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The fact that you arrive at the pharmacy and that the pharmacist discovers the scheme and says, \u0026apos;What the hell is this?\u0026apos; And that he\u0026apos;s taken the document to read it and all that, well that makes it a little less credible (respondent, late returnee, 44 years old, tested 8 years earlier).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe pharmacists interviewed had not received the RESISTE information letter, they explained that letters are often received at management level. One of the GPs received the information leaflet and kept it; she also encouraged those woman who consulted her to practice HBVSS. The influence of health professionals on their decision to self-screen was highlighted by the women. Several women (6) would have self-sampled if a health professional had reassured them about the device: 4 would if they had received the kit in person from\u0026nbsp;their GP, a pharmacist, a midwife or through a mobile outreach clinic and 2 if it had been possible to self-sample in front of the health professional. Following explanations at the end of interviews, 5 non-respondents would now like to self-sample\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I think the only person who would have reassured me would have been my GP (...) if my GP had known about it, if she had told me, it was normal, then yes, I would have had more confidence in it! I would have told my doctor to do it, or to do the smear test for me in fact. I don\u0026apos;t think I would have done it myself. (Non-respondent, age 31, screened 2 years earlier)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEleven women (respondents and non-respondents) would nonetheless prefer to be screened by a doctor.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I put it away somewhere, but I can\u0026apos;t remember where I put it. Maybe I\u0026apos;ll use it, but not for the moment. I\u0026apos;ll take it to the midwife for help.\u0026rdquo; (Non-respondent, 47 years old, screened 12 years earlier).\u003c/em\u003e\u003c/p\u003e\n\u003ch4\u003ePost-HBVSS monitoring\u003c/h4\u003e\n\u003ch5\u003eAbility to Understand Test Results\u003c/h5\u003e\n\u003cp\u003eMany women thought that a positive HPV result was a cancer diagnosis\u0026nbsp;(7). Receiving a positive result is a \u0026ldquo;shock\u0026rdquo;, even for women who don\u0026rsquo;t think a positive result necessarily means they have cancer. The need for medical follow-up and further testing was recognised, although the participants did not always understand why. Some women (3) thought their partner had been unfaithful when they tested positive. One woman, who had prior suspicions, split up with her partner after receiving a positive test result. Another woman wondered if her HPV result was positive because she had Covid when she self-sampled.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Even if they say no, I immediately think of cancer, it makes you think of difficult treatment, and of death. Injections, chemotherapy, and more (...) I\u0026rsquo;ll have to see a gynaecologist again, I want to find a woman, she\u0026apos;s going to take a sample and maybe do an operation. It has to be done. I\u0026apos;ve already made an appointment for Monday. I\u0026apos;ll ask her if it hurts. I don\u0026apos;t know exactly why I need to go and see a gynaecologist.\u0026rdquo; (Respondent, HPV positive, age 44, screened 5 years earlier)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRegarding the CC screening calendar, women knew that screening has to be done regularly, but there was a lot of confusion about the interval between screenings. More than half of the participants (16) said they could not remember what was in the letter and did not know exactly when they needed to be screened again. This was also the case for 2 HPV-positive women who still needed to have a follow-up test. Eleven women knew that smear tests are conducted every 2 to 3 years, 2 mentioned the 5-year interval for HPV testing, and 3 thought that screening should be done every year. There was also some confusion about the age at which screening should be done, it was considered more important after the age of 40 or 50, and sometimes less important after 60 when sexual activity was considered less regular.\u0026nbsp;\u003c/p\u003e\n\u003ch5\u003eMotivation to\u0026nbsp;Undergo Additional Screening\u003c/h5\u003e\n\u003cp\u003eReceiving a positive result is a \u0026quot;scary\u0026quot; experience for women. All 8 HPV positive respondents went to a doctor for a smear test.\u0026nbsp;Many (6/8) went straight to their GP or immediately made an \u0026ldquo;urgent\u0026rdquo; appointment with a gynaecologist. The other two women with positive HPV results consulted a month after receiving their initial results by text message, one because she wanted to be screened by a woman (and she had to wait before having an appointment with a woman), and the other because she was waiting for more official confirmation of the results by post and she did not trust the text message (see below).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I saw the gynaecologist quickly, I said it was an emergency and I got an appointment quickly\u0026quot; (respondent, HPV positive, age 42, screened 6 months earlier).