Feasibility and acceptability of self-sampling for Human Papillomavirus (HPV) screening in a rural community in Western Kenya

Feasibility and acceptability of self-sampling for Human Papillomavirus (HPV) screening in a rural community in Western Kenya | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Feasibility and acceptability of self-sampling for Human Papillomavirus (HPV) screening in a rural community in Western Kenya Lydia Mwanzia, Erika Biederman, Claire Draucker Burke, Victoria L. Champion This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6732617/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 17 You are reading this latest preprint version Abstract Introduction Cervical cancer (CC) is the leading cause of female related cancer deaths and the second most common cancer affecting women in Africa. Furthermore, over 3000 mortalities are linked to low screening uptake and Kenya currently reports a CC screening rate of 16%. We sought to determine the feasibility and acceptability of “self-collection” for human papillomavirus (HPV testing) in Webuye Sub County, Western Kenya as a method to overcome low CC screening rates to decrease CC mortality. Methods A qualitative descriptive study design was used to collect data from 20 women who attended a rural village “chama” (meeting for health promotion) on importance of CC screening. Of the 20 women who participated in this study, 15 women completed the self-collection kit when offered at the chama , and 5 women declined self-collection. Data were collected using in-depth interviews. Investigators used a deductive approach, or a priori , analysis of the data by applying predetermined codes derived from the Health Belief Model. Results Overall, women who accepted screening indicated that knowledge about CC motivated them to take and use the Evalyn® Brush self-collection kit. Additionally, women who acknowledged the greatest risk for CC were those who had multiple sexual partners. Women who declined self-collection discussed fear of adverse physical effects, fear of receiving a positive diagnosis, stigma and loss of privacy as the main barriers to CC screening. Fear voiced by women included pain, bruising, and bleeding from the self-collection device, which in this case was an Evalyn® Brush. Perceived benefits included autonomy in conducting self-collection. Peer support at chama reinforced acceptance of self-collection. Conclusions Self-collection may promote autonomy and uptake of HPV screening in low resourced settings. Self-collection cervical cancer screening HPV Introduction Cervical cancer (CC) is a significant public health challenge with 90 percent of CC deaths in low-and middle-income countries. 1 In Kenya, a low-income country, CC is a leading cause of female cancer-related deaths with over 5000 women diagnosed and 3000 CC mortalities occurring annually. 1 Higher income countries have seen a great reduction in CC incidence and mortality over the past 50–70 years, largely due to national uptake of CC screening following either national CC programs or guidelines emphasizing the importance of CC screening, including Papanicolaou (Pap) smears and later human papillomavirus (HPV) testing. 2 – 4 Building on the success of CC screening in reducing CC rates, the World Health Organization (WHO) set forth guidelines recommending that 70% of women in Kenya be screened at least two times between the ages of 25 and 49. 5 However, fewer than one in five eligible Kenyan women (approximately 16–18%) have ever been screened for CC, 6 which is well below WHO guidelines and suggests the urgency of methods to increase CC screening uptake in this country. The primary modality for CC screening In Africa is visual inspection of the cervix using acetic acid (VIA) and less common modalities is Papanicolaou (Pap) smears. 7 These conventional screening methods had limited success in the Kenyan context. 7 VIA, the predominant CC screening method in most Kenyan health facilities, is easier to administer compared to a Pap smear but has moderate sensitivity with accuracy dependent on provider training and experience. 8 , 9 Few facilities in Kenya offer cytology or HPV tests due to resource constraints and infrastructure challenges such as lack of equipment, laboratories, and trained personnel. 10 The performance limitations of VIA (e.g. variability in visual interpretation and missed precancerous lesions) and the scarcity of cytology services have contributed to inconsistent screening quality and persistently low CC screening coverage. 9 , 11 These barriers demonstrate the need for new approaches to reach unscreened women to decrease CC incidence and mortality. Human papillomavirus (HPV) testing has emerged as a more sensitive and effective primary screening tool for CC with many higher income countries using it as part of screening guidelines and programs. 12 , 13 Both the WHO and Kenya’s national guidelines now recommend HPV testing as the preferred screening method for eligible women; 5 , 14 however, HPV testing is completed by a small number of women in Kenya. 15 Both VIA and Pap smear screening necessitate a pelvic exam performed by providers, and this type of screening requires a private, physical space such as a clinic or mobile unit for the screening to occur. The advent of HPV testing opens the possibility for an innovative strategy, “self-collection,” where women collect their own vaginal sample with a swab or brush device, which is then tested for HPV. Self-collection has been found to be effective at detecting HPV infection with more than 95% of self-collection samples demonstrating DNA results and a high concordance between samples collected by women and clinicians. 16 Self-collection allows a community-based, self-care approach that can overcome many barriers of facility-based screening. Women can collect a sample in privacy, at a convenient time and place, avoiding the discomfort or embarrassment of a pelvic exam and reducing dependence on skilled providers. 17 , 18 Mounting evidence suggests that self-collection is highly acceptable to women in sub-Saharan Africa, including Kenya. 15 , 19 Previous studies reported positive experiences with self-collection in Kenyan women. 19 , 20 In one study, 80% of Kenyan urban women reported being comfortable using a self-collection device and expressed a preference for at-home testing over clinic-based testing. 19 Furthermore, a recent systematic review and meta-analysis found that self-collection increases screening uptake particularly in low-income countries. 21 These findings suggest that most women would be willing to try self-collection if offered a kit. Factors that influenced screening uptake included knowledge, perception of risk, improved health outcomes and partner encouragement. 20 , 21 Additionally, community health Promotor (CHP) led CC screening interventions have demonstrated effectiveness in many high income countrie 22 , 23 and feasibility and acceptability in low- and middle-income countries. 24 Fewer studies have examined community based approaches to self-collection, which involves a different process and steps than traditional, provider-based CC screening. Some studies in higher income countries have suggested a community-based approach to self-collection is acceptable and feasible, 25 , 26 but fewer studies have examined community-based approaches in lower income countries. One study in Kenya used a door-to-door strategy for delivery of self-collection kits in a community suggesting that community-based approaches to kit distribution and return are feasible in Kenya. 20 While self-collection seems feasible and acceptable in Kenya, important gaps in knowledge remain regarding self-collection as a screening method in Kenya. One challenge is ensuring that women return their self-collection kits after performing the test because many women do not return a kit, but the reasons that kits aren’t returned are unknown because most previous studies have not included responses from women who do not return kits. 20 , 27 Women’s beliefs, perceptions, and understanding of the self-collection process may influence whether they complete the screening. 27 For example, women may lack confidence in their ability to collect an adequate sample, have misconceptions about the accuracy of self-collected vs. provider collected samples, have concerns about contamination, be afraid of the test results, or have other cultural beliefs that hinder kit return. 21 , 27 However, these potential barriers have not been well studied among Kenyan rural women. Additionally, while door-to-door kit distribution was employed in one study, 20 a CHP intervention was not used, which has been an effective way to distribute and increase kit return in other studies. 28 , 29 To address these gaps, the present study explores Kenyan women’s beliefs and attitudes about returning self-collection kits. Ultimately, this research will guide the development of an intervention with a CHP that enables more women to successfully use and return self-collection kits, thereby strengthening CC prevention efforts in Kenya. Materials and Methods A qualitative descriptive study design was used to collect data from women in Webuye Sub County Hospital that serves the Eastern communities of Bungoma County, Kenya. The study was approved by the Institutional Research and Ethics committee of Moi University and Moi Teaching and Referral Hospital. A total of 20 women participated in the study. Purposive sampling technique was used to select 20 women among the 80 women attending two rural village “chama” (meetings) on two separate occasions. The chamas were part of a larger study that sought to increase CC screening by offering self-collection kits and at the same time providing HPV vaccination for any women or children who were age eligible. 30 At the chama , each woman received a promotional flier that described the self-collection kit. Flyers were provided in either an English or Kiswahili version to increase understanding of CC screening using a self-collection kit. During the chama , women were educated about HPV infection, how it is acquired, and the risk factors and the causes of CC related to persistent HPV infection. The women were introduced to the self-collection brush, how it is used and how to repackage it for transport to the laboratory. Women were allowed to ask questions and seek clarification before being issued the Evalyn ® Brush self-collection kit. The health messages were provided by the AMPATH project coordinator and the nurses at the CC screening clinic at the Webuye hospital. 30 During the meeting, there were provisions for privacy where women who accepted use of the self-collection brush were allowed to collect the sample as instructed. After sample collection, the Evelyn brush was inserted into a pre labelled package and sent to a laboratory in Nairobi for analyses. Women were instructed to collect their sample results in two weeks at the CC screening clinic at the Webuye hospital. Women who tested positive for HPV received a Pap smear. If both the HPV test and Pap smear were considered positive, the woman was scheduled for a colposcopy. If colposcopy revealed a lesion, women were scheduled for thermo-ablation or cryotherapy treatment at the clinic. A total of 20 women including those who both accepted (n = 15) or declined (n = 5) to use the self-sampling kit at the chama were selected for this study to provide the perspectives of women about the self-collection process. Women who participated in qualitative interviews were contacted from a list of women who attended the initial chamas and asked to travel to the clinic. The inclusion criteria for this study included being female and 18 or older and consenting to an interview following the chama . Interviews were completed at the hospital gynaecological clinic. The participants were interviewed using an in-depth interview guide developed for each group (those who accepted and those who declined self-collection). The in-depth interview guides comprised open ended questions developed for exploring theoretical beliefs related to acceptance of the HPV self-sampling it. The questions in the interview guide included the participants’ description of the reasons for attending the CC awareness chama ; a description of whether the participant had knowledge about CC before the chama ; their personal thoughts and feelings about self-collection for women of reproductive age; their awareness of anyone in their family who had been diagnosed with CC; their description of the risk factors for CC and their reasons for accepting or declining to take the self-collection kit. The interview also included questions about acceptability and usability of the informational flyer which was provided in the initial chama . An experienced research assistant was trained as moderator and served to lead the interview guide developed by the investigators. A second research assistant recorded the interview. Each interview lasted 15–30 minutes. Women were given a transportation reimbursement for participating in the study. The in-depth interviews were recorded using a hand-held Sony recorder, transcribed and proof-read by bilingual researchers in preparation for qualitative data analysis. A rigorous deductive analysis guided by the Health Belief Model (HBM) supported analyses. Concepts in the HBM (barriers, benefits, knowledge, risk, self-efficacy) were used to categorize responses during the interviews. Trustworthiness and authenticity of study findings were ensured through peer checking of the transcripts by the authors of whom one is an expert in qualitative research design, and another is an expert at the Health Belief Model as used in cancer screening. Results Data were analysed by a team including the principal investigator, four nurse researchers, two oncology behavioural experts with experience in self-collection research, and an expert in qualitative research. Each team member read the transcripts in their entirety to obtain a broad understanding of the participants’ experiences. Directed content analysis as described by Hsieh and Shannon was used to summarize the participants’ responses to the interview questions. 