ENHANCING FOLLOW-UP ADHERENCE IN CERVICAL CANCER SCREENING
FOR LOW-INCOME INDIVIDUALS
by
Rebecca Struivig de Groot
B.Sc.N., Langara College, 2013

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
IN
NURSING- FAMILY NURSE PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
April 2025
ÓRebecca Struivig de Groot, 2025

ii
Abstract
Cervical cancer (CC) remains a major public health concern, disproportionately affecting
low-income populations due to barriers in screening and follow-up care. Inadequate follow-up
after a positive HPV self-sample result puts individuals at higher risk of disease progression, yet
there is limited research on effective follow-up strategies for this group. This integrative review
explores interventions aimed at improving adherence to follow-up care in low-income women.
A systematic search identified eight studies examining follow-up interventions in lowincome populations. Follow-up rates varied widely (5.6%–92%), with higher adherence observed
when multiple follow-up methods were used, such as phone calls, text messages, postal mail, and
home visits. Patient education, patient navigation, and the provision of a second self-sampling kit
also showed promise in increasing follow-up rates. However, inconsistencies in study
methodologies and healthcare settings make direct comparisons challenging.
These findings highlight the need for standardized, evidence-based follow-up strategies
to address disparities in CC care. Future research should focus on scalable, cost-effective
interventions, including mobile health (mHealth) approaches and patient navigation models.
Policy efforts should prioritize integrating multi-modal follow-up strategies into national
screening programs to improve outcomes for vulnerable populations.

iii
Table of Contents
Abstract

ii

Table of Contents

iii

List of Tables

v

List of Figures

vi

Glossary

vii

Acknowledgement

viii

Chapter One

Introduction
Background
Etiology of Cervical Cancer
Cervical Cancer Screening
Vulnerable Populations
Screening Rates in Vulnerable Populations
Screening Barriers
Follow-up for Cervical Cancer Screening
Interventions to Increase Adherence to Follow-up Care

1
3
3
4
5
6
6
7
8

Chapter Two

Methods
Design
Databases
Search Terms
Data Management
Inclusion and Exclusion Criteria
Data Analysis

9
9
9
10
10
13
14

Chapter Three

Findings
Study Characteristics
Inconsistent Follow-up Rates
Multiple Follow-up Methods
Additional Interventions
Patient Education
Patient Navigation
Provision of Additional Self-Sample
Strengths and Limitations of the Literature in this Review

15
15
19
19
21
22
24
25
25

Chapter Four

Discussion
Multi-follow-up Strategy
Home Visits
Mobile Health Interventions

28
28
29
30

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Patient Navigation
Education
Provision of Additional Self-Sample
Time Consideration
Implications for Research and Policy
Strengths and Limitations of this Integrative Review

30
31
32
32
33
33

Conclusion

35

References

36

Appendix A

Detailed Search Strategy

43

Appendix B

Review Matrices

45

v
List of Tables
Table 1: Search Terms

10

Table 2: Inclusion and Exclusion Criteria for Research Article Selection

14

Table 3: Study Characteristics

16

Table 4: Participant Income Status

18

Table 5: Follow-up Method and Rates

20

Table 6: Intervention Details

22

vi
List of Figures
Figure 1: Preferred Reporting Items for Systematic Reviews and Meta-Analysis
(PRISMA) Flowchart

12

vii
Glossary
Cervical Cancer: cancer of the cells of the cervix (Canadian Cancer Society, 2023)
Colposcopy: a procedure to examine cells of the cervix and vagina (BC Cancer, 2025)
Human Papillomavirus: a group of over 200 related viruses, with 40 of them known to affect
the genitals, mouth and throat (Government of Canada, 2024b)
Lost to Follow-up: describes individuals not reporting and inability to trace them during a study
period or required follow-up timeframe (Patel et al., 2021)
Human Papillomavirus Self-sampling: a procedure where the individual uses a swab to collect
cells from the vagina and cervix to be tested for human papillomavirus (CPAC, 2019)
Papanicolaou Test (Pap test): a procedure performed by a health care provider in which a small
brush is used to collect cervical cells which are then sampled for cancerous lesions or precancerous cell changes caused by human papillomavirus (CPAC, n.d.)
Patient Navigation: assistance for patients interacting with the health care system, including
booking and attending follow-up appointments (National Cancer Institute, n.d.)
Mobile Health Interventions (mHealth): the use of mobile or wireless devices to deliver health
care, such as text messaging and mobile applications (Dugas et al., 2020)

Author Note: In this review, the term “women” is used to reflect the language commonly found
in the literature and healthcare guidelines on cervical cancer screening and HPV follow-up care.
However, it is important to acknowledge that not all people with cervixes identify as women.
This review is intended to be inclusive of all people with cervixes, including transgender men,
non-binary individuals, and gender diverse people requiring this care.

viii
Acknowledgement
To my endlessly supportive partner Sean, who has encouraged me and motivated me
throughout the program, thank you. I truly could have not done it without you.
To my thesis advisor Catharine, thank you for your mentorship over the last eight months.
Your experience, knowledge and patience were instrumental in guiding me through this process.
To my friends in the program, your support and presence got me through many rocky
starts. I am forever grateful for your humour, passion, and resourcefulness as we navigated this
road together.
To my family and friends, your encouragement from afar has never gone unnoticed. I am
who I am because of your belief in me.