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWomen with positive results discussed them with friends and family, who encouraged them to have further tests. Others looked for information on the internet, which generally reassured them.\u0026nbsp;\u003c/p\u003e\n\u003ch5\u003eOpportunities for Post-HBVSS Monitoring\u003c/h5\u003e\n\u003cp\u003eHalf\u0026nbsp;of the HPV positive respondents (4/8) would have preferred to receive their results by phone, so as to be able to be able to ask questions and receive more in-depth information right away. One HPV-positive woman deleted the text message as soon as she received it because she was shocked and did not want her adult children to find out \u0026quot;without really knowing what [she] had\u0026quot;. After receiving the letter, she informed her family and then consulted a doctor.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I received the results after two months, by text message, saying that my test was positive (...) For me it was a normal, run-of-the-mill test. I was really, really surprised when I got the text message (...) I found it really bizarre, being told that my test was positive and it was also a high-risk test. I didn\u0026apos;t think it was a good idea to receive this kind of result by text message. I was shocked. Receiving it by text message. Afterwards, of course, I deleted the text message, I didn\u0026apos;t want my children to see, not really knowing what was wrong with me. (...) A month later, I told my children about it because I\u0026apos;d received a letter at home saying that I should contact a health professional as soon as possible. It\u0026apos;s easier to read than to receive a text message. For me, a text message is more familiar\u0026quot;. (Respondent, HPV positive, aged 50, screened 8 years earlier)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn some cases, there was some confusion between the trial HPV results and organised screening pap-smear results.\u0026nbsp;One woman who received a positive HPV result from a self-sample immediately went to a gynaecologist for a smear test. She had not yet received the results of this smear test when her GP, to whom she had returned the self-sample, phoned to tell her about the positive results, without specifying that it was the HPV test. She thought it was the result of the smear test and became concerned. Another woman received the kit when she had just had a smear test, the results of which she had not yet received. She thought this meant her results must be positive and she needed further screening. She was very concerned and went straight to her GP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;When I received the kit, I was worried, because I already had the sample taken by my GP. And I thought there was a problem! That\u0026apos;s why I went back to see my GP, and he said \u0026quot;No, it\u0026apos;s not the same\u0026quot;. \u0026quot; (Non-respondent, 42 years old, screened 1 month earlier).\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAfter receiving the kit, women who had not been screened for several years screened either by self-sampling or with a practitioner. Women said they were more motivated to screen after receiving a kit than after receiving a simple reminder letter. Sending a kit to women's homes does more to encourage screening than a simple reminder. Another randomised trial has also shown increased participation amongst women who receive a HBVSS kit by post compared to those who receive a reminder letter or a HBVSS kit order form [19].\u003c/p\u003e \u003cp\u003eWe found that ease of use, convenience and privacy are key factors in self-sampling uptake. Previous studies also identified these factors as promoting HBVSS (\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Receiving results directly and quickly, identified by both respondents and non-respondents as an important factor in uptake, has also previously been identified as being highly valued by women (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFeeling that screening is relevant is another essential determinant of uptake. As in our pre-intervention study (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and in other prior research, we found that having symptoms (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), being over 50 years of age (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), or engaging in risky sexual behaviour, defined in Reunion Island as having multiple partners, (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) meant that women considered screening to be more relevant to their personal circumstances. Our results show that receiving the kit at home also creates a sense that one is being targeted and thus that screening is relevant. This is an important motivational factor that, to our knowledge, has not been previously documented in HBVSS research. However, it is important to note that the resulting sense of urgency may lead to undue anxiety (about having cancer) and duplicate screening. Furthermore, duplicate screening can lead to cross-communication of results. This was particularly the case when the women\u0026rsquo;s GP was not involved in the screening process from the beginning.