31 All participant remarks relevant to the research aims were extracted and coded with a brief phrase that summarized the remark and captured its meaning. The codes were proposed by one team member and verified by another. A case-by-topic display table as described by Miles, Huberman, & Saldaña 32 was prepared with participant identification numbers (cases) presented on the vertical axis and key constructs from the Health Belief Model (barriers, benefits, knowledge, risk, self-efficacy) presented on the horizontal axis. The codes were placed in the appropriate cells in the table (e.g., Participant 002 codes on barriers, benefits, knowledge, risk and self-efficacy on CC). The codes in each column were then categorized through team discussions by clustering together codes with similar meanings. The categories were verified with a re-examination of transcript data. Based on the categories, narrative descriptions of participant remarks pertaining to each topic were prepared by one team member and verified and refined by another. These descriptions are presented below with verbatim exemplars of participant remarks. All the participants interviewed were Kenyans residing in Bungoma County. Women ranged in age from 25–49 with a mean age of 42. Women had an average of 5 children, although the range was 1–9 children/woman. A total of 52% of women reported a secondary level of education, 20% primary and 10% post high school level of education. Most women were married and living with their partner (82%) and 18% were either widowed or separated. Twelve out of 20 (60%) participants had sought previous CC screening while 8(40%) had never been screened for CC. On health seeking behaviour, 5(20%) of the participants usually presented for wellness check-ups while 15(80%) of the participants usually sought healthcare only when ill. Most of the women (85%) had heard about CC screening prior to attending the chama . Lydia can we put these results in a table? Thanks!! Data analysis The five themes provided the participants included: (1) knowledge about CC, (2) perceived susceptibility to cervical CC, (3) benefits of self-collection, (4) barriers to self-collection, and (5) self-efficacy related to self-collection. Knowledge About Cervical Cancer Nineteen (19) participants made remarks reflecting knowledge they had acquired about CC provided by the CHP leading the chama and by the brochure included with the self-collection kit. One participant said, “ the community health promotor (CHP) usually teaches us about CC screening when we come to the clinic and the CHP also visited us in the support group [for women living with HIV]… She taught us that CC is a bug caused by a virus called human papilloma virus .” Some participants shared general facts they had learned about CC such “ 90% is not hereditary ,”. Women understood, CC was caused by cancerous cells multiplying. They also understood that screening could help early detection. A few participants listed the signs and symptoms of CC they acquired, such as abdominal pain, severe menstrual bleeding, pain during sex, abnormal urination or stools, stopping and starting menopause, and having a “ bad smell .” Most participants said they had been taught about the risk factors for CC and cited the risk factors of having multiple sexual partners, not using condoms, and having multiple births. One participant said, “ If you are a woman and have many men, the one who has the virus leaves it inside of you and you will get infected .” Another said, “ I realized that sex is not something that you can have with this one and that one.” Participants also indicated they had learned CC could be caused by eating foods high in fat, smoking, and using scented or perfumed soaps. Some said they had been taught there was a link between HIV and CC, especially if one had a high viral load. Perceived Susceptibility to Cervical Cancer Sixteen participants (80%) made remarks indicating they believed that they were at risk for CC. Some suggested they were susceptible because all women could get CC, and women may not be aware the disease is present. One participant said, “ You could be among those who have it and maybe you don’t know your status .” Others felt susceptible because they were aware of people who had cancer, many of whom died from the disease. Some participants had lost close relatives including an aunt, mother-in-law, sister, friend, and mother to CC, and others knew of women in the community who had the disease or had died from it. Some participants implied that personally knowing someone who had suffered or died from CC could prompt women to be screened or conversely cause them to avoid screening out of fear. Some participants felt they were susceptible to CC because they engaged in behaviours or had conditions, they knew to be risk factors for CC. As discussed previously, most participants had been taught risks factors for CC, and some acknowledged that they had one or more of those risk factors. One participant, for example, stated that she was susceptible to CC because she had HIV, her viral load was not suppressed, and she smoked. As a result, she regularly screened for CC. Several participants revealed they felt susceptible to CC because they had multiple sex partners. One woman who had not screened due to fear of a positive result said, “ Yes because I can’t lie or try to please you, I had more than three men. I can’t lie to you about that, so you never know [whether she has CC].” Benefits to Self-Collection Eighteen (18) participants made remarks about the benefits of self-collection. Many indicated generally that this method was better than traditional screening, could lead to early detection and treatment, would make women “ happy ,” and would “ attract ” women in the community. Even women who had not accepted the invitation to self-sample recognized its benefits. Most of the participants who described the benefits of self-collection focused on the advantages of women being able to screen for CC “ on their own .” They suggested that this made them feel “ happy,” “ comfortable ,” and less afraid. Being able to self-sample gave them more privacy. They indicated that women would not have to “ spread their legs ” and no one would have to see their “ private parts.” For some participants, self-collection provided a sense of confidence (self-efficacy) about their ability to have cervical screening. One participant said, “ After testing it felt good because it was something we could do ourselves .” Other women stated that self-collection was better than the traditional method of screening because it involved less pain and discomfort, and the kit was “ easy ” to use. Some of the participants who had used the Evalyn® Brush found it to be smooth and small. They indicated that it had not caused pain, discharge, or bruising. One participant said, “ Self-collection was better than sticking steel inside of you .” Others remarked that they did not find it hard to self-sample, the instructions on the flyer were easy to follow, and obtaining the sample did not take much time. One participant said, “ When I used it, I didn’t feel anything. It’s something very simple. I didn’t see it had any problem. It is okay .” Barriers to Self-Collection Eighteen (90%) of the participants made remarks that reflected barriers to CC screening. The participants’ perceptions of barriers often stemmed from experiences they had had, or things they had heard about, traditional screening rather than self-collection procedure itself. Many participants were worried about physical discomfort including pain, pricking, bruising, and bleeding. Those who spoke of pain typically referred to pain on insertion of the speculum in the traditional testing method and the pain that followed when they urinated or had sex. In some instances, the participants had heard frightening reports of traditional screening; one participant said women were often told that “ iron rods will be inserted in you and churn you up .” These fears of physical discomfort based on the “old method” translated to similar fears for self-collection. The fear of being pricked often occurred when participants were shown the Evalyn brush. One participant said, “ Firstly, I was afraid of the way it looks. I thought it would prick me .” Several participants who had self-sampled reported that these fears did not materialize as they found the brush to be “ soft .” A few women said a barrier to screening was fear of stigma and fear of a positive diagnosis. Participants indicated that stigma could be associated with testing, especially since CC was associated with HIV. Participants were concerned that others might think women were being tested for HIV rather than receiving a cancer screening. A few participants acknowledged that a barrier to self-collection was fear of a positive diagnosis. One woman, who had not accepted the invitation to self-collect, said, “ I was afraid of what my sister (with CC) went through, and I just wanted to live without finding out .” Another participant did not screen because she believed herself to be of high risk because she had HIV and her father died of cancer. Participants mentioned a variety of practical barriers to screening when using either the traditional or self-collection method, including lack of time (having too many things to do), not being able to travel to the hospital because travel was too costly, and having many other time demands such as work and childcare. One participant who had not yet screened but intended to do so said, “ I have had a lot of things to do, I had to go and take care of my father who was sick and then I also had classes at the church, but I am almost done and I will come for a screening .” Other barriers that participants mentioned included fear the speculum had been used on someone else (traditional screening), wanting to wait until more persons got tested (self-collection), being new (self-collection), and having the samples mixed up (self-collection). One participant who had not accepted the invitation to self-sample said, “ What made me refuse was that this is a new thing, and some things have side effects so I was afraid. I wanted other people to use them first so that I can be able to see if they have side effects or not so that I can use it later on. I was afraid that maybe it might have side effects .” Participants also mentioned traditional or cultural beliefs that were barriers to both methods, such as the belief that “ private parts [are] just private for husbands and not something else. ” Facilitators of Self-Collection Seventeen (17) participants made remarks about supports that would facilitate the uptake of self-collection by women. Although they saw many benefits to self-collection, they indicated that the process of self-collection would need to be expedited in a variety of ways. Some participants indicated that the CHP and their chama facilitated the self-collection. These community supports were critical in promoting the “ new method ” of sampling. As mentioned previously, the CHP had educated the women about CC and the need for CC screening. However, she also alerted the participants to the “ new method,” invited them to self-collect, showed them the Evalyn® Brush and taught them how to obtain a sample (“ insert the brush, rotate it five times, and remove and cover it ”). The participants’ experiences suggest that trust in a CHP may be needed to promote uptake of self-collection. One participant said, “I had accepted to come and get screened because of the importance that [CHP] had.” The instructions given to