Moving Human Papillomavirus (HPV) Self-Sampling Into Primary Care Settings: A Healthy-Equity Centered, Pre-Implementation Study To Address Cervical Cancer Screening Inequities In Minnesota

Abstract

Since the implementation of cervical cancer screening methods (i.e., cervical cytology/Pap test), cervical cancer rates have been declining. Nevertheless, racial/ethnic disparities in cervical cancer screening continue to exist, and are caused by a wide range of factors, including limited awareness about human papillomavirus (HPV) and cervical cancer, difficulties accessing health care services, and cultural or religious beliefs. Self-sampling techniques for the collection of HPV specimens (“HPV self-sampling”) have been proposed as an evidence-based and effective alternative to overcome some of these barriers. Most research in this area, however, has focused on home-based (e.g., mail-in) HPV self-sampling approaches and has overlooked the potential to adapt HPV self-sampling into point-of-care (e.g., clinic-based) settings. Recent guideline adoptions also recommend that women ages 30-65 can undergo primary HPV testing every five years. HPV self-sampling, further, can be used to facilitate patient-initiated primary HPV testing. This collection approach, however, has failed to be mainstreamed in US primary care due to its limited applications and evidence in US-based contexts. Planning for the implementation of HPV self-sampling within US health systems, hence, will require a multilevel (individual, community, institutions, policies) understanding of how proven cancer prevention interventions are adopted into routine care. The aim of this dissertation was to gather multilevel perspectives on the possible implementations and adaptations of an HPV self-sampling practice for racially- and ethnically-diverse patient populations in Minnesota (MN). In the first manuscript, a systematic review was conducted to explore how implementation science (IS) frameworks have been used across health systems to adapt evidence-based cancer prevention interventions for diverse populations. In the second manuscript, healthcare professionals were interviewed on their perspectives on the possible implementations and adaptations of an HPV self-sampling practice in MN. In the final manuscript, racially- and ethnically-diverse women from MN were surveyed online about their awareness and preferences for HPV self-sampling. To date, IS frameworks are used minimally and varyingly across cancer prevention studies. Of the few studies that applied IS frameworks to adapt evidence-based cancer prevention interventions, they were intentionally used to identify and plan for adaptations to increase intervention fit. Next, while healthcare professionals have yet to adopt HPV self-sampling, they expressed interest and suggestions for how it could be implemented, with the biggest hurdle being how to effectively convince key decision-makers. Finally, women who were surveyed reported a low level of HPV self-sampling awareness. Although most women reported high self-efficacy to perform the test, less than half preferred HPV self-sampling to Pap tests. Taken together, these results suggest that until greater population uptake of HPV self-sampling has occurred in the United States, it remains unknown the extent to which this alternative cervical cancer screening method may be preferable to Pap tests for reducing cervical cancer disparities among minority women. Pragmatic HPV self-sampling interventions, therefore, need to be more widely implemented and tested in US contexts, so that more women become aware of this new modality and experience the self-collection approach and its respective location options, before further scale-out and adaptations of an HPV self-sampling practice can be instituted in US primary care settings.