1
Chapter One: Introduction
Cervical cancer (CC) is among the four most common cancers in women around the
world and is now the fastest increasing cancer in women globally (Canadian Cancer Society,
2023; Martinez-Gutierrez et al., 2023). Since 2015, Canada has seen an increase in rates of CC of
3.7% per year, after 30 years of overall decreasing rates due to the introduction of screening
programs and human papillomavirus (HPV) vaccination (Canadian Cancer Society, 2023; Fay et
al., 2024). The reason for this increase is multifactorial, and has been associated with inadequate
screening uptake, including suboptimal rates and poor adherence to follow-up recommendations,
higher rates of HPV due to evolving sexual practices, and poor HPV vaccine coverage (Canadian
Cancer Society, 2023).
In 2023, it is estimated that 1500 people were diagnosed with CC and 400 died from the
disease (Canadian Cancer Society, 2023). Risk factors for developing CC are broad and include
ethnicity, socioeconomic status, living rurally, health status, as well as individual factors
(Canadian Partnership Against Cancer [CPAC], n.d.; Government of Canada, 2024a; Simkin et
al., 2021).The age-standardized incidence rate per 100,000 of CC is highest among those living
in the lowest neighbourhood income quintile (9.0 per 100,000) and those living in rural
communities (9.4 per 100,000) (Statistics Canada, 2023). Moreover, 30% of CC diagnoses in
Canada occur in under-screened groups (Tatar et al., 2023)
The World Health Organization has called for a global strategy to eliminate CC by 2030
through improvements in vaccination, screening, and treatment (World Health Organization,
2020). Canada responded with the Action Plan for the Elimination of Cervical Cancer in Canada
by 2040 through three priorities: improving HPV immunization rates, robust screening HPV
screening, and improving follow-up of abnormal screening results (CPAC, 2019).

2
Cancer screening for CC is available in all Canadian provinces and territories. Canada
has set a target of achieving a screening rate of at least 80% of eligible participants, and in 2017,
the overall participation rate was 76.6% (CPAC, n.d.). British Columbia’s (BC) participation
rates were below the target in 2018 at 67.5% in all age groups (25-69), corrected for
hysterectomies (BC Cancer, 2020). In the lowest neighbourhood income quintile, representing
those whose income falls in the lowest 20% of income distribution federally, screening rates
were notable lower at 66.2%, representing an under-screened and vulnerable group (CPAC, n.d.).
Furthermore, inadequate follow-up for positive screening tests in low-income groups contributes
to disparities in CC rates and subsequent cancer care (CPAC, 2019; Kristiansen, 2019; MartinezGutierrez et al., 2023). Unfortunately, according to CPAC (2019), there is currently no
standardized approach to tracking and monitoring follow-up rates, increasing the risk of patients
being lost to follow-up.
The effectiveness of screening in CC treatment and prevention is highly dependent on the
patient completing follow-up testing. A systematic review by Martinez-Gutierrez et al. (2023)
found high rates of inadequate follow-up, ranging from 4-75%, where younger age, low
socioeconomic status, and lower education levels contributed to inadequate follow-up. Despite
these statistics and the elevated rates of CC in low-income and rural populations, there is a
paucity of Canadian data detailing follow-up rates, nor studies exploring different follow-up
strategies to improve rates in this vulnerable population. This integrative literature review aims
to explore the following question: in low-income women, what strategies are effective in
improving adherence to follow-up care after a positive HPV self-sample?
In this review, I will begin by discussing the etiology of CC and its effects on underscreened groups, including incidence, screening rates and barriers to screening. CC screening in

3
BC, including recent changes in care and new guidelines, will be explored. Current follow-up
practices for positive HPV self-samples will be reviewed. The methods and findings of this
integrative review will be presented, along with a discussion of the results, the limitations found
in existing research studies, and recommendations arising out of this integrative review.
Background
Etiology of Cervical Cancer
The human papillomavirus is a common sexually transmitted infection, affecting up to
70% of Canadians. HPV is the cause of anogenital warts, cancer of the vulva, vagina, penis, and
anus, and is the leading cause of CC (Government of Canada, 2024b; Schmeler, 2024;
Walboomers, 1999). Persistent infections with oncogenic types of HPV, such as HPV 16 and 18,
cause over 70% of CCs, while HPV types 31, 33, 35, 45, 52 and 58 are responsible for
approximately 20% of CCs (Caird et al., 2022). As mentioned, HPV infections are common,
however only a small percentage of affected patients go on to develop CC, as most infections are
transient and cleared by the immune system (Schmeler, 2024). On average, it takes 15 years for
an oncogenic strain of HPV to cause CC, from the initial infection to the development of cervical
neoplasia and invasive cancer (Schmeler, 2024).
Early CC is frequently asymptomatic, highlighting the importance of screening (National
Cancer Institute, 2022). Symptoms present in early disease can include post-coital bleeding,
irregular or heavy vaginal bleeding and changes to vaginal discharge (National Cancer Institute,
2022; Schmeler, 2024). Once the cancer has become advanced and spread to other areas of the
body, symptoms such as fatigue, back pain and pelvic pain, and urinary and bowel symptoms
may present (National Cancer Institute, 2022; Schmeler, 2024).