the women regarding self-collection served as a facilitator of the collection process. The participants said they liked the pictures, cover, colourfulness, and words on the instruction flyer they had been given. Some said it was easy to understand and the instructions were clear. However, they also provided some suggestions to make the instructions more acceptable. They recommend the instructions printed in local languages for women who cannot read English or Kiswahili. They also stressed that the size of the font and the pictures should be large enough for all women to be able to follow the instructions easily. Several participants suggested that bringing self-collection kits to the villages would facilitate the self-collection process. Participants stressed that women would be more likely to self-collect if they did not have to go long distances to hospitals or other facilities. The participants indicated that “ bringing it to the village ” would overcome the barriers of the cost of transportation, needing to take time away from care for children and other family members, and leaving work for long periods to get tested. Participants suggested that such outreach would also save women from waiting in long lines. The participants acknowledged that a private place in or near the women’s home would be needed to afford them privacy and they might benefit from a local support group. A few participants who advocated for self-collection at local villages also thought that healthcare professionals should be involved to ensure adequate hygiene and safe transport of the samples. A few participants suggested that women would facilitate other women in self-collection. They indicate women would “spread the message,” help “doctors look for people,” and educate other women. One participant said, “Women who use it [self-collection] will facilitate others to use it.” Discussion Qualitative interviews indicated that HPV self-collection could increase the percentage of women screened for CC in low-income countries by overcoming structural and personal barriers to screening. Prior to implementing a screening modality, understanding the drivers of a woman’s willingness to use the screening method and barriers that might prevent use are important. This study uniquely examined the beliefs of “non-returners,” or women who were provided the self-collection kit and did not return it, compared to those who did return the kit. Insights to the beliefs and attitudes from rural women in Kenya could help tailor intervention and implementation considerations for self-collection among women at high-risk for CC. Thus, we interviewed women who were part of a larger study which provided HPV self-collection kits to those who attended a chama . Interviews included both women who accepted and used the self-collection kit and those who refused, providing comprehensive insights into factors influencing self-collection acceptance. Women’s responses fit into one of five categories including knowledge about CC, perceived personal susceptibility to CC, benefits of self-collection, barriers to self-collection, and facilitators of self-efficacy. Most participants described receiving information about CC screening both during the initial chamas and through contact with CHP during clinic visits increasing both their knowledge and perceived susceptibility to CC. Literature indicates that interventions that promote CC screening, particularly if delivered by a CHP, have been an effective way to increase provider-based CC screening 22 , 24 and may also help increase acceptance of self-collection although further research is needed to confirm that association. 28 , 29 While many women had accurate knowledge about CC and screening, there were also misconceptions. For instance, some of the risk factors described by the women were incorrect such as CC being related to fat intake or soaps. Previous literature has shown that although women report receiving information from CHP, this information may not be fully understood. 33 Several of the women interviewed had negative attitudes toward CC screening from knowledge passed on by family and friends, which had more impact than the information acquired from health care providers or CHP. 17 Most women, including both returners and non-returners, described benefits and barriers to screening. Women who returned the self-collection kit described the benefits of screening as being able to screen without having a clinic appointment which supports the benefits of having privacy, being less fearful of the exam, and the device and collection procedure being comfortable, which is consistent with previous literature. Barriers to CC screening (both provider-collected and self-collected) reported by the women included fear, stigma, pain, and discomfort, which are like previously reported CC screening barriers among women in Kenya and other low-income countries. 20 , 34 Several women mentioned not screening because they were afraid of a cervical cancer diagnosis. These women often reported knowing someone or having a family member died from cervical cancer, which increased their fear. Fear of cervical cancer has been reported as an important barrier to screening previously in the literature. 34 This barrier mentioned by several women supports the necessity of emphasizing that screening will prevent dying from CC because it enables a provider to identify CC in an early stage when minimal treatment will cure this disease. Other potential barriers to self-collection were related to the device and fear of a new technology. A recent review indicated that women preferred Evalyn® Brush, Cervex-Brush. FLOQSwabs®, and Delphi Screener self-sampling devices compared to other self-collection devices; 35 however several women in this study reported they were afraid the Evalyn® Brush would prick them, which suggests that the device used for self-collection could be an important factor related to self-collection acceptance. One participant reported that a barrier to screening was that she was worried about side-effects and wanted other people to use the device first. This suggests that perhaps some women will not want to use a new technology like self-collection kits when its first implemented in clinics, but uptake could increase after women learn that other women have used the brush without harm. Fear of new medical technology, although uncommon in self-collection literature, mirrors hesitancies observed with other medical innovations, especially vaccines. 36 , 37 Facilitators to screening included learning about self-collection through a trusted CHP and chama , accessible distribution methods (such as home delivery), and clear instructional materials i.e., brochures. CHPs are effective at delivering interventions in other countries 23 and may even be more important in low resource countries like Kenya where knowledge of CC screening is low. Along with the CHP, the women reported that the self-collection kit should be delivered at the villages. Since transportation is a common barrier to CC screening, 38 it is not surprising the women preferred home delivery of the kit. Women reported that they liked the brochure but that other languages should be available. Due to low health literacy among many women in Kenya, investigators may want to explore other methods to deliver instructions such as videos which could be presented at chamas . Overall, women were positive about self-collection and acknowledged that they would recommend it to others. This finding is important because it suggests the importance of carefully rolling out a technology such as self-collection, so that positive experiences can be shared with friends and family. Previous literature has reported that social networks such as friends and family are important sources of health information for Kenyans. 39 Several limitations of this study should be noted. First, eligible participants were women who were invited to a chama , a meeting which include both self-collection and HPV vaccinations to eligible women and girls aged 10–14 years of age, potentially excluding those who were not vaccine eligible or had vaccine eligible children. Second, women had to provide the sample in a private space at the chama instead of the privacy of their own home so that some women may have not been comfortable collecting the sample at the chama secluded area. Third, all women were given an opportunity to complete self-collection regardless of whether they had previous CC screening so that women who had CC screening in the last year may have self-selected to forego self-collection but not because they did not find it acceptable. Future research should consider self-collection factors such as type of device (Evalyn® Brush vs. Dacron Swab®) and instructions that accompany the kit (brochure vs. video) as well as using a community health promotor-led intervention for kit delivery to their homes. Using a self-collection device that may be more familiar to women such as a Dacron Swab could be important to self-collection uptake so future research should examine if women prefer one device over the other. 35 Dacron Swabs are used to test for various diseases such as a nasal swab to test for Covid and during Pap smears as well as looking like a Q-tip so may not appear as foreign. Although women liked the self-collection brochure, some women described language difficulties. In addition, health literacy is low in Kenya so that video may be more appropriate for demonstrating self-collection and could be edited in different languages. Future research could compare a brochure vs. video on self-collection uptake where a community health promotor could possibly show a video during a chama . Also, it may beneficial for women who have completed a self-collection screening to describe their positive experience at the chama and future studies could examine if sharing positive experiences at a community meeting increases self-collection uptake. Conclusions In conclusion, this study explored the beliefs related to CC screening among returners and non-returners of self-collection. This study found that the women’s responses could fall into five categories including knowledge about CC and CC screening, perceived susceptibility to cervical cancer, benefits of self-collection, barriers to self-collection, and facilitators of self-efficacy. Most of the women used the self-collection kit suggesting that it is acceptable, and a CHP led chama is an important method of delivery of the kit. Future research should examine other implementation factors such as the device and kit instructions. Declarations Human Ethics Declaration The study was approved by the Institutional Research and Ethics committee of Moi University and Moi Teaching and Referral Hospital in Kenya ( IREC/2019/196–0003414 ) and the National IRB in Kenya ( NACOSTI/P/20/3327 ). Women exercised their right to self determination to participate in the study and their choice to accept or decline the sampling kit during the chama meeting was respected regardless of their health or social status. Consent to Participate All women participants who met the selection criteria (‘had attended a chama meeting and were offered a self-sampling method of HPV screening’) signed an informed consent form before being invited to respond to the interview questions at Webuye Sub County hospital (see appendix 1 & 2) conducted by the principal investigators or research assistant. The interviews included women who completed a self-sample for HPV screening and those who declined the sampling kit. Conflict of Interest The authors declare no conflict of interest. AI We declare that no artificial intelligence tools were used in any part of this manuscript development. Funding Project field work was funded by Indiana University School of Nursing Indianapolis, USA. Author Contribution VC - Sourced for project funds and collaborations for a sub study opportunity with colleagues in Medicine.LM & VC - Collected field interviews data in Kenya along a research assistant.LM - Conducted the descriptive analysis of demographic data and wrote the initial manuscript draft.CD- Team lead during the inductive qualitative data analysis process of developing codes, categories and themes by assigning roles for each author (VC, LM, EB, CD) during the analysis.EB- Final proof reading in readiness for submission Acknowledgement We acknowledge the AMPATH Research and Sponsored Projects Office RSPO team, Dr. Orango Omenge and his research team for allowing us to carry out a qualitative sub-study within his U54 main study and Mr. Kapten Muthoka who supported the logistical planning for the study field activities. Data Availability Data analysis sets for the descriptive qualitative interviews are available at Synapse project ID syn66696587 accessible from https://www.synapse.org/ References Sung H, Ferlay J, Siegel RL, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians . 2021;71(3):209-249. Landy R, Pesola F, Castañón A, Sasieni P. Impact of cervical screening on cervical cancer mortality: estimation using stage-specific results from a nested case–control study. British journal of cancer . 2016;115(9):1140-1146. Smith M, Canfell K. Impact of the Australian National Cervical Screening Program in women of different ages. Medical Journal of Australia . 2016;205(8):359-364. Yang DX, Soulos PR, Davis B, Gross CP, Yu JB. Impact of widespread cervical cancer screening: number of cancers prevented and changes in race-specific incidence. American journal of clinical oncology . 2018;41(3):289-294. World Health Organization. Global strategy to accelerate the elimination of cervical cancer as a public health problem . World Health Organization; 2020. Gebreegziabher ZA, Semagn BE, Kifelew Y, Abebaw WA, Tilahun WM. Cervical cancer screening and its associated factors among women of reproductive age in Kenya: further analysis of Kenyan demographic and health survey 2022. BMC Public Health . 2024;24(1):741. Mwenda V, Murage D, Kilonzo C, et al. Baseline assessment of cervical cancer screening and treatment capacity in 25 counties in Kenya, 2022. Frontiers in Oncology . 2024;14:1371529. Sauvaget C, Fayette J-M, Muwonge R, Wesley R, Sankaranarayanan R. Accuracy of visual inspection with acetic acid for cervical cancer screening. International Journal of Gynecology & Obstetrics . 2011;113(1):14-24. Sankaranarayanan R, Budukh AM, Rajkumar R. Effective screening programmes for cervical cancer in low-and middle-income developing countries. Bulletin of the World Health Organization . 2001;79(10):954-962. Rosser JI, Hamisi S, Njoroge B, Huchko MJ. Barriers to cervical cancer screening in rural Kenya: perspectives from a provider survey. Journal of community health . 2015;40:756-761. Smith SK, Nwosu O, Edwards A, et al. Performance of screening tools for cervical neoplasia among women in low-and middle-income countries: A systematic review and meta-analysis. PLOS Global Public Health . 2023;3(2):e0001598. Meijer CJ, Berkhof J, Castle PE, et al. Guidelines for human papillomavirus DNA test requirements for primary cervical cancer screening in women 30 years and older. International journal of cancer . 2009;124(3):516-520. Ronco G, Dillner J, Elfström KM, et al. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. The lancet . 2014;383(9916):524-532. Ministry of Health (Kenya). National Cancer Screening Guidelines 2018 . 2018. Accessed 5/19/2025. https://publications.health.go.ke/handle/123456789/3508 Huchko MJ, Ibrahim S, Blat C, et al. Cervical cancer screening through human papillomavirus testing in community health campaigns versus health facilities in rural western Kenya. International Journal of Gynecology & Obstetrics . 2018;141(1):63-69. Arbyn M, Verdoodt F, Snijders PJ, et al. Accuracy of human papillomavirus testing on self-collected versus clinician-collected samples: a meta-analysis. The lancet oncology . 2014;15(2):172-183. Nelson EJ, Maynard BR, Loux T, Fatla J, Gordon R, Arnold LD. The acceptability of self-sampled screening for HPV DNA: a systematic review and meta-analysis. Sexually transmitted infections . 2017;93(1):56-61. Arbyn M, Smith SB, Temin S, Sultana F, Castle P. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. Bmj . 2018;363 Rositch AF, Gatuguta A, Choi RY, et al. Knowledge and acceptability of pap smears, self-sampling and HPV vaccination among adult women in Kenya. PloS one . 2012;7(7):e40766. Oketch SY, Kwena Z, Choi Y, 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's health . 2019;19:1-10. Di Gennaro G, Licata F, Trovato A, Bianco A. Does self-sampling for human papilloma virus testing have the potential to increase cervical cancer screening? An updated meta-analysis of observational studies and randomized clinical trials. Frontiers in public health . 2022;10:1003461. Attipoe-Dorcoo S, Chattopadhyay SK, Verughese J, et al. Engaging community health workers to increase cancer screening: a community guide systematic economic review. American journal of preventive medicine . 2021;60(4):e189-e197. Okasako-Schmucker DL, Peng Y, Cobb J, et al. Community health workers to increase cancer screening: 3 Community Guide systematic reviews. American journal of preventive medicine . 2023;64(4):579-594. O’Donovan J, O’Donovan C, Nagraj S. The role of community health workers in cervical cancer screening in low-income and middle-income countries: a systematic scoping review of the literature. BMJ global health . 2019;4(3):e001452. Szarewski A, Cadman L, Mesher D, et al. HPV self-sampling as an alternative strategy in non-attenders for cervical screening–a randomised controlled trial. British journal of cancer . 2011;104(6):915-920. Barbee L, Kobetz E, Menard J, et al. Assessing the acceptability of self-sampling for HPV among Haitian immigrant women: CBPR in action. Cancer Causes & Control . 2010;21:421-431. Racey CS, Withrow DR, Gesink D. Self-collected HPV testing improves participation in cervical cancer screening: a systematic review and meta-analysis. Canadian Journal of Public Health . 2013;104:e159-e166. Arrossi S, Thouyaret L, Herrero R, et al. Effect of self-collection of HPV DNA offered by community health workers at home visits on uptake of screening for cervical cancer (the EMA study): a population-based cluster-randomised trial. The Lancet Global Health . 2015;3(2):e85-e94. Kobetz E, Seay J, Koru-Sengul T, et al. A randomized trial of mailed HPV self-sampling for cervical cancer screening among ethnic minority women in South Florida. Cancer Causes & Control . 2018;29:793-801. Orang’o O, Tonui P, Muthoka K, et al. A community-based approach to cervical cancer prevention in western Kenya: An AMPATH feasibility project. SAGE Open Medicine . 2022;10:20503121221102111. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qualitative health research . 2005;15(9):1277-1288. Miles MB, Huberman AM, Saldaña J. Qualitative data analysis: A methods sourcebook. 3rd. Thousand Oaks, CA: Sage; 2014. Gatumo M, Gacheri S, Sayed A-R, Scheibe A. Women’s knowledge and attitudes related to cervical cancer and cervical cancer screening in Isiolo and Tharaka Nithi counties, Kenya: a cross-sectional study. BMC cancer . 2018;18:1-9. Black E, Hyslop F, Richmond R. Barriers and facilitators to uptake of cervical cancer screening among women in Uganda: a systematic review. BMC women's health . 2019;19(1):1-12. Aimagambetova G, Atageldiyeva K, Marat A, et al. Comparison of diagnostic accuracy and acceptability of self-sampling devices for human Papillomavirus detection: a systematic review. Preventive Medicine Reports . 2024;38:102590. MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine . 2015;33(34):4161-4164. Lazarus JV, Ratzan SC, Palayew A, et al. A global survey of potential acceptance of a COVID-19 vaccine. Nature medicine . 2021;27(2):225-228. Lim JN, Ojo AA. Barriers to utilisation of cervical cancer screening in Sub Sahara Africa: a systematic review. European journal of cancer care . 2017;26(1):e12444. Bühler C, Kohler H-P. Talking about AIDS: The influence of communication networks on individual risk perceptions of HIV/AIDS infection and favored protective behaviors in South Nyanza District, Kenya. Demographic Research . 2003;1:397-438. Additional Declarations No competing interests reported. Supplementary Files APPENDIX12InterviewGuideforWomenParticipants.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 22 Dec, 2025 Reviews received at journal 21 Dec, 2025 Reviews received at journal 14 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers agreed at journal 01 Dec, 2025 Reviews received at journal 03 Sep, 2025 Reviewers agreed at journal 31 Aug, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviewers agreed at journal 25 Aug, 2025 Reviewers agreed at journal 25 Aug, 2025 Reviewers agreed at journal 26 Jun, 2025 Reviewers invited by journal 24 Jun, 2025 Editor invited by journal 28 May, 2025 Editor assigned by journal 28 May, 2025 Submission checks completed at journal 28 May, 2025 First submitted to journal 23 May, 2025 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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Champion","email":"","orcid":"","institution":"Indiana University – Purdue University Indianapolis","correspondingAuthor":false,"prefix":"","firstName":"Victoria","middleName":"L.","lastName":"Champion","suffix":""}],"badges":[],"createdAt":"2025-05-23 11:53:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6732617/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6732617/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85493099,"identity":"f5cbb270-32d9-456d-ab3c-a9143a7db75d","added_by":"auto","created_at":"2025-06-26 13:21:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":619854,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6732617/v1/a89e3658-d2b2-4138-bafa-e6aa8aabcb90.pdf"},{"id":85491507,"identity":"82cae85f-e5fd-4817-beed-5a5b4d011d12","added_by":"auto","created_at":"2025-06-26 13:05:48","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14394,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIX12InterviewGuideforWomenParticipants.docx","url":"https://assets-eu.researchsquare.com/files/rs-6732617/v1/bce7e1eef4ac32b47e010d06.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Feasibility and acceptability of self-sampling for Human Papillomavirus (HPV) screening in a rural community in Western Kenya","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCervical cancer (CC) is a significant public health challenge with 90 percent of CC deaths in low-and middle-income countries.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In Kenya, a low-income country, CC is a leading cause of female cancer-related deaths with over 5000 women diagnosed and 3000 CC mortalities occurring annually.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Higher income countries have seen a great reduction in CC incidence and mortality over the past 50\u0026ndash;70 years, largely due to national uptake of CC screening following either national CC programs or guidelines emphasizing the importance of CC screening, including Papanicolaou (Pap) smears and later human papillomavirus (HPV) testing.\u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Building on the success of CC screening in reducing CC rates, the World Health Organization (WHO) set forth guidelines recommending that 70% of women in Kenya be screened at least two times between the ages of 25 and 49.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e However, fewer than one in five eligible Kenyan women (approximately 16\u0026ndash;18%) have ever been screened for CC,\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e which is well below WHO guidelines and suggests the urgency of methods to increase CC screening uptake in this country.\u003c/p\u003e \u003cp\u003eThe primary modality for CC screening In Africa is visual inspection of the cervix using acetic acid (VIA) and less common modalities is Papanicolaou (Pap) smears.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e These conventional screening methods had limited success in the Kenyan context.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e VIA, the predominant CC screening method in most Kenyan health facilities, is easier to administer compared to a Pap smear but has moderate sensitivity with accuracy dependent on provider training and experience.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Few facilities in Kenya offer cytology or HPV tests due to resource constraints and infrastructure challenges such as lack of equipment, laboratories, and trained personnel.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e The performance limitations of VIA (e.g. variability in visual interpretation and missed precancerous lesions) and the scarcity of cytology services have contributed to inconsistent screening quality and persistently low CC screening coverage.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e These barriers demonstrate the need for new approaches to reach unscreened women to decrease CC incidence and mortality.\u003c/p\u003e \u003cp\u003eHuman papillomavirus (HPV) testing has emerged as a more sensitive and effective primary screening tool for CC with many higher income countries using it as part of screening guidelines and programs.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Both the WHO and Kenya\u0026rsquo;s national guidelines now recommend HPV testing as the preferred screening method for eligible women;\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e however, HPV testing is completed by a small number of women in Kenya.