\u003c/p\u003e \u003cp\u003eOne of the respondents in our study said she had self-sampled despite having had a negative past experience with screening. HBVSS could provide an alternative for women, enabling them to overcome past painful screening experiences, a factor identified in the pre-intervention study (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) as a strong barrier to OCCS. This contrasts with other studies which identify a previous painful gynaecological examination as inducing a fear of all screening objects, including the VSS stick (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Further investigation is needed to confirm the potential of HBVSS in overcoming past negative screening experiences.\u003c/p\u003e \u003cp\u003eRelatives generally have a facilitating effect, encouraging the practice of self-sampling at home. Other studies have highlighted the influence of pairs (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) and husbands (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), particularly in cultural contexts of close family proximity. In one study, women with friends or family members to discuss screening with were three times more likely to participate in screening than those who did not (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The suggestion of several women that the opinions of women who have carried out HBVSS should be shared (so-called \"community champions\") (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) seems justified. Conversely, misconception about the screening programme especially by close relatives could be a major barrier to home screening (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In our study, some husbands reinforced women's fears that the study was a scam or the procedure too technical to completed at home. This highlights the need for prior communication targeting women as well as the general public.\u003c/p\u003e \u003cp\u003eA lack of prior information about vaginal self-collection and the perceived complexity of the procedure (likened to a smear test) were the main demotivating factors for women in Reunion Island. Both non-respondents and respondents did not feel entirely apt to perform a self-sample, they were concerned that they would not be able to collect a sample of sufficient quality or that they would hurt themselves. A few felt ashamed. A lack of self-confidence in sample collection has been observed in other contexts (\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) and can lead to low uptake and poorer quality self-collection (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). As in our preintervention study, women emphasised their need for support (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLack of motivation to self-sample is also related to a lack of trust in the programme. Insufficient information about vaginal self-sampling may lead to misinterpretation of home-based screening programme and to non-participation. In Reunion Island, the barriers to optimal understanding were: a lack of HBVSS media coverage, low levels of health literacy, and a lack of availability coupled with the perceived complexity of the letter and kit (seen as requiring sufficient dedicated time to read and then complete). The pre-intervention study (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and other studies conducted in mainland France (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) also identify the lack of prior information as one of the reasons women do not consider HBVSS a viable option, highlighting the direct (on the woman) and indirect impact (on next of kin) on uptake (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe lack of information at the level of health professionals, particularly doctors and pharmacists, represents a missed opportunity and a major barrier to HBVSS as most of them discouraged uptake. In addition, the impact of returning the sample to a professional could not be fully explored as very few accepted to take the samples. Nonetheless, women emphasised their need and wish to be accompanied by a practitioner (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe financial incentive does not seem to reverse non-response; on the contrary, it sometimes contributes to doubts about the authenticity of the programme. To our knowledge, there has been no qualitative study of a programme that included a financial incentive for screening. The importance of free screening has been documented in women of low socioeconomic status (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The fact that this was a trial also influenced the results of this study by giving the impression that the programme was not solely about women's health.\u003c/p\u003e \u003cp\u003eFinally, a positive result provided a strong motivation for women to seek advice and have a smear test. The concerns expressed by health professionals during the pre-intervention study regarding the loss of HPV positive women after self-testing (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) do not appear to be founded.