4
Risk factors for CC are diverse and include HPV and non-HPV related factors. HPVrelated factors include becoming sexually active at an early age, having multiple partners, or
having a partner with multiple partners, a history of other sexually transmitted infections, a
history of vulvar or vaginal cancers, and immunosuppression (Government of Canada, 2024a;
Schmeler, 2024). Low socioeconomic status is an important non-HPV risk factor, likely related
to decreased access to screening and health services (Government of Canada, 2024a; Schmeler,
2024). Additional non-HPV related risk factors for CC include smoking cigarettes, current use of
oral contraceptives, and genetics (Government of Canada, 2024a; Schmeler, 2024).
Cervical Cancer Screening
CC is now considered a preventable disease (CPAC, 2019). Through high sensitivity
testing and early identification and treatment, the disease is highly curable (CPAC, 2019).
Screening for CC comes in two forms: the well-known Papanicolaou test, or Pap test, and the
HPV test (BC Cancer, 2024). The Pap test, also referred to as the cytology method, involves a
health care provider collecting cervical cells which are then sampled for cancerous lesions or
pre-cancerous cell changes caused by HPV (CPAC, n.d.). This method is widely used globally
and has led to a dramatic reduction of the incidence of CC since its implementation in the 1960s
(CPAC, 2019). In HPV testing, cervical cells are collected and tested directly for high-risk types
of HPV (CPAC, 2019). The seminal paper by Walboomers et al. (1999) identified that HPV
causes over 99% of cervical cancer and recommended the use of HPV testing over cytology.
While guidelines globally are slowly incorporating this recommendation, Australia, the United
Kingdom, and The Netherlands have implemented HPV testing as their primary screening
method (CPAC, 2019).

5
The HPV test has several advantages over the Pap test, including the ability to test highrisk HPV strains earlier, before they cause cellular changes that could lead to CC (CPAC, 2019).
Because this testing method has been shown to be more sensitive and objective than the Pap test,
it has allowed screening intervals to be extended to once every five years (BC Cancer, 2024;
CPAC, 2019; Rijkaart et al., 2012). A distinct advantage of the HPV test is the possibility of selfsampling: people may collect their own sample at a time and place that is comfortable and
convenient for them (CPAC, 2019). HPV self-sampling helps overcome barriers associated with
provider collected Pap tests, including lack of a primary care provider or difficulty attending inperson appointments, and stigma related to sexually transmitted infections (STIs).
Currently in Canada, Prince Edward Island and British Columbia have implemented HPV
screening as the primary screening for CC (CPAC, n.d.). Ontario plans to roll out HPV testing
system-wide in 2025, and all provinces and territories but one are planning implementation
(CPAC, n.d.). The Action Plan for the Elimination of Cervical Cancer in Canada has set a target
of reaching 80% of eligible individuals from all groups be up to date with CC screening by 2030
(CPAC, 2019). HPV self-sampling is an integral component of reaching this target for all.
Vulnerable Populations
CC is unequally distributed amongst socioeconomic groups in high-income countries,
despite the availability of publicly-funded HPV immunizations, screening, and treatment, as
evidenced by higher incidence and mortality rates of the disease in low-income groups (Fay et
al., 2024; Murfin et al., 2019; Schmeler, 2024; Statistics Canada, 2023). A trend analysis
conducted in Canada between 1990-2019 found that Canadians with lower household incomes
and education levels experienced higher rates of CC mortality (Fay et al., 2024). This study
corroborates findings of other studies of high-income countries in Europe and the United States

6
(Murfin et al., 2019; Schmeler, 2024). Murfin et al. (2019) posits that these disparities can be
attributed to reduced HPV immunization status and reduced screening rates among low-income
groups.
Screening Rates in Vulnerable Populations
A variety of groups are at risk of being under-screened or never-screened for CC. These
populations include low-income groups, new immigrants, Indigenous groups, sexual and gender
minorities, those living in rural or remote communities, those without primary care providers,
and those with a history of trauma (BC Cancer, 2024; Tatar et al., 2024). The definition of underscreening in the literature varies, but generally refers to individuals overdue for screening based
on established guidelines, i.e. more than five years overdue for screening, or those who have
never been screened (Brewer et al., 2021; Caird et al., 2022; Dutton et al., 2020; Smith et al.,
2018; Tatar et al., 2024). Statistics Canada (2023) reports reduced CC screening rates in the
lowest neighbourhood income quintiles in Canada (Q1, Q2) at 66.2% and 73.3% respectively,
compared with an average of 81.03% CC screening rates in the highest neighbourhood income
quintiles (Q3-Q5).
Screening Barriers
Barriers for CC screening exist in multiple forms: system barriers, socioeconomic
barriers, sociocultural barriers, and psychological barriers (Caird et al., 2022; Tatar et al., 2024).
Restricted screening, such as only providing CC screening in health clinics, is both a system
barrier and a socioeconomic barrier. Restricted CC screening prioritizes those physically and
financially able to access medical clinics, while those without access to a vehicle or childcare are
more likely to be excluded from accessing screening. A lack of cultural sensitivity, including
gender and modesty preferences or mistrust in healthcare providers, can represent a significant