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Both VIA and Pap smear screening necessitate a pelvic exam performed by providers, and this type of screening requires a private, physical space such as a clinic or mobile unit for the screening to occur. The advent of HPV testing opens the possibility for an innovative strategy, \u0026ldquo;self-collection,\u0026rdquo; where women collect their own vaginal sample with a swab or brush device, which is then tested for HPV. Self-collection has been found to be effective at detecting HPV infection with more than 95% of self-collection samples demonstrating DNA results and a high concordance between samples collected by women and clinicians.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Self-collection allows a community-based, self-care approach that can overcome many barriers of facility-based screening. Women can collect a sample in privacy, at a convenient time and place, avoiding the discomfort or embarrassment of a pelvic exam and reducing dependence on skilled providers.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMounting evidence suggests that self-collection is highly acceptable to women in sub-Saharan Africa, including Kenya.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Previous studies reported positive experiences with self-collection in Kenyan women.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e In one study, 80% of Kenyan urban women reported being comfortable using a self-collection device and expressed a preference for at-home testing over clinic-based testing.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Furthermore, a recent systematic review and meta-analysis found that self-collection increases screening uptake particularly in low-income countries.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e These findings suggest that most women would be willing to try self-collection if offered a kit. Factors that influenced screening uptake included knowledge, perception of risk, improved health outcomes and partner encouragement.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Additionally, community health Promotor (CHP) led CC screening interventions have demonstrated effectiveness in many high income countrie\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e and feasibility and acceptability in low- and middle-income countries.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Fewer studies have examined community based approaches to self-collection, which involves a different process and steps than traditional, provider-based CC screening. Some studies in higher income countries have suggested a community-based approach to self-collection is acceptable and feasible,\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e but fewer studies have examined community-based approaches in lower income countries. One study in Kenya used a door-to-door strategy for delivery of self-collection kits in a community suggesting that community-based approaches to kit distribution and return are feasible in Kenya.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhile self-collection seems feasible and acceptable in Kenya, important gaps in knowledge remain regarding self-collection as a screening method in Kenya. One challenge is ensuring that women return their self-collection kits after performing the test because many women do not return a kit, but the reasons that kits aren\u0026rsquo;t returned are unknown because most previous studies have not included responses from women who do not return kits.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Women\u0026rsquo;s beliefs, perceptions, and understanding of the self-collection process may influence whether they complete the screening.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e For example, women may lack confidence in their ability to collect an adequate sample, have misconceptions about the accuracy of self-collected vs. provider collected samples, have concerns about contamination, be afraid of the test results, or have other cultural beliefs that hinder kit return.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e However, these potential barriers have not been well studied among Kenyan rural women. Additionally, while door-to-door kit distribution was employed in one study,\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e a CHP intervention was not used, which has been an effective way to distribute and increase kit return in other studies.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e To address these gaps, the present study explores Kenyan women\u0026rsquo;s beliefs and attitudes about returning self-collection kits. Ultimately, this research will guide the development of an intervention with a CHP that enables more women to successfully use and return self-collection kits, thereby strengthening CC prevention efforts in Kenya.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA qualitative descriptive study design was used to collect data from women in Webuye Sub County Hospital that serves the Eastern communities of Bungoma County, Kenya. The study was approved by the Institutional Research and Ethics committee of Moi University and Moi Teaching and Referral Hospital. A total of 20 women participated in the study. Purposive sampling technique was used to select 20 women among the 80 women attending two rural village \u003cem\u003e\u0026ldquo;chama\u0026rdquo;\u003c/em\u003e (meetings) on two separate occasions. The \u003cem\u003echamas\u003c/em\u003e were part of a larger study that sought to increase CC screening by offering self-collection kits and at the same time providing HPV vaccination for any women or children who were age eligible.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAt the \u003cem\u003echama\u003c/em\u003e, each woman received a promotional flier that described the self-collection kit. Flyers were provided in either an English or Kiswahili version to increase understanding of CC screening using a self-collection kit. During the \u003cem\u003echama\u003c/em\u003e, women were educated about HPV infection, how it is acquired, and the risk factors and the causes of CC related to persistent HPV infection. The women were introduced to the self-collection brush, how it is used and how to repackage it for transport to the laboratory. Women were allowed to ask questions and seek clarification before being issued the Evalyn\u003csup\u003e\u0026reg;\u003c/sup\u003e Brush self-collection kit. The health messages were provided by the AMPATH project coordinator and the nurses at the CC screening clinic at the Webuye hospital.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e During the meeting, there were provisions for privacy where women who accepted use of the self-collection brush were allowed to collect the sample as instructed. After sample collection, the Evelyn brush was inserted into a pre labelled package and sent to a laboratory in Nairobi for analyses.\u003c/p\u003e\u003cp\u003eWomen were instructed to collect their sample results in two weeks at the CC screening clinic at the Webuye hospital. Women who tested positive for HPV received a Pap smear. If both the HPV test and Pap smear were considered positive, the woman was scheduled for a colposcopy. If colposcopy revealed a lesion, women were scheduled for thermo-ablation or cryotherapy treatment at the clinic.\u003c/p\u003e\u003cp\u003eA total of 20 women including those who both accepted (n\u0026thinsp;=\u0026thinsp;15) or declined (n\u0026thinsp;=\u0026thinsp;5) to use the self-sampling kit at the \u003cem\u003echama\u003c/em\u003e were selected for this study to provide the perspectives of women about the self-collection process. Women who participated in qualitative interviews were contacted from a list of women who attended the initial \u003cem\u003echamas\u003c/em\u003e and asked to travel to the clinic. The inclusion criteria for this study included being female and 18 or older and consenting to an interview following the \u003cem\u003echama\u003c/em\u003e. Interviews were completed at the hospital gynaecological clinic. The participants were interviewed using an in-depth interview guide developed for each group (those who accepted and those who declined self-collection). The in-depth interview guides comprised open ended questions developed for exploring theoretical beliefs related to acceptance of the HPV self-sampling it.\u003c/p\u003e\u003cp\u003eThe questions in the interview guide included the participants\u0026rsquo; description of the reasons for attending the CC awareness \u003cem\u003echama\u003c/em\u003e; a description of whether the participant had knowledge about CC before the \u003cem\u003echama\u003c/em\u003e; their personal thoughts and feelings about self-collection for women of reproductive age; their awareness of anyone in their family who had been diagnosed with CC; their description of the risk factors for CC and their reasons for accepting or declining to take the self-collection kit. The interview also included questions about acceptability and usability of the informational flyer which was provided in the initial \u003cem\u003echama\u003c/em\u003e. An experienced research assistant was trained as moderator and served to lead the interview guide developed by the investigators. A second research assistant recorded the interview. Each interview lasted 15\u0026ndash;30 minutes. Women were given a transportation reimbursement for participating in the study.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe in-depth interviews were recorded using a hand-held Sony recorder, transcribed and proof-read by bilingual researchers in preparation for qualitative data analysis. A rigorous deductive analysis guided by the Health Belief Model (HBM) supported analyses. Concepts in the HBM (barriers, benefits, knowledge, risk, self-efficacy) were used to categorize responses during the interviews. Trustworthiness and authenticity of study findings were ensured through peer checking of the transcripts by the authors of whom one is an expert in qualitative research design, and another is an expert at the Health Belief Model as used in cancer screening.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eData were analysed by a team including the principal investigator, four nurse researchers, two oncology behavioural experts with experience in self-collection research, and an expert in qualitative research. Each team member read the transcripts in their entirety to obtain a broad understanding of the participants\u0026rsquo; experiences. Directed content analysis as described by Hsieh and Shannon was used to summarize the participants\u0026rsquo; responses to the interview questions.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e All participant remarks relevant to the research aims were extracted and coded with a brief phrase that summarized the remark and captured its meaning. The codes were proposed by one team member and verified by another. A case-by-topic display table as described by Miles, Huberman, \u0026amp; Salda\u0026ntilde;a\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e was prepared with participant identification numbers (cases) presented on the vertical axis and key constructs from the Health Belief Model (barriers, benefits, knowledge, risk, self-efficacy) presented on the horizontal axis. The codes were placed in the appropriate cells in the table (e.g., Participant 002 codes on barriers, benefits, knowledge, risk and self-efficacy on CC). The codes in each column were then categorized through team discussions by clustering together codes with similar meanings. The categories were verified with a re-examination of transcript data. Based on the categories, narrative descriptions of participant remarks pertaining to each topic were prepared by one team member and verified and refined by another. These descriptions are presented below with verbatim exemplars of participant remarks.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAll the participants interviewed were Kenyans residing in Bungoma County. Women ranged in age from 25\u0026ndash;49 with a mean age of 42. Women had an average of 5 children, although the range was 1\u0026ndash;9 children/woman. A total of 52% of women reported a secondary level of education, 20% primary and 10% post high school level of education. Most women were married and living with their partner (82%) and 18% were either widowed or separated.\u003c/p\u003e\u003cp\u003eTwelve out of 20 (60%) participants had sought previous CC screening while 8(40%) had never been screened for CC. On health seeking behaviour, 5(20%) of the participants usually presented for wellness check-ups while 15(80%) of the participants usually sought healthcare only when ill. Most of the women (85%) had heard about CC screening prior to attending the \u003cem\u003echama\u003c/em\u003e. \u003cb\u003eLydia can we put these results in a table? Thanks!!