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eParticipants in our study appreciated receiving a VSS kit at home and would like to do so in the future. Some women even wanted the kit to be sent out at initial screening (not just with the a reminder letter). However, to improve awareness, ease of use and support from health professionals, the system needs to be adapted.\u003c/p\u003e \u003cp\u003eIncreased and diversified coverage (radio, television, social networks, events) before introducing the system would help improve awareness levels and contribute to motivation. Women suggested media coverage should include guidance from health professionals and share the experience of women who have self-sampled. A video could be made available in health centres and pharmacies, as well as on social security websites and social networks. Mass media communication should also be addressed to husbands, who can play a key role in encouraging participation. The planned takeover of the programme by the National Health Insurance Scheme in 2024 should provide reassurance about the provenance of kits. Financial incentives do not seem to be a key factor in motivating women to participate and can be dropped.\u003c/p\u003e \u003cp\u003eTo ensure that women feel confident to perform the HBVSS, the information provided with the kit should be brief, clear, accurate and written in non-medical language. Clear information about the reliability of the results, the preservation of the sample and the ease of the procedure is also important. A QR code to access a short explanatory video could be included to accompany the written instructions.\u003c/p\u003e \u003cp\u003eThe illustrated instructions were considered clear but the position for self-sampling and the depth of penetration needs to be better specified \u0026ndash; that there\u0026rsquo;s no need to imitate the position used for a pap-smear or to touch the cervix. All messages on cervical cancer should include all available screening options and provide the screening schedule.\u003c/p\u003e \u003cp\u003eUser-friendliness would also be enhanced by a shorter time frame for receiving results (to be indicated in the information letter). This will help to reduce anxiety and maintain enthusiasm for the programme. Results should be emailed to women\u0026rsquo;s GP for speed and convenience and a link to access results sent directly to women via text message and email - so they can view them at their convenience. In the case of positive results, immediate feedback to the GP by email, followed by a phone call to the women, would provide optimal communication, reducing anxiety and ensuring optimal follow-up.\u003c/p\u003e \u003cp\u003eMany women prefer to receive and return the kit by post. Others appreciate the support of a health professional. Healthcare professionals can play an important role in the implementation of HBVSS. Offering the option of receiving the kit at home or of picking it up then returning it to a GP or pharmacy could help build confidence in the programme and allow women to access more personalised support. It would also provide greater opportunity to discuss alternative screening options with women choose not to self-test. Healthcare professionals requested more information and learning materials on HBVSS so they are better able to guide women. Particular attention should be paid to GPs and pharmacists, who play an important role in patient education on Reunion Island. Pharmacists are the only health professionals that women can see without an appointment.\u003c/p\u003e \u003cp\u003eWomen and professionals requested outreach activities in more geographically and socially isolated neighbourhoods. A mobile caravan conducted by midwives, health mediators and translators (Creole, Shimaor\u0026eacute;, Malagasy) would help reassure women about HBVSS and other cervical cancer screening alternatives.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"80%\" valign=\"top\"\u003e\n \u003cp\u003eCervical cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eCCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"80%\" valign=\"top\"\u003e\n \u003cp\u003eCervical cancer organised screening\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eCSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"80%\" valign=\"top\"\u003e\n \u003cp\u003eSupplementary health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eFCU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"80%\" valign=\"top\"\u003e\n \u003cp\u003eCervico-uterine smear\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eGP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"80%\" valign=\"top\"\u003e\n \u003cp\u003eGeneral practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eHBVSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"80%\" valign=\"top\"\u003e\n \u003cp\u003eHome-based vaginal self-sampling\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eHPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"80%\" valign=\"top\"\u003e\n \u003cp\u003eHuman papillomavirus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eHPV-HR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"80%\" valign=\"top\"\u003e\n \u003cp\u003eHigh-risk oncogenic human papillomavirus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eRCSCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"80%\" valign=\"top\"\u003e\n \u003cp\u003eRegional cancer screening coordination