7
sociocultural barrier for new immigrants or Indigenous people in accessing CC screening
(Molokwu et al., 2018; Tatar et al., 2024). Psychological factors also represent screening barriers,
such as the stigma associated with testing positive for an STI, embarrassment, and lack of
knowledge regarding the relationship between HPV and CC (Molokwu et al., 2018; Tatar et al.,
2024; Victoria et al., 2020). Together, these barriers are significant and may contribute to reduced
CC screening rates in vulnerable populations.
Follow-up for Cervical Cancer Screening
Appropriate follow-up is an integral component of CC screening. Without timely followup, further investigations and early treatment initiation will not occur and the individual will be
at risk of the disease progressing (CPAC, 2019). The barriers to screening previously described
are important to consider, as they represent barriers to adherence to follow-up as well. The
follow-up process for an HPV-positive self-sample is a multi-step and timely process and largely
falls on the individual patient to complete.
In BC, all HPV self-sample CC screening results are reported to both the patient and their
primary care provider (BC Cancer, 2024). Patients without a primary care provider are notified
of their result by BC Cancer, either online or by mail, and directed to the appropriate follow-up
test (BC Cancer, 2024). Individuals who test positive for HPV 16/18 are referred for colposcopy,
and those who test positive for other high-risk strains are recommended to have a provider
collected Pap test (BC Cancer, 2024). A colposcopy is a procedure to further examine the cervix
for abnormalities; if abnormalities are noted, a biopsy will be taken to determine the next steps
(BC Cancer, 2025). Depending on the biopsy results, the individual is referred to treatment (BC
Cancer, 2025).

8
As mentioned, certain groups, such as low-income populations, face barriers to access
CC screening. Furthermore, adherence to follow-up recommendations in high-risk groups is less
than optimal. Hui et al. (2014) found that adherence rates were lowest among low-income, inner
city African American women, with 30-40% adherence to follow-up recommendations.
Similarly, a British retrospective analysis (Douglas et al., 2015) reported that individuals living
in the lowest income quintile were less likely to adhere to a recommendation for a follow-up
colposcopy. A systematic review conducted by Martinez-Gutierrez et al. (2023) identified 41
distinct factors associated with inadequate adherence to follow-up care, however lowsocioeconomic status emerged only in some studies. Despite these inconsistent findings, lowincome populations remain at greater risk for CC-related morbidity and mortality, highlighting
the need for further research on effective follow-up strategies in this population (Fay et al., 2024;
Murfin et al., 2019; Schmeler, 2024; Statistics Canada, 2023).
Interventions to Increase Adherence to Follow-up Care
Interventions designed to reduce barriers to follow-up care and increase the engagement
of high-risk groups are essential for improving HPV-positive follow-up rates. Several follow-up
strategies have been proposed and studied in middle-and high-income countries following a
positive Pap test; however, examining effective follow-up interventions specifically in lowincome individuals after a positive HPV self-sample has remained under explored (MartinezGutierrez et al., 2023; Varon et al., 2024). Some proposed interventions include direct
communication with patients to deliver their HPV results, multi-component notification systems,
patient navigation to assist with booking and attending follow-up appointments, and education
regarding HPV and its connection to CC (Arrossi et al., 2022; Dunn et al., 2013; Kristiansen et
al., 2019; Martinez-Gutierrez et al., 2023; Varon et al., 2024).

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Chapter Two: Methods
An integrative review is a method of presenting a thorough and comprehensive overview
on a topic through the synthesis and analysis of diverse types of literature (Toronto &
Remington, 2020; Whittemore & Knafl, 2005). The aim of this integrative review is to explore
the following question: In low-income women, what follow-up strategies are effective in
improving adherence to follow-up care after a positive HPV self-sample? This integrative review
was conducted following the Whittemore and Knafl (2005) methodology.
Design
The research question was designed with the Population, Intervention, Outcome (PIO)
framework, which is a variant of the Population, Intervention, Comparison, Outcome (PICO)
model (Grove, 2021a). The PIO design was selected due to the limited amount of data available
comparing different follow-up strategies; thus, no specific comparator was utilized. The
population of focus was low-income women; the intervention was follow-up strategies; and the
outcome was improving adherence to follow-up recommendations in HPV-positive self-samples.
Databases
Several databases were utilized for the search process. The Cumulative Index to Nursing
and Allied Health Literature (CINAHL) and Medline through OVID were accessed via the
University of Northern British Columbia online library database. These databases were selected
due to their nursing and medical focus. Hand searching was performed via Google Scholar to
reach articles that may not have been indexed in the databases and ensure that the overall search
was comprehensive. Ancestry searching was performed by reviewing the reference list of
relevant articles; this step did increase the volume of articles retrieved for review.