\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe five themes provided the participants included: (1) knowledge about CC, (2) perceived susceptibility to cervical CC, (3) benefits of self-collection, (4) barriers to self-collection, and (5) self-efficacy related to self-collection.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eKnowledge About Cervical Cancer\u003c/h3\u003e\n\u003cp\u003eNineteen (19) participants made remarks reflecting knowledge they had acquired about CC provided by the CHP leading the \u003cem\u003echama\u003c/em\u003e and by the brochure included with the self-collection kit. One participant said, \u0026ldquo;\u003cem\u003ethe community health promotor (CHP) usually teaches us about CC screening when we come to the clinic and the CHP also visited us in the support group\u003c/em\u003e [for women living with HIV]\u0026hellip; \u003cem\u003eShe taught us that CC is a bug caused by a virus called human papilloma virus\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003eSome participants shared general facts they had learned about CC such \u0026ldquo;\u003cem\u003e90% is not hereditary\u003c/em\u003e,\u0026rdquo;. Women understood, CC was caused by cancerous cells multiplying. They also understood that screening could help early detection. A few participants listed the signs and symptoms of CC they acquired, such as abdominal pain, severe menstrual bleeding, pain during sex, abnormal urination or stools, stopping and starting menopause, and having a \u0026ldquo;\u003cem\u003ebad smell\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003eMost participants said they had been taught about the risk factors for CC and cited the risk factors of having multiple sexual partners, not using condoms, and having multiple births. One participant said, \u0026ldquo;\u003cem\u003eIf you are a woman and have many men, the one who has the virus leaves it inside of you and you will get infected\u003c/em\u003e.\u0026rdquo; Another said, \u0026ldquo;\u003cem\u003eI realized that sex is not something that you can have with this one and that one.\u0026rdquo;\u003c/em\u003e Participants also indicated they had learned CC could be caused by eating foods high in fat, smoking, and using scented or perfumed soaps. Some said they had been taught there was a link between HIV and CC, especially if one had a high viral load.\u003c/p\u003e\n\u003ch3\u003ePerceived Susceptibility to Cervical Cancer\u003c/h3\u003e\n\u003cp\u003eSixteen participants (80%) made remarks indicating they believed that they were at risk for CC. Some suggested they were susceptible because all women could get CC, and women may not be aware the disease is present. One participant said, \u0026ldquo;\u003cem\u003eYou could be among those who have it and maybe you don\u0026rsquo;t know your status\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003eOthers felt susceptible because they were aware of people who had cancer, many of whom died from the disease. Some participants had lost close relatives including an aunt, mother-in-law, sister, friend, and mother to CC, and others knew of women in the community who had the disease or had died from it. Some participants implied that personally knowing someone who had suffered or died from CC could prompt women to be screened or conversely cause them to avoid screening out of fear. Some participants felt they were susceptible to CC because they engaged in behaviours or had conditions, they knew to be risk factors for CC. As discussed previously, most participants had been taught risks factors for CC, and some acknowledged that they had one or more of those risk factors. One participant, for example, stated that she was susceptible to CC because she had HIV, her viral load was not suppressed, and she smoked. As a result, she regularly screened for CC. Several participants revealed they felt susceptible to CC because they had multiple sex partners. One woman who had not screened due to fear of a positive result said, \u0026ldquo;\u003cem\u003eYes because I can\u0026rsquo;t lie or try to please you, I had more than three men. I can\u0026rsquo;t lie to you about that, so you never know\u003c/em\u003e [whether she has CC].\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003eBenefits to Self-Collection\u003c/h3\u003e\n\u003cp\u003eEighteen (18) participants made remarks about the benefits of self-collection. Many indicated generally that this method was better than traditional screening, could lead to early detection and treatment, would make women \u0026ldquo;\u003cem\u003ehappy\u003c/em\u003e,\u0026rdquo; and would \u0026ldquo;\u003cem\u003eattract\u003c/em\u003e\u0026rdquo; women in the community. Even women who had not accepted the invitation to self-sample recognized its benefits.\u003c/p\u003e \u003cp\u003eMost of the participants who described the benefits of self-collection focused on the advantages of women being able to screen for CC \u0026ldquo;\u003cem\u003eon their own\u003c/em\u003e.\u0026rdquo; They suggested that this made them feel \u0026ldquo;\u003cem\u003ehappy,\u0026rdquo;\u003c/em\u003e \u0026ldquo;\u003cem\u003ecomfortable\u003c/em\u003e,\u0026rdquo; and less afraid. Being able to self-sample gave them more privacy. They indicated that women would not have to \u0026ldquo;\u003cem\u003espread their legs\u003c/em\u003e\u0026rdquo; and no one would have to see their \u0026ldquo;\u003cem\u003eprivate parts.\u0026rdquo;\u003c/em\u003e For some participants, self-collection provided a sense of confidence (self-efficacy) about their ability to have cervical screening. One participant said, \u0026ldquo;\u003cem\u003eAfter testing it felt good because it was something we could do ourselves\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003eOther women stated that self-collection was better than the traditional method of screening because it involved less pain and discomfort, and the kit was \u0026ldquo;\u003cem\u003eeasy\u003c/em\u003e\u0026rdquo; to use. Some of the participants who had used the Evalyn\u0026reg; Brush found it to be smooth and small. They indicated that it had not caused pain, discharge, or bruising. One participant said, \u0026ldquo;\u003cem\u003eSelf-collection was better than sticking steel inside of you\u003c/em\u003e.\u0026rdquo; Others remarked that they did not find it hard to self-sample, the instructions on the flyer were easy to follow, and obtaining the sample did not take much time. One participant said, \u0026ldquo;\u003cem\u003eWhen I used it, I didn\u0026rsquo;t feel anything. It\u0026rsquo;s something very simple. I didn\u0026rsquo;t see it had any problem. It is okay\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to Self-Collection\u003c/h2\u003e \u003cp\u003eEighteen (90%) of the participants made remarks that reflected barriers to CC screening. The participants\u0026rsquo; perceptions of barriers often stemmed from experiences they had had, or things they had heard about, traditional screening rather than self-collection procedure itself.\u003c/p\u003e \u003cp\u003eMany participants were worried about physical discomfort including pain, pricking, bruising, and bleeding. Those who spoke of pain typically referred to pain on insertion of the speculum in the traditional testing method and the pain that followed when they urinated or had sex. In some instances, the participants had heard frightening reports of traditional screening; one participant said women were often told that \u0026ldquo;\u003cem\u003eiron rods will be inserted in you and churn you up\u003c/em\u003e.\u0026rdquo; These fears of physical discomfort based on the \u0026ldquo;old method\u0026rdquo; translated to similar fears for self-collection. The fear of being pricked often occurred when participants were shown the Evalyn brush. One participant said, \u0026ldquo;\u003cem\u003eFirstly, I was afraid of the way it looks. I thought it would prick me\u003c/em\u003e.\u0026rdquo; Several participants who had self-sampled reported that these fears did not materialize as they found the brush to be \u0026ldquo;\u003cem\u003esoft\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003eA few women said a barrier to screening was fear of stigma and fear of a positive diagnosis. Participants indicated that stigma could be associated with testing, especially since CC was associated with HIV. Participants were concerned that others might think women were being tested for HIV rather than receiving a cancer screening. A few participants acknowledged that a barrier to self-collection was fear of a positive diagnosis. One woman, who had not accepted the invitation to self-collect, said, \u0026ldquo;\u003cem\u003eI was afraid of what my sister\u003c/em\u003e (with CC) \u003cem\u003ewent through, and I just wanted to live without finding out\u003c/em\u003e.\u0026rdquo; Another participant did not screen because she believed herself to be of high risk because she had HIV and her father died of cancer.\u003c/p\u003e \u003cp\u003eParticipants mentioned a variety of practical barriers to screening when using either the traditional or self-collection method, including lack of time (having too many things to do), not being able to travel to the hospital because travel was too costly, and having many other time demands such as work and childcare. One participant who had not yet screened but intended to do so said, \u0026ldquo;\u003cem\u003eI have had a lot of things to do, I had to go and take care of my father who was sick and then I also had classes at the church, but I am almost done and I will come for a screening\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003eOther barriers that participants mentioned included fear the speculum had been used on someone else (traditional screening), wanting to wait until more persons got tested (self-collection), being new (self-collection), and having the samples mixed up (self-collection). One participant who had not accepted the invitation to self-sample said, \u0026ldquo;\u003cem\u003eWhat made me refuse was that this is a new thing, and some things have side effects so I was afraid. I wanted other people to use them first so that I can be able to see if they have side effects or not so that I can use it later on. I was afraid that maybe it might have side effects\u003c/em\u003e.\u0026rdquo; Participants also mentioned traditional or cultural beliefs that were barriers to both methods, such as the belief that \u0026ldquo;\u003cem\u003eprivate parts\u003c/em\u003e [are] \u003cem\u003ejust private for husbands and not something else.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFacilitators of Self-Collection\u003c/h3\u003e\n\u003cp\u003eSeventeen (17) participants made remarks about supports that would facilitate the uptake of self-collection by women. Although they saw many benefits to self-collection, they indicated that the process of self-collection would need to be expedited in a variety of ways.\u003c/p\u003e \u003cp\u003eSome participants indicated that the CHP and their \u003cem\u003echama\u003c/em\u003e facilitated the self-collection. These community supports were critical in promoting the \u0026ldquo;\u003cem\u003enew method\u003c/em\u003e\u0026rdquo; of sampling. As mentioned previously, the CHP had educated the women about CC and the need for CC screening. However, she also alerted the participants to the \u0026ldquo;\u003cem\u003enew method,\u0026rdquo;\u003c/em\u003e invited them to self-collect, showed them the Evalyn\u0026reg; Brush and taught them how to obtain a sample (\u0026ldquo;\u003cem\u003einsert the brush, rotate it five times, and remove and cover it\u003c/em\u003e\u0026rdquo;). The participants\u0026rsquo; experiences suggest that trust in a CHP may be needed to promote uptake of self-collection. One participant said, \u003cem\u003e\u0026ldquo;I had accepted to come and get screened because of the importance that\u003c/em\u003e [CHP] \u003cem\u003ehad.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe instructions given to the women regarding self-collection served as a facilitator of the collection process. The participants said they liked the pictures, cover, colourfulness, and words on the instruction flyer they had been given. Some said it was easy to understand and the instructions were clear. However, they also provided some suggestions to make the instructions more acceptable. They recommend the instructions printed in local languages for women who cannot read English or Kiswahili. They also stressed that the size of the font and the pictures should be large enough for all women to be able to follow the instructions easily.