centre\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eVSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"80%\" valign=\"top\"\u003e\n \u003cp\u003eVaginal self-sampling\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe RESISTE protocol was the subject of an initial favourable opinion on 6 February 2020 by the \"Sud-Ouest et Outre-Mer II\" ethics committee. Version 04 dated 29 July 2023 is currently in force - ID-RCB no.: 2020-A0002237 (File 2-20-006 id6698) 2°HPs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate and consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore taking part in the interviews, participants were informed about the purpose of the study, \u0026nbsp;the publication of results and \u0026nbsp;the study’ non-binding and confidential nature. An information sheet and consent form were provided prior to each interview. To ensure confidentiality, women and health professionals names \u0026nbsp;were not mentioned or recorded at any time during the interviews. All interviews were recorded with the prior consent of the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analysed during the current study are not publicly available due to their confidential nature but are available from the corresponding author on reasonable request.\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 research was funded by the French Ministry of Solidarity and Health (PREPS-19-0008) and by the French Institute of Cancer (INCa-AAP DEPISTAGE 2019-Projet DEP19-003-BARDOU).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAC and DP carried out the interviews and subsequent analysis and writing. The English version was revised by AC. AD and MB supervised the study and were the main reviewers of the article. AH selected potential women to be contacted based on the selection criteria and reviewed the content of the article. E.O. prepared Figure 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the women and health professionals who gave so generously of their time, answering sometimes sensitive questions, sharing their experiences, views and suggestions to improve screening.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021 May;71(3):209\u0026ndash;49. \u003c/li\u003e\n\u003cli\u003eSingh GK, Jemal A. Socioeconomic and Racial/Ethnic Disparities in Cancer Mortality, Incidence, and Survival in the United States, 1950\u0026ndash;2014: Over Six Decades of Changing Patterns and Widening Inequalities. Journal of Environmental and Public Health. 2017 Mar 20;2017:e2819372. \u003c/li\u003e\n\u003cli\u003eINSEE. Panorama de la pauvret\u0026eacute; \u0026agrave; La R\u0026eacute;union. Une forte pauvret\u0026eacute; et des fragilit\u0026eacute;s territoriales li\u0026eacute;es \u0026agrave; l\u0026rsquo;insertion professionnelle et \u0026agrave; la situation familiale. Saint-Denis, La R\u0026eacute;union; 2023 Oct. (Insee Dossier La R\u0026eacute;union). Report No.: 7. \u003c/li\u003e\n\u003cli\u003eORS. Le cancer du col de l\u0026rsquo;ut\u0026eacute;rus \u0026agrave; La R\u0026eacute;union - Infographie. Lettre de l\u0026rsquo;ORS n\u0026deg;10. 2023; \u003c/li\u003e\n\u003cli\u003eSant\u0026eacute; publique France. Estimations r\u0026eacute;gionales et d\u0026eacute;partementales de l\u0026rsquo;incidence et de la mortalit\u0026eacute; par cancer en France, 2007-2016 [Internet]. Saint-Maurice; 2019 [cited 2023 Nov 23]. Available from: https://www.santepubliquefrance.fr/maladies-et-traumatismes/cancers/articles/estimations-regionales-et-departementales-de-l-incidence-et-de-la-mortalite-par-cancer-en-france-2007-2016\u003c/li\u003e\n\u003cli\u003eORS La R\u0026eacute;union. Les chiffres cl\u0026eacute; du cancer du col de l\u0026rsquo;ut\u0026eacute;rus \u0026agrave; La R\u0026eacute;union [Internet]. 2022 [cited 2024 Jul 15]. Available from: https://www.ors-reunion.fr/IMG/pdf/info_2022_06_10-l8_cancer_col_uterus_mb.pdf\u003c/li\u003e\n\u003cli\u003eInstitut National du Cancer. Le cancer du col de l\u0026rsquo;ut\u0026eacute;rus en France, \u0026eacute;tat des lieux 2010. InCA; 2010. \u003c/li\u003e\n\u003cli\u003eTouzani R, Bendiane MK, Bouhnik AD, Bruneau L, Mancini J, Chirpaz E, et al. Connaissances sur le d\u0026eacute;pistage et le cancer du col de l\u0026rsquo;ut\u0026eacute;rus \u0026agrave; la R\u0026eacute;union : application d\u0026rsquo;une classification ascendante hi\u0026eacute;rarchique. Revue d\u0026rsquo;\u0026Eacute;pid\u0026eacute;miologie et de Sant\u0026eacute; Publique. 2018 May 1;66:S187\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eHassine A, Antoni G, Fender M, Slama K, L\u0026eacute;andri FX, Fanon JL, et al. Combined incentive actions, focusing on primary care professionals, to improve cervical cancer screening in women living in socioeconomically disadvantaged geographical areas: a study protocol of a hybrid cluster randomised effectiveness and implementation trial- RESISTE. BMJ Open. 2022 Nov 1;12(11):e065952. \u003c/li\u003e\n\u003cli\u003ePourette D, Cripps A, Guerrien M, Despr\u0026egrave;s C, Opigez E, Bardou M, et al. Assessing the Acceptability of Home-Based HPV Self-Sampling: A Qualitative Study on Cervical Cancer Screening Conducted in Reunion Island Prior to the RESISTE Trial. Cancers. 