10
Search Terms
Search terms were generated based on the research question and the various synonyms
for each term. See Appendix A for a description of how the terms were applied in the databases.
Table 1 provides the search terms aligned with each component of the PIO question design.
Table 1
Search Terms
Population

Intervention

Outcome

("MH Socioeconomic Factors" or "MH Poverty" or "MH Working Poor" or
"MH Social Class" or "MH Medically Underserved" or "MH Healthcare
Disparities" or (low* adj3 (income or socioeconomic* or "social class" or
SES or "social status")) or (poverty or impoverished or disadvantaged or
"working poor") or (economic* adj3 (disadvantag* or hardship* or
deprive*)) or (underserved or "under served" or underresourced) or
(vulnerab* adj3 (population* or group* or communit*)))
((cervix or cervical) N4 (self-screen* or "self screen*" or self-collect* or
"self collect*" or self-sampl* or "self sampl*" or self test* or self-test*) OR
((HPV or "Human papillomavirus") N4 (self-screen* or "self screen*" or
self-collect* or "self collect*" or self-sampl* or "self sampl*" or self-test* or
self test)) OR
((MH cervical smears) or (MH papillomavirus infections) or (MH Human
papillomavirus Viruses) or (MH Cancer Screening) or (MH Early Detection
of Cancer) AND (self-screen* or "self screen*" or self-collect* or "self
collect*" or self-sampl* or "self sampl*" or self test* or self-test*))
("Follow-Up Studies/" or "Patient Follow-Up/" or "Continuity of Patient
Care/" or "Aftercare/" or follow-up or "post-treatment care" or monitoring or
tracking or care continuity or recall or re-engagement or retention in care)

Data Management
In total, the search generated 88 studies for consideration in this integrative review. The
search produced seven studies from CINAHL, 23 from Medline through OVID, 21 from Google
Scholar, and 37 from ancestry searching. The studies were input into Covidence, an online,
systematic review tool, for title, abstract, and full text review (Veritas Health Innovation, n.d.).
Covidence removed 12 duplicate studies, leaving 76 studies to be reviewed by title and abstract,
which further excluded 22 studies. The final 54 studies were read in full and considered based on

11
inclusion and exclusion criteria. As the data was retrieved and sorted by the author, Covidence
generated a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)
flowchart according to these steps. This flowchart is shown in Figure 1.

12
Figure 1

Identification

PRISMA Flowchart

CINAHL
(n = 7)

Medline
through OVID
(n = 23)

Google
Scholar
(n = 21)

Ancestry
searching
(n = 37)

Included

Screening

Duplicates
removed
(n = 12)

Studies screened (n = 76)

Studies excluded (n = 22)

Studies sough for retrieval (n = 54)

Studies not retrieved (n = 0)

Studies assessed for eligibility (n = 54)

Studies included in review (n = 8)

Studies excluded n = 46
Wrong setting (n = 3)
Wrong outcome (n = 18)
Wrong intervention n = 5
Wrong study design (n =
4)
Wrong population (n = 11)
No final result (n = 2)

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Inclusion and Exclusion Criteria
Integrative reviews typically address broad, overarching questions and this may result in
a high number of articles retrieved in the initial database search (Toronto & Remington, 2020).
Implementing limiting criteria is a method of refining a search to ensure it remains relevant and
focused on the research question of the integrative review. Inclusion and exclusion criteria are
characteristics that the literature must contain for the study to be included in the integrative
review (Toronto & Remington, 2020).
The literature search was focused on finding articles that discuss follow-up strategies for
low-income women who received a positive HPV self-sample result. As a result, one of the
inclusion criteria was that the study population focused on low-income women. There were no
exclusion criteria related to ethnicity so that the results could capture all groups of low-income
women who had been studied. Articles that focused on HPV self-sampling specifically were
included, while studies that focused on Pap testing were excluded. To be included in the
integrative review, the studies needed to focus on adherence to follow-up and follow-up
recommendations by the study population. Follow-up was defined as completion of further
recommendations for care, such as completion of a Pap test or colposcopy. Only completed
primary research articles were included in the review, and therefore systematic reviews were
excluded. There were no exclusion criteria related to geography in order to maximize available
data. Studies published between 2015 from 2024 were selected to ensure a broad and relevant
review, and this time frame reflects the emerging availability of HPV self-sampling data. Based
on these criterion, eight studies were ultimately selected for this integrative review.

14
All inclusion and exclusion criteria are summarized in Table 2. The studies selected for
this integrative review were read comprehensively three times by the author before data was
extracted and organized into the review matrices as shown in Appendix B.
Table 2
Inclusion and Exclusion Criteria for Research Article Selection

Population
Intervention
Outcome
Study characteristics
Geography
Date

Inclusion
Low-income
HPV self-sample
Adherence to follow-up
Primary research studies
Worldwide
2015-2024

Exclusion
All others
Pap test
All others
Systematic Reviews
None
Prior to 2015

Data Analysis
The eight studies included in this integrative review were critically appraised by the
author using the Critical Appraisal Skills Program (CASP) checklists (CASP, 2025). Quality
appraisals for the included studies ranged from moderate to high quality. No study was excluded
based on its CASP rating to ensure that all available literature on this topic was captured in the
integrated review findings. The CASP rating for each study is included in the review matrices in
Appendix B.