\u003c/p\u003e \u003cp\u003eSeveral participants suggested that bringing self-collection kits to the villages would facilitate the self-collection process. Participants stressed that women would be more likely to self-collect if they did not have to go long distances to hospitals or other facilities. The participants indicated that \u0026ldquo;\u003cem\u003ebringing it to the village\u003c/em\u003e\u0026rdquo; would overcome the barriers of the cost of transportation, needing to take time away from care for children and other family members, and leaving work for long periods to get tested. Participants suggested that such outreach would also save women from waiting in long lines. The participants acknowledged that a private place in or near the women\u0026rsquo;s home would be needed to afford them privacy and they might benefit from a local support group. A few participants who advocated for self-collection at local villages also thought that healthcare professionals should be involved to ensure adequate hygiene and safe transport of the samples.\u003c/p\u003e \u003cp\u003eA few participants suggested that women would facilitate other women in self-collection. They indicate women would \u0026ldquo;spread the message,\u0026rdquo; help \u0026ldquo;doctors look for people,\u0026rdquo; and educate other women. One participant said, \u0026ldquo;Women who use it [self-collection] will facilitate others to use it.\u0026rdquo;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eQualitative interviews indicated that HPV self-collection could increase the percentage of women screened for CC in low-income countries by overcoming structural and personal barriers to screening. Prior to implementing a screening modality, understanding the drivers of a woman\u0026rsquo;s willingness to use the screening method and barriers that might prevent use are important. This study uniquely examined the beliefs of \u0026ldquo;non-returners,\u0026rdquo; or women who were provided the self-collection kit and did not return it, compared to those who did return the kit. Insights to the beliefs and attitudes from rural women in Kenya could help tailor intervention and implementation considerations for self-collection among women at high-risk for CC. Thus, we interviewed women who were part of a larger study which provided HPV self-collection kits to those who attended a \u003cem\u003echama\u003c/em\u003e. Interviews included both women who accepted and used the self-collection kit and those who refused, providing comprehensive insights into factors influencing self-collection acceptance. Women\u0026rsquo;s responses fit into one of five categories including knowledge about CC, perceived personal susceptibility to CC, benefits of self-collection, barriers to self-collection, and facilitators of self-efficacy.\u003c/p\u003e \u003cp\u003eMost participants described receiving information about CC screening both during the initial \u003cem\u003echamas\u003c/em\u003e and through contact with CHP during clinic visits increasing both their knowledge and perceived susceptibility to CC. Literature indicates that interventions that promote CC screening, particularly if delivered by a CHP, have been an effective way to increase provider-based CC screening\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e and may also help increase acceptance of self-collection although further research is needed to confirm that association.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e While many women had accurate knowledge about CC and screening, there were also misconceptions. For instance, some of the risk factors described by the women were incorrect such as CC being related to fat intake or soaps. Previous literature has shown that although women report receiving information from CHP, this information may not be fully understood.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Several of the women interviewed had negative attitudes toward CC screening from knowledge passed on by family and friends, which had more impact than the information acquired from health care providers or CHP.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMost women, including both returners and non-returners, described benefits and barriers to screening. Women who returned the self-collection kit described the benefits of screening as being able to screen without having a clinic appointment which supports the benefits of having privacy, being less fearful of the exam, and the device and collection procedure being comfortable, which is consistent with previous literature. Barriers to CC screening (both provider-collected and self-collected) reported by the women included fear, stigma, pain, and discomfort, which are like previously reported CC screening barriers among women in Kenya and other low-income countries.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e Several women mentioned not screening because they were afraid of a cervical cancer diagnosis. These women often reported knowing someone or having a family member died from cervical cancer, which increased their fear. Fear of cervical cancer has been reported as an important barrier to screening previously in the literature.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e This barrier mentioned by several women supports the necessity of emphasizing that screening will prevent dying from CC because it enables a provider to identify CC in an early stage when minimal treatment will cure this disease.\u003c/p\u003e \u003cp\u003eOther potential barriers to self-collection were related to the device and fear of a new technology. A recent review indicated that women preferred Evalyn\u0026reg; Brush, Cervex-Brush. FLOQSwabs\u0026reg;, and Delphi Screener self-sampling devices compared to other self-collection devices;\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e however several women in this study reported they were afraid the Evalyn\u0026reg; Brush would prick them, which suggests that the device used for self-collection could be an important factor related to self-collection acceptance. One participant reported that a barrier to screening was that she was worried about side-effects and wanted other people to use the device first. This suggests that perhaps some women will not want to use a new technology like self-collection kits when its first implemented in clinics, but uptake could increase after women learn that other women have used the brush without harm. Fear of new medical technology, although uncommon in self-collection literature, mirrors hesitancies observed with other medical innovations, especially vaccines.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFacilitators to screening included learning about self-collection through a trusted CHP and \u003cem\u003echama\u003c/em\u003e, accessible distribution methods (such as home delivery), and clear instructional materials i.e., brochures. CHPs are effective at delivering interventions in other countries\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e and may even be more important in low resource countries like Kenya where knowledge of CC screening is low. Along with the CHP, the women reported that the self-collection kit should be delivered at the villages. Since transportation is a common barrier to CC screening,\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e it is not surprising the women preferred home delivery of the kit. Women reported that they liked the brochure but that other languages should be available. Due to low health literacy among many women in Kenya, investigators may want to explore other methods to deliver instructions such as videos which could be presented at \u003cem\u003echamas\u003c/em\u003e. Overall, women were positive about self-collection and acknowledged that they would recommend it to others. This finding is important because it suggests the importance of carefully rolling out a technology such as self-collection, so that positive experiences can be shared with friends and family. Previous literature has reported that social networks such as friends and family are important sources of health information for Kenyans.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSeveral limitations of this study should be noted. First, eligible participants were women who were invited to a \u003cem\u003echama\u003c/em\u003e, a meeting which include both self-collection and HPV vaccinations to eligible women and girls aged 10\u0026ndash;14 years of age, potentially excluding those who were not vaccine eligible or had vaccine eligible children. Second, women had to provide the sample in a private space at the \u003cem\u003echama\u003c/em\u003e instead of the privacy of their own home so that some women may have not been comfortable collecting the sample at the \u003cem\u003echama\u003c/em\u003e secluded area. Third, all women were given an opportunity to complete self-collection regardless of whether they had previous CC screening so that women who had CC screening in the last year may have self-selected to forego self-collection but not because they did not find it acceptable.\u003c/p\u003e \u003cp\u003eFuture research should consider self-collection factors such as type of device (Evalyn\u0026reg; Brush vs. Dacron Swab\u0026reg;) and instructions that accompany the kit (brochure vs. video) as well as using a community health promotor-led intervention for kit delivery to their homes. Using a self-collection device that may be more familiar to women such as a Dacron Swab could be important to self-collection uptake so future research should examine if women prefer one device over the other.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e Dacron Swabs are used to test for various diseases such as a nasal swab to test for Covid and during Pap smears as well as looking like a Q-tip so may not appear as foreign.\u003c/p\u003e \u003cp\u003eAlthough women liked the self-collection brochure, some women described language difficulties. In addition, health literacy is low in Kenya so that video may be more appropriate for demonstrating self-collection and could be edited in different languages. Future research could compare a brochure vs. video on self-collection uptake where a community health promotor could possibly show a video during a \u003cem\u003echama\u003c/em\u003e. Also, it may beneficial for women who have completed a self-collection screening to describe their positive experience at the \u003cem\u003echama\u003c/em\u003e and future studies could examine if sharing positive experiences at a community meeting increases self-collection uptake.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, this study explored the beliefs related to CC screening among returners and non-returners of self-collection. This study found that the women\u0026rsquo;s responses could fall into five categories including knowledge about CC and CC screening, perceived susceptibility to cervical cancer, benefits of self-collection, barriers to self-collection, and facilitators of self-efficacy. Most of the women used the self-collection kit suggesting that it is acceptable, and a CHP led \u003cem\u003echama\u003c/em\u003e is an important method of delivery of the kit. Future research should examine other implementation factors such as the device and kit instructions.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eHuman Ethics Declaration\u003c/h2\u003e \u003cp\u003eThe study was approved by the Institutional Research and Ethics committee of Moi University and Moi Teaching and Referral Hospital in Kenya (\u003cb\u003eIREC/2019/196\u0026ndash;0003414\u003c/b\u003e) and the National IRB in Kenya (\u003cb\u003eNACOSTI/P/20/3327\u003c/b\u003e). Women exercised their right to self determination to participate in the study and their choice to accept or decline the sampling kit during the \u003cem\u003echama\u003c/em\u003e meeting was respected regardless of their health or social status.\u003c/p\u003e \u003c/div\u003e\u003cp\u003e \u003ch2\u003eConsent to Participate\u003c/h2\u003e \u003cp\u003eAll women participants who met the selection criteria (\u0026lsquo;had attended a \u003cem\u003echama\u003c/em\u003e meeting and were offered a self-sampling method of HPV screening\u0026rsquo;) signed an informed consent form before being invited to respond to the interview questions at Webuye Sub County hospital (see appendix 1 \u0026amp; 2) conducted by the principal investigators or research assistant. The interviews included women who completed a self-sample for HPV screening and those who declined the sampling kit.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflict of Interest\u003c/h2\u003e \u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eAI\u003c/h2\u003e \u003cp\u003eWe declare that no artificial intelligence tools were used in any part of this manuscript development.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eProject field work was funded by Indiana University School of Nursing Indianapolis, USA.