2022;14(6):1380. \u003c/li\u003e\n\u003cli\u003eFassin D. D\u0026eacute;marche de la recherche. In: Fassin D, Jaffr\u0026eacute; Y, editors. Soci\u0026eacute;t\u0026eacute;s, d\u0026eacute;veloppement et sant\u0026eacute;. Paris: Les \u0026Eacute;ditions Ellipses; 1990. p. 68\u0026ndash;86. \u003c/li\u003e\n\u003cli\u003eFassin D. D\u0026eacute;crire. Entretien et observation. In: Fassin D, Jaffr\u0026eacute; Y, editors. Soci\u0026eacute;t\u0026eacute;s, d\u0026eacute;veloppement et sant\u0026eacute;. Paris: Les \u0026Eacute;ditions Ellipses; 1990. p. 87\u0026ndash;106. \u003c/li\u003e\n\u003cli\u003eOlivier de Sardan JP. La rigueur du qualitatif. Les contraintes empiriques de l\u0026rsquo;interpr\u0026eacute;tation socio-anthropologique. Louvain-la-Neuve: Academia Bruylant; 2008. 365 p. (Anthropologie prospective). \u003c/li\u003e\n\u003cli\u003eMichie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science. 2011 Apr 23;6(1):42. \u003c/li\u003e\n\u003cli\u003eGhasarian C. Patrimoine culturel et ethnicit\u0026eacute; \u0026agrave; la R\u0026eacute;union : dynamiques et dialogismes. Ethnologie fran\u0026ccedil;aise. 1999;29(3):365\u0026ndash;74. \u003c/li\u003e\n\u003cli\u003eAnderson C, Breithaupt L, Marais AD, Rastas C, Richman A, Barclay L, et al. Acceptability and ease of use of mailed HPV self-collection among infrequently screened women in North Carolina. Sex Transm Infect. 2018 Mar;94(2):131\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eDevotta K, Vahabi M, Prakash V, Lofters AK. Implementation of a Cervical Cancer Screening Intervention for Under- or Never-Screened Women in Ontario, Canada: Understanding the Acceptability of HPV Self-Sampling. Current Oncology. 2023 Jul;30(7):6786\u0026ndash;804. \u003c/li\u003e\n\u003cli\u003eNishimura H, Yeh PT, Oguntade H, Kennedy CE, Narasimhan M. HPV self-sampling for cervical cancer screening: a systematic review of values and preferences. BMJ Glob Health. 2021 May;6(5):e003743. \u003c/li\u003e\n\u003cli\u003eMegersa BS, Bussmann H, B\u0026auml;rnighausen T, Muche AA, Alemu K, Deckert A. Community cervical cancer screening: Barriers to successful home-based HPV self-sampling in Dabat district, North Gondar, Ethiopia. A qualitative study. PLOS ONE. 2020 Dec 11;15(12):e0243036. \u003c/li\u003e\n\u003cli\u003eKellen E, Benoy I, Vanden Broeck D, Martens P, Bogers JP, Haelens A, et al. A randomized, controlled trial of two strategies of offering the home-based HPV self-sampling test to non- participants in the Flemish cervical cancer screening program. Int J Cancer. 2018 Aug 15;143(4):861\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eAllen-Leigh B, Uribe-Z\u0026uacute;\u0026ntilde;iga P, Le\u0026oacute;n-Maldonado L, Brown BJ, L\u0026ouml;rincz A, Salmeron J, et al. Barriers to HPV self-sampling and cytology among low-income indigenous women in rural areas of a middle-income setting: a qualitative study. BMC Cancer. 2017 Nov 9;17(1):734. \u003c/li\u003e\n\u003cli\u003eBrandt T, Wubneh SB, Handebo S, Debalkie G, Ayanaw Y, Alemu K, et al. Genital self-sampling for HPV-based cervical cancer screening: a qualitative study of preferences and barriers in rural Ethiopia. BMC Public Health. 2019 Jul 31;19(1):1026. \u003c/li\u003e\n\u003cli\u003eOketch SY, Kwena Z, Choi Y, Adewumi K, Moghadassi M, Bukusi EA, et al. Perspectives of women participating in a cervical cancer screening campaign with community-based HPV self-sampling in rural western Kenya: a qualitative study. BMC Women\u0026rsquo;s Health. 2019 Jun 13;19(1):75. \u003c/li\u003e\n\u003cli\u003eSewali B, Okuyemi KS, Askhir A, Belinson J, Vogel RI, Joseph A, et al. Cervical cancer screening with clinic-based Pap test versus home HPV test among Somali immigrant women in Minnesota: a pilot randomized controlled trial. Cancer Med. 2015 Apr;4(4):620\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eLofters A, Prakash V, Devotta K, Vahabi M. The potential benefits of \u0026ldquo;community champions\u0026rdquo; in the healthcare system. Healthc Manage Forum. 2023 Nov 1;36(6):382\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eTeng FF, Mitchell SM, Sekikubo M, Biryabarema C, Byamugisha JK, Steinberg M, et al. Understanding the role of embarrassment in gynaecological screening: a qualitative study from the ASPIRE cervical cancer screening project in Uganda. BMJ Open. 2014 Apr 1;4(4):e004783. \u003c/li\u003e\n\u003cli\u003eCamara H, Zhang Y, Lafferty L, Vallely AJ, Guy R, Kelly-Hanku A. Self-collection for HPV-based cervical screening: a qualitative evidence meta-synthesis. BMC Public Health. 2021 Aug 4;21(1):1503. \u003c/li\u003e\n\u003cli\u003eLe Goff J, Le Duc-Banaszuk AS, Lefeuvre C, Pivert A, Ducancelle A, De Pauw H, et al. Acceptability to Healthcare Professionals of Home-Based HPV Self-Sampling for Cervical Screening: A French Qualitative Study Conducted in an Area with Low Access to Health Services. Cancers. 2023 Jan;15(21):5163. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e The term \"Catholic Creole\" refers to the practice of the Catholic religion by women who identify themselves as being of mixed cultural origin and predominantly African (especially Malagasy).