Acceptability and Usability of Self-Collected Sampling for HPV Testing Among African-American Women Living in the Mississippi Delta

Abstract

Background

Human papillomavirus (HPV) DNA testing has been shown to be an effective approach to cervical cancer screening, and self-collection sampling for HPV testing could be a potential alternative to Pap test, provided that women who tested positive by any method get timely follow-up and care. This feasibility study examined acceptability and usability of self-collected sampling for HPV testing among African-American (AA) women in the Mississippi Delta to inform the development of interventions to promote cervical cancer screening in this population.

Methods

The study consisted of two phases. Phase I consisted of eight focus groups (n = 87) with AA women to explore knowledge, attitudes, and beliefs about cervical cancer and HPV infection as well as acceptability of self-collected sampling for HPV testing. In phase II, we examined the usability of this technology through one discussion group (n = 9). The Health Belief Model guided data collection and analysis.

Results

Although participants perceived themselves as susceptible to cervical cancer and acknowledged its severity, there was a lack of knowledge of the link between HPV and cervical cancer, and they expressed a number of misconceptions. The most frequent barriers to screening included embarrassment, discomfort, and fear of the results. Women in both phases were receptive to self-collected sampling for HPV testing. All participants in the usability phase expressed that self-collection was easy and they did not experience any difficulties.

Conclusion

Self-collection for HPV testing is an acceptable and feasible method among AA women in the Mississippi Delta to complement current cytology cervical cancer screening programs.

Introduction

The incidence rate of cervical cancer among African American (AA) women is 11.1 per 100,000 compared with 7.9 per 100,000 among White women, which places cervical cancer as the seventh leading type of new cancer cases among AA women (Jemal, Siegel, Xu, & Ward, 2010). The excess mortality ratio associated with cervical cancer between AA and White women nationwide is 2.4 per 100,000 (4.6 vs. 2.2, respectively), which places cervical cancer among the top 10 leading causes of cancer deaths among AA women (Edwards et al., 2010). These disparities are even greater in the Delta region of Mississippi, where the incidence of cervical cancer is 13.4 per 100,000 in AA women compared with 9.1 per 100,000 in White women. The excess mortality ratio between AA and White women living in the Delta is 7.5 per 100,000 (9.7 vs. 2.2, respectively; Mississippi Cancer Registry, 2003-2007) Population characteristics of women living in this region are high levels of poverty, low educational attainment, and limited access to care, all contributory factors to cervical cancer incidence and mortality (Freeman & Wingrove, 2007).

Despite the fact that cytology screening programs are widely available in the United States, some racial/ethnic minorities and women with low education and income do not fully take part in these programs due to structural and intra/interpersonal barriers, resulting in higher rates of cervical cancer in these underscreened women (Brewster et al., 2005; Freeman & Wingrove, 2007; Scarinci et al., 2010; U.S. Centers for Disease Control and Prevention, N.D.). The discovery that virtually all cervical cancer is caused by persistent cervical infections with certain carcinogenic human papillomavirus (HPV) genotypes has led to two major technologic advances: 1) Prophylactic HPV vaccination for primary prevention and 2) HPV DNA testing for secondary prevention (screening).

DNA testing for HPV provides improved, more reliable identification of women with cervical precancer and cancer than Pap testing (Castle et al., 2011b; Cuzick et al., 2006; Mayrand et al., 2007; Naucler et al., 2007; Rijkaart et al., 2012; Ronco et al., 2010). The increased sensitivity of molecular HPV testing over Pap testing translates into two important healthcare benefits: 1) Earlier detection of precancerous lesions that, if treated, results in a reduced incidence of cervical cancer within 4 to 5 years (Rijkaart et al., 2012; Ronco et al., 2010) and reduced death within 8 years (Sankaranarayanan et al., 2009) and 2) greater reassurance against cancer (lower cancer risk) after a negative result for many years (Castle et al., 2012; Dillner et al., 2008), which permits screening at an extended interval.

The added sensitivity of HPV DNA testing makes the use self-collection and HPV DNA testing for cervical cancer screening a viable option that could be used to complement current programs to reach those women not undergoing routine Pap testing. Previous studies have examined the sensitivity and predictive value of HPV detection by comparing self-collected and clinician-collected samples of HPV testing, indicating HPV self-collection to be a feasible alternative to traditional clinician-collected sampling for cervical cancer screening (Belinson et al., 2010; Belinson et al., 2003; Garcia et al., 2003; Ogilvie et al., 2007). A recent pooled analysis of five studies in China showed that self-collection as at least as sensitive as Pap testing (Zhao et al., 2012). Although there is a reduced sensitivity with self-collected specimens compared with clinician-collected specimens tested for HPV DNA, women can potentially collect a cervicovaginal specimen in the privacy and convenience of their home and mail the kit to a lab for HPV DNA testing with same cervical cancer prevention benefits as a Pap test, a standard of care. It should be noted that method of screening matters little without excellent follow-up of screen positives to ensure timely management and treatment of cervical disease.

However, the public health benefits of such technology will only be attained if the approach is accepted and adopted by at risk populations. Previous studies lacked in depth understanding of the sociocultural, structural, and intra/interpersonal factors associated with self-collection sampling for HPV testing, and most were limited to women who were recruited at clinics (Balasubramanian et al., 2010; Belinson et al., 2003; Gravitt et al., 2001; Harper et al., 1999; Harper, Noll, Belloni, & Cole, 2002; Kahn et al., 2004; Lindau et al., 2009; Lenselink et al., 2009; Morrison, Goldberg, Hagan, Kadish, & Burk, 1992; Moscicki, 1993; Palmisano et al., 2003; Rompalo et al., 2001).

The purpose of this feasibility study was to examine the knowledge, beliefs, and attitudes regarding cervical cancer and HPV infection, as well as acceptability and usability of self-collected sampling for HPV testing among AA women recruited through public health clinics and the community in the Mississippi Delta with the ultimate goal of developing theory-based, culturally relevant interventions to promote cervical cancer screening in this population.