15
Chapter Three: Findings
Eight studies were included in this integrative review to evaluate effective follow-up
methods for improving adherence to care recommendations after a positive HPV self-sample in
low-income women. The findings of these studies revealed that follow-up rates were
inconsistent, multiple follow-up notification methods resulted in improved adherence to followup care, and including additional interventions contributed to enhanced adherence of follow-up
recommendations.
Study Characteristics
Of the eight studies included in the review, three were randomized controlled trials
(Brewer et al., 2021; Molokwu et al., 2018; Pretsch et al., 2023), four were cross-sectional
studies (Crosby et al., 2015; Dutton et al., 2020; Lea et al., 2019; Mremi et al., 2021) and one
was a descriptive quantitative study (Tamalet et al., 2016). Since integrative reviews aim to
synthesize diverse sources of evidence, including a variety of study designs allows for a more
comprehensive analysis of the topic (Whittemoore & Knafl, 2005). See Table 3 for study
characteristics.

16
Table 3
Study Characteristics
Study

Type

Location

Setting

Sampling

Mean
Age

LowIncome
Status

Last Cervical
Screening

Brewer
et al.,
2021

RCT Auckland,

Urban

Purposive

44

Majority

>3 years

Crosby
et al.,
2015

C-S

Kentucky,
USA

Rural

Purposive,
convenience

47.5

All

>3 years

Dutton et
al., 2020

C-S

New
South
Wales,
Australia

Rural

Snowball,
convenience

40.5

All

>3 years

Lea et
al., 2019

C-S

North
Carolina,
USA

Mixed

Purposive

44.6

All

>3 years

Molokwu
et al.,
2021

RTC

Texas,
USA

Urban

Purposive

46

All

>3 years

Mremi et
al., 2021

C-S

Tanzania

Rural

Purposive

44

All

Not stated

Pretsch
et al.,
2023

RTC

North
Carolina,
USA

Urban

Purposive

42

All

>3 years

Tamalet
et al.,
2016

DQ

Marseille,
France

Urban

Purposive

50.6

All

>2 years

NZ

Note. C-S = cross-sectional; DQ = descriptive quantitative; RTC = randomized controlled trial.

17
Four studies were conducted in North America (Crosby et al., 2015; Lea et al., 2019;
Molokwu et al., 2018; Pretsch et al., 2023), two studies in Oceania (Brewer et al., 2021; Dutton
et al., 2020), one study in Africa (Mremi et al., 2021), and one study in Europe (Tamalet et al.,
2016). The studies were conducted in a variety of contexts: three studies were conducted in rural
areas (Crosby et al., 2015; Dutton et al., 2020; Mremi et al., 2021), one study was completed in
an area of mixed rural and urban (Lea et al., 2019), and four studies were in urban contexts
(Brewer et al., 2021; Molokwu et al., 2018; Pretsch et al., 2023; Tamalet et al., 2016).
The studies recruited their participants by purposive, snowball, and convenience
sampling. Six studies employed purposive sampling (Brewer et al., 2021; Lea et al., 2019;
Molokwu et al., 2018; Mremi et al., 2021; Pretsch et al., 2023; Tamalet et al., 2016), while
Dutton et al. (2020) recruited participants through convenience and snowball sampling, and
Crosby et al. (2015) combined purposive and convenience sampling. Each of these sampling
methods was appropriate for recruiting participants in these studies. Purposive sampling was
suitable as it ensured participants met the specific characteristics required for the studies being
conducted (Andrade, 2020). Snowball sampling, or network sampling, utilizes the network of the
purposive sample as a means of expanding the sample size, thereby reaching more participants
with similar characteristics (Grove, 2021b). Although convenience sampling is a non-probability
method, it was justified in Crosby et al. (2015) and Dutton et al. (2020) since the study
communities included participants with the necessary characteristics for their respective studies
(Grove, 2021b). The studies included a total of 7,616 participants, with an average age of 44.9
years old.
Since it has been demonstrated in the literature that socioeconomic status plays a critical
role in CC morbidity and mortality, this review focused on studies examining low-income

18
populations. In all studies included in this integrative review, either the majority or entirety of
participants were classified as low-income. Brewer et al. (2021) included a majority low-income
population at 60% of the sample, while Dutton et al. (2020), Crosby et al. (2015), Lea et al.
(2019), Molokwu et al. (2018), Mremi et al. (2021), Pretsch et al. (2023), and Tamalet et al.
(2016) exclusively studied low-income individuals. Low-income status was determined using
various criteria, including residence in economically depressed regions, enrollment in Medicare
or Medicaid, lack of health insurance, income below 200% or 250% of the U.S. federal poverty
line, and education level not exceeding Grade 12. Refer to Table 4 for low-income determination
per study.
Table 4
Participant Income Status
Study

Low-Income Status Determination

Brewer et al. (2021)

Geographical region

Crosby et al. (2015)

Geographical region

Dutton et al. (2020)

Geographical region

Lea et al. (2019)

Enrolled in Medicaid, uninsured, 200% below US poverty line

Molokwu et al. (2018)

Majority uninsured

Mremi et al. (2021)

Geographical region, majority not education beyond age 12

Pretsch et al. (2023)

Enrolled in Medicaid, uninsured, 250% below US poverty line

Tamalet et al. (2016)