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e The term \"Malbar Creole\" refers to the practice of Hinduism and/or mixed cultural origins, which are predominantly Indian and Hindu. The term \"Malbar\" refers to the inhabitants of the Malabar Coast in India who came to Reunion Island as indentured labourers. On Reunion Island, this term is used to refer to people considered to be of Indian descent (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cervical cancer, human papilloma virus, home-based HPV vaginal self-sampling, qualitative study, underprivileged women, Reunion","lastPublishedDoi":"10.21203/rs.3.rs-4843003/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4843003/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eIn 2022, RESISTE conducted a cluster-randomised trial to assess the feasibility and effectiveness of home delivery of HPV vaginal self-sampling kits. The trial targeted women living in deprived areas who were not up to date with their screening. This article presents the results of the post-intervention qualitative study conducted in Reunion Island. The study explores women's motivation and capacity to conduct home-based vaginal self-sampling and analyses the influence of providing a financial incentive (voucher upon return) and of returning the kit by post or to a health professional.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eA total of 35 semi-structured interviews were conducted with women respondents who returned the kit (16), non-respondents (13) and health professionals contacted by women during the trial (6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAfter receiving the kit, several women underwent screening either by self-sampling or by visiting a health professional. Ease of use, convenience and privacy were key factors in self-sampling uptake. Receiving the kit at home creates a sense of being targeted which reinforces the perceived relevance of screening and further encourages uptake. Relatives generally had a facilitating effect, encouraging self-sampling and follow-up. Amongst women respondents, a HPV positive result, was a strong motivator to undergo a follow-up smear test.\u003c/p\u003e\n\u003cp\u003eNevertheless, a lack of prior knowledge of vaginal self-sampling, led to a lack of trust in the programme amongst women sometimes likened by women to a scam. This and the perceived complexity of the procedure were the main demotivating factors. The financial incentive did not reverse this trend. On the contrary, it contributed to doubts regarding authenticity. In addition, the health professionals contacted rarely encouraged women to self-sample.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Women appreciated receiving an HPV vaginal self-sampling kit at home. Motivation and capacity could however be improved by increasing prior communication – to both women and health professionals - on self-sampling in general, and more specifically on reliability, sample preservation and ease of use. User-friendliness could also be improved by providing HPV tests results more quickly. Providing the option of collecting and returning the kit to a health professional of women’s choice helps ensure they receive adapted information and support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration:\u003c/strong\u003e 6 February 2020 - \"Sud-Ouest et Outre-Mer II\" ethics committee - Version 04 dated 29 July 2023 is currently in force - ID-RCB no.: 2020-A0002237 (File 2-20-006 id6698) 2°HPs.\u003c/p\u003e","manuscriptTitle":"“I would never have gone for screening if it hadn't arrived, this home kit”. Motivation, Capacity and Opportunities for Cervical Cancer Home-based Vaginal Self-sampling in Reunion Island: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-29 12:29:09","doi":"10.21203/rs.3.rs-4843003/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-26T06:49:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-03T13:42:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9131159289196819988881246823636627818","date":"2024-09-23T16:20:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"238639279934493489765202993866433420358","date":"2024-09-20T06:47:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-14T09:46:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212040322049225940348407969198481859719","date":"2024-08-07T19:50:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-07T19:48:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-08-05T09:33:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-02T11:32:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-02T11:29:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-08-01T14:36:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ac5e4e33-92fc-41f3-8d37-3e7c957e1634","owner":[],"postedDate":"August 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-07-13T16:00:02+00:00","versionOfRecord":{"articleIdentity":"rs-4843003","link":"https://doi.org/10.1186/s12889-026-28369-y","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-07-11 15:57:19","publishedOnDateReadable":"July 11th, 2026"},"versionCreatedAt":"2024-08-29 12:29:09","video":"","vorDoi":"10.1186/s12889-026-28369-y","vorDoiUrl":"https://doi.org/10.1186/s12889-026-28369-y","workflowStages":[]},"version":"v1","identity":"rs-4843003","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4843003","identity":"rs-4843003","version":["v1"]},"buildId":"cTy_lsJlmDsVRNrSptgXS","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}