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eVC - Sourced for project funds and collaborations for a sub study opportunity with colleagues in Medicine.LM \u0026amp; VC - Collected field interviews data in Kenya along a research assistant.LM - Conducted the descriptive analysis of demographic data and wrote the initial manuscript draft.CD- Team lead during the inductive qualitative data analysis process of developing codes, categories and themes by assigning roles for each author (VC, LM, EB, CD) during the analysis.EB- Final proof reading in readiness for submission\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe acknowledge the AMPATH Research and Sponsored Projects Office RSPO team, Dr. Orango Omenge and his research team for allowing us to carry out a qualitative sub-study within his U54 main study and Mr. Kapten Muthoka who supported the logistical planning for the study field activities.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData analysis sets for the descriptive qualitative interviews are available at Synapse project ID syn66696587 accessible from https://www.synapse.org/\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL, et al. 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Barriers to cervical cancer screening in rural Kenya: perspectives from a provider survey. \u003cem\u003eJournal of community health\u003c/em\u003e. 2015;40:756-761.\u003c/li\u003e\n\u003cli\u003eSmith SK, Nwosu O, Edwards A, et al. Performance of screening tools for cervical neoplasia among women in low-and middle-income countries: A systematic review and meta-analysis. \u003cem\u003ePLOS Global Public Health\u003c/em\u003e. 2023;3(2):e0001598.\u003c/li\u003e\n\u003cli\u003eMeijer CJ, Berkhof J, Castle PE, et al. Guidelines for human papillomavirus DNA test requirements for primary cervical cancer screening in women 30 years and older. \u003cem\u003eInternational journal of cancer\u003c/em\u003e. 2009;124(3):516-520.\u003c/li\u003e\n\u003cli\u003eRonco G, Dillner J, Elfstr\u0026ouml;m KM, et al. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. \u003cem\u003eThe lancet\u003c/em\u003e. 2014;383(9916):524-532.\u003c/li\u003e\n\u003cli\u003eMinistry of Health (Kenya). \u003cem\u003eNational Cancer Screening Guidelines 2018\u003c/em\u003e. 2018. Accessed 5/19/2025. https://publications.health.go.ke/handle/123456789/3508\u003c/li\u003e\n\u003cli\u003eHuchko MJ, Ibrahim S, Blat C, et al. Cervical cancer screening through human papillomavirus testing in community health campaigns versus health facilities in rural western Kenya. \u003cem\u003eInternational Journal of Gynecology \u0026amp; Obstetrics\u003c/em\u003e. 2018;141(1):63-69.\u003c/li\u003e\n\u003cli\u003eArbyn M, Verdoodt F, Snijders PJ, et al. Accuracy of human papillomavirus testing on self-collected versus clinician-collected samples: a meta-analysis. \u003cem\u003eThe lancet oncology\u003c/em\u003e. 2014;15(2):172-183.\u003c/li\u003e\n\u003cli\u003eNelson EJ, Maynard BR, Loux T, Fatla J, Gordon R, Arnold LD. The acceptability of self-sampled screening for HPV DNA: a systematic review and meta-analysis. \u003cem\u003eSexually transmitted infections\u003c/em\u003e. 2017;93(1):56-61.\u003c/li\u003e\n\u003cli\u003eArbyn M, Smith SB, Temin S, Sultana F, Castle P. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. \u003cem\u003eBmj\u003c/em\u003e. 2018;363\u003c/li\u003e\n\u003cli\u003eRositch AF, Gatuguta A, Choi RY, et al. Knowledge and acceptability of pap smears, self-sampling and HPV vaccination among adult women in Kenya. \u003cem\u003ePloS one\u003c/em\u003e. 2012;7(7):e40766.\u003c/li\u003e\n\u003cli\u003eOketch SY, Kwena Z, Choi Y, 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. \u003cem\u003eBMC women\u0026apos;s health\u003c/em\u003e. 2019;19:1-10.\u003c/li\u003e\n\u003cli\u003eDi Gennaro G, Licata F, Trovato A, Bianco A. Does self-sampling for human papilloma virus testing have the potential to increase cervical cancer screening? An updated meta-analysis of observational studies and randomized clinical trials. \u003cem\u003eFrontiers in public health\u003c/em\u003e. 2022;10:1003461.\u003c/li\u003e\n\u003cli\u003eAttipoe-Dorcoo S, Chattopadhyay SK, Verughese J, et al. Engaging community health workers to increase cancer screening: a community guide systematic economic review. \u003cem\u003eAmerican journal of preventive medicine\u003c/em\u003e. 2021;60(4):e189-e197.\u003c/li\u003e\n\u003cli\u003eOkasako-Schmucker DL, Peng Y, Cobb J, et al. Community health workers to increase cancer screening: 3 Community Guide systematic reviews. \u003cem\u003eAmerican journal of preventive medicine\u003c/em\u003e. 2023;64(4):579-594.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Donovan J, O\u0026rsquo;Donovan C, Nagraj S. The role of community health workers in cervical cancer screening in low-income and middle-income countries: a systematic scoping review of the literature. \u003cem\u003eBMJ global health\u003c/em\u003e. 2019;4(3):e001452.\u003c/li\u003e\n\u003cli\u003eSzarewski A, Cadman L, Mesher D, et al. HPV self-sampling as an alternative strategy in non-attenders for cervical screening\u0026ndash;a randomised controlled trial. \u003cem\u003eBritish journal of cancer\u003c/em\u003e. 2011;104(6):915-920.\u003c/li\u003e\n\u003cli\u003eBarbee L, Kobetz E, Menard J, et al. Assessing the acceptability of self-sampling for HPV among Haitian immigrant women: CBPR in action. \u003cem\u003eCancer Causes \u0026amp; Control\u003c/em\u003e. 2010;21:421-431.\u003c/li\u003e\n\u003cli\u003eRacey CS, Withrow DR, Gesink D. Self-collected HPV testing improves participation in cervical cancer screening: a systematic review and meta-analysis. \u003cem\u003eCanadian Journal of Public Health\u003c/em\u003e. 2013;104:e159-e166.\u003c/li\u003e\n\u003cli\u003eArrossi S, Thouyaret L, Herrero R, et al. Effect of self-collection of HPV DNA offered by community health workers at home visits on uptake of screening for cervical cancer (the EMA study): a population-based cluster-randomised trial. \u003cem\u003eThe Lancet Global Health\u003c/em\u003e. 2015;3(2):e85-e94.\u003c/li\u003e\n\u003cli\u003eKobetz E, Seay J, Koru-Sengul T, et al. A randomized trial of mailed HPV self-sampling for cervical cancer screening among ethnic minority women in South Florida. \u003cem\u003eCancer Causes \u0026amp; Control\u003c/em\u003e. 2018;29:793-801.\u003c/li\u003e\n\u003cli\u003eOrang\u0026rsquo;o O, Tonui P, Muthoka K, et al. A community-based approach to cervical cancer prevention in western Kenya: An AMPATH feasibility project. \u003cem\u003eSAGE Open Medicine\u003c/em\u003e. 2022;10:20503121221102111.\u003c/li\u003e\n\u003cli\u003eHsieh H-F, Shannon SE. Three approaches to qualitative content analysis. \u003cem\u003eQualitative health research\u003c/em\u003e. 2005;15(9):1277-1288.\u003c/li\u003e\n\u003cli\u003eMiles MB, Huberman AM, Salda\u0026ntilde;a J. Qualitative data analysis: A methods sourcebook. 3rd. Thousand Oaks, CA: Sage; 2014.\u003c/li\u003e\n\u003cli\u003eGatumo M, Gacheri S, Sayed A-R, Scheibe A. Women\u0026rsquo;s knowledge and attitudes related to cervical cancer and cervical cancer screening in Isiolo and Tharaka Nithi counties, Kenya: a cross-sectional study. \u003cem\u003eBMC cancer\u003c/em\u003e. 2018;18:1-9.\u003c/li\u003e\n\u003cli\u003eBlack E, Hyslop F, Richmond R. Barriers and facilitators to uptake of cervical cancer screening among women in Uganda: a systematic review. \u003cem\u003eBMC women\u0026apos;s health\u003c/em\u003e. 2019;19(1):1-12.\u003c/li\u003e\n\u003cli\u003eAimagambetova G, Atageldiyeva K, Marat A, et al. Comparison of diagnostic accuracy and acceptability of self-sampling devices for human Papillomavirus detection: a systematic review. \u003cem\u003ePreventive Medicine Reports\u003c/em\u003e. 2024;38:102590.\u003c/li\u003e\n\u003cli\u003eMacDonald NE. Vaccine hesitancy: Definition, scope and determinants. \u003cem\u003eVaccine\u003c/em\u003e. 2015;33(34):4161-4164.\u003c/li\u003e\n\u003cli\u003eLazarus JV, Ratzan SC, Palayew A, et al. A global survey of potential acceptance of a COVID-19 vaccine. \u003cem\u003eNature medicine\u003c/em\u003e. 2021;27(2):225-228.\u003c/li\u003e\n\u003cli\u003eLim JN, Ojo AA. Barriers to utilisation of cervical cancer screening in Sub Sahara Africa: a systematic review. \u003cem\u003eEuropean journal of cancer care\u003c/em\u003e. 2017;26(1):e12444.\u003c/li\u003e\n\u003cli\u003eB\u0026uuml;hler C, Kohler H-P. Talking about AIDS: The influence of communication networks on individual risk perceptions of HIV/AIDS infection and favored protective behaviors in South Nyanza District, Kenya. \u003cem\u003eDemographic Research\u003c/em\u003e. 2003;1:397-438.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Self-collection, cervical cancer screening, HPV","lastPublishedDoi":"10.21203/rs.3.rs-6732617/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6732617/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCervical cancer (CC) is the leading cause of female related cancer deaths and the second most common cancer affecting women in Africa. Furthermore, over 3000 mortalities are linked to low screening uptake and Kenya currently reports a CC screening rate of 16%. We sought to determine the feasibility and acceptability of “self-collection” for human papillomavirus (HPV testing) in Webuye Sub County, Western Kenya as a method to overcome low CC screening rates to decrease CC mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA qualitative descriptive study design was used to collect data from 20 women who attended a rural village \u003cem\u003e“chama”\u003c/em\u003e (meeting for health promotion) on importance of CC screening. Of the 20 women who participated in this study, 15 women completed the self-collection kit when offered at the \u003cem\u003echama\u003c/em\u003e, and 5 women declined self-collection. Data were collected using in-depth interviews. Investigators used a deductive approach, or \u003cem\u003ea priori\u003c/em\u003e, analysis of the data by applying predetermined codes derived from the Health Belief Model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, women who accepted screening indicated that knowledge about CC motivated them to take and use the Evalyn® Brush self-collection kit. Additionally, women who acknowledged the greatest risk for CC were those who had multiple sexual partners. Women who declined self-collection discussed fear of adverse physical effects, fear of receiving a positive diagnosis, stigma and loss of privacy as the main barriers to CC screening. Fear voiced by women included pain, bruising, and bleeding from the self-collection device, which in this case was an Evalyn® Brush. Perceived benefits included autonomy in conducting self-collection. Peer support at \u003cem\u003echama\u003c/em\u003e reinforced acceptance of self-collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSelf-collection may promote autonomy and uptake of HPV screening in low resourced settings.\u003c/p\u003e","manuscriptTitle":"Feasibility and acceptability of self-sampling for Human Papillomavirus (HPV) screening in a rural community in Western Kenya","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-26 13:05:44","doi":"10.21203/rs.3.rs-6732617/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-22T08:28:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-21T17:32:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-14T15:09:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25756861353461586188086416007976013901","date":"2025-12-03T12:24:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243879752350384125995022549854582037722","date":"2025-12-01T14:15:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-03T17:27:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"245069849204107567649735930469548507598","date":"2025-08-31T12:57:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"197644190369577026318786398390492478212","date":"2025-08-27T21:22:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"209697986506438573969075038079078131204","date":"2025-08-27T16:47:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286551437791550820017966721590045759971","date":"2025-08-25T19:34:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3027831549522706913853096108079340111","date":"2025-08-25T13:23:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"335545273546064117374367950650875244169","date":"2025-06-26T19:08:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-24T09:02:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-28T13:49:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-28T09:00:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-28T08:55:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-05-23T11:42:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"268d2350-057d-44c6-90a2-c62c22760000","owner":[],"postedDate":"June 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T16:54:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-26 13:05:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6732617","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6732617","identity":"rs-6732617","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}