Geographical region

Four studies explicitly identified participants as low-income (Lea et al., 2019; Crosby et
al., 2015; Pretsch et al., 2023; Tamalet et al., 2016). In others, low-income status was inferred
based on limited educational attainment (Mremi et al., 2021) or a high percentage of uninsured

19
participants (Molokwu et al., 2018). Additionally, 60% of Brewer et al.’s (2021) participants
lived in areas of high socioeconomic deprivation, further supporting their classification as lowincome. Dutton et al. (2020) did not provide detailed demographic data, but the study was
conducted in rural and remote Aboriginal communities in New South Wales, Australia - regions
known for having some of the lowest income levels in the state (Vidyattama et al., 2019).
Furthermore, Aboriginal populations in Australia are twice as likely to experience poverty
compared to non-Aboriginal individuals (Vidyattama et al., 2019).
Inconsistent Follow-up Rates
A key finding across the studies included in this review was the inconsistency of adequate
follow-up among HPV-positive participants after HPV self-sampling. In the studies reviewed,
follow-up rates for HPV-positive participants ranged from 5.6%- 92%. Crosby et al. (2015)
achieved the lowest follow-up rate (5.6%) of all the studies included, and Brewer et al. (2021)
achieved the highest rate of follow-up (92%). The average follow-up rate for all the studies was
57%.
Adequate follow-up was defined in these studies as achieving at least 60% follow-up in
HPV-positive participants. That is, at least 60% of participants attended follow-up
recommendations based on their HPV results. This threshold was met in four studies (Brewer et
al., 2021; Molokwu et al., 2018; Mremi et al., 2021; Tamalet et al., 2016).
Multiple Follow-up Methods
Every study in the review communicated directly with the participants to deliver HPV
self-sample results. Each study followed-up with the participants directly with a phone call to
communicate HPV results, either as the sole method of communication or in combination with

20
one of the following other methods: phone call, text message, postal mail, or home visit. See
Table 5 for the follow-up methods used in each study, as well as the rates of follow-up achieved.
Table 5
Follow-up Methods and Rates of Follow-up
Study

Phone

Text
message

Mail

Brewer et al., 2021

X

Crosby et al., 2015

X

Dutton et al., 2020

X

Lea et al., 2019

X

Molokwu et al.,
2018

X

Mremi et al. 2021

X

Pretsch et al., 2023

X

X

Tamalet et al., 2016

Y

Y

Home
visit

Did not
specify

X

HPV + follow-up
rate
92%
5.6%

X

X

46%
58%

X

66%

X

82%
43%
X

66%

Note. X = method used by study; Y = method used by study after second HPV-positive selfsample.
Two studies delivered the results by phone call alone (Crosby et al., 2015; Lea et al.,
2019). The six remaining studies employed a combination of follow-up strategies: phone call and
mail notification (Molokwu et al., 2018; Pretsch et al., 2023), phone call and text message
(Mremi et al., 2021), phone call and home visit (Brewer et al., 2021), or phone call, mail
notification and home visit (Dutton et al., 2020). Tamalet et al. (2016) did not specify the initial
communication follow-up strategy used with participants; however, the authors did specify that
they had contacted participants by phone call or mail after a second positive HPV self-sample
had been received.

21
Adequate follow-up was more likely to be achieved when more than one follow-up
strategy was used. Four out of eight studies achieved a follow-up rate of over 60% (Brewer et al.,
2021; Molokwu et al., 2018; Mremi et al., 2021; Tamalet et al., 2016). Each of these studies used
a combination of methods described above. The combination of phone call and home visit
achieved the highest follow-up rate at 92% (Brewer et al., 2021), followed by text message and
phone call at 82% (Mremi et al., 2021). Molokwu et al. (2018) and Tamalet et al. (2016)
achieved a follow-up rate of 66%; both studies used phone call and mail notification for result
delivery.
The remaining four studies did not achieve the 60% follow-up threshold, and they all
used similar result notification strategies. Crosby et al. (2015) utilized phone follow-up alone and
achieved a 5.6% follow-up rate. Similarly, Lea et al. (2019) used phone follow-up as the sole
method of communication and reached 58% follow-up. Pretsch et al. (2023) used phone and mail
notification for result delivery and achieved a follow-up rate of 43%. Dutton et al. (2020)
employed the most intensive follow-up strategies (phone call, mail notification, and home visit),
but achieved a follow-up rate of only 46%.
Only one study commented on the total time spent with participants to communicate the
HPV result (Brewer et al., 2021). This study reported an average time of 2.5 hours delivering
results to each participant and achieved a follow-up rate of 92%. None of the other studies
reported the amount of time spent communicating results to participants.
Additional Interventions
In addition to the follow-up methods described above, several studies employed further
interventions as part of their study protocols. Such additional interventions utilized by the
researchers included providing patient education (Crosby et al., 2015; Molokwu et al., 2018;

22
Mremi et al., 2021), patient navigation for scheduling follow-up procedures (Crosby et al., 2015;
Mremi et al., 2021; Pretsch et al., 2023) and mailing a second HPV self-sample to HPV-positive
participants without follow-up at 12 months (Tamalet et al., 2016). See Table 6 for intervention
details.
Table 6
Intervention Details
Study

Education

Second HPV
self-sample

Patient
navigation

HPV + follow-up
rate

Brewer et al. (2021)
Crosby et al. (2015)

92%
X

X

5.6%

Dutton et al. (2020)

46%

Lea et al. (2019)

58%

Molokwu et al.
(2018)

X

Mremi et al. (2021)

X

66%

Pretsch et al. (2023)
Tamalet et al. (2016)

X

82%

X

43%

X

66%

Patient Education
Three studies provided HPV education to participants at different points in their protocols
(Crosby et al., 2015; Molokwu et al., 2018; Mremi et al., 2021). This educational information
was delivered to participants by health outreach workers or by nurses involved in the study. The
timing of the education was as follows: either prior to HPV self-sampling (Molokwu et al., 2018;
Mremi et al., 2021), or during follow-up phone calls (Crosby et al., 2015).

23
Molokwu et al. (2018) developed patient education materials at a Grade 6 reading level
and included information regarding susceptibility and severity of HPV infections, CC screening
and prevention through immunization, and safe sex practices. Participants in the study received
education through one of two formats: a high-intensity PowerPoint presentation delivered by a
community worker, or a low-intensity pamphlet (Molokwu et al., 2018). Both groups were given
the pamphlet to keep. Information regarding self-sampling, sample collection technique, and test
reliability was also included. Post-survey questionnaires found that HPV knowledge was
significantly associated with a follow-up Pap test (p=0.033), and that the high-intensity
intervention resulted in statistically significant improvement in HPV knowledge (p=<0.001).
Molokwu et al. (2018) achieved a follow-up rate of 66% in the HPV-positive study participants.
Mremi et al. (2021) delivered HPV education after providing instructions on how to
collect the self-sample. The study nurses reviewed the implications of an HPV-positive result
with each participant individually. Following self-sampling, the participants completed a
questionnaire and 98.9% of the participants reported no difficulty understanding the self-sample
collection instructions. Additionally, most of the participants reported high acceptability of HPV
self-sampling and “found the procedure easy to perform” (Mremi et al., 2021, p. 808). They had
a follow-up rate of 82% (Mremi et al., 2021).
Crosby et al. (2015) delivered tailored education to the HPV-positive participants during
the result notification phone call from the study nurse. The education included information on
HPV and its link to CC, the risk of developing CC with a positive HPV result, and the
importance of a follow-up Pap test to detect cellular changes of the cervix. All participants were
successfully contacted and received both their results and HPV-related education in a single

24
phone call. Despite this intervention, the study achieved a follow-up rate of only 5.6% (Crosby et
al., 2015).
Patient Navigation
Patient navigation, defined as assisting participants to book their follow-up procedures,
was demonstrated in three studies (Crosby et al., 2015; Mremi et al., 2021; National Cancer
Institute, n.d.; Pretsch et al., 2023). Patient navigation occurred either via text message or phone
call.
Mremi et al. (2021) delivered patient navigation via text message to HPV-positive
participants. The text messages did not include the actual test result, but rather requested that the
participant present for a follow-up appointment at a future date. These text messages were sent
out four times between 14 days and one day prior to the appointment with reminders to attend
the follow-up appointment. If participants did not attend, they were then called directly and
navigated to follow-up. These collective efforts resulted in a follow-up rate of 82% (Mremi et al.,
2021).
Crosby et al. (2015) and Pretsch et al. (2023) called their study participants to provide
patient navigation. Crosby et al.’s (2015) participants were offered scheduling assistance when
their results were delivered by phone. The patient navigation included information on free or
sliding-scale screening available locally for follow-up procedures. The participants were
contacted an additional two times for further navigation assistance if they did not complete the
recommended follow-up (Crosby et al., 2015). Further, when analyzing covariates, Crosby et al.
(2015) found that those who were contacted for a second navigation attempt were less likely to
attend follow-up. The authors could not deduce whether motivational issues or access issues

25
impacted the poor follow-up rate, creating a lack of statistical power in the study (Crosby et al.,
2015). These interventions resulted in a follow-up rate of 5.6%.
Pretsch et al.’s (2023) study delivered HPV results by phone, contacting participants up
to three times for patient navigation to schedule a follow-up appointment. Participants in this
study also received information on low-or no-cost Pap tests. This resulted in a follow-up rate of
43% for HPV-positive participants (Pretsch et al., 2023).
Provision of Additional Self-Sample
Tamalet et al. (2016) employed one additional intervention that was not used in any other
study. Participants who tested positive for HPV but did not complete follow-up recommendations
within 12 months were sent another HPV self-sample in the mail. This strategy enabled recovery
of 50% of the participants initially lost to follow-up and resulted in a total follow-up rate of 66%.
Furthermore, the authors found that 43% of those with previous HPV-positive results were
ultimately able to clear the infection.
Strengths and Limitations of the Literature in this Review
Strengths and limitations were noted in several domains in the literature included in this
for review. While the diverse methodologies provided a broad perspective on follow-up
strategies, they also introduced variability that impacted the ability to draw direct comparisons. A
total of three different study designs were represented in the articles included in this review. Four
studies used a cross-sectional study design without a control group (Crosby et al., 2015: Dutton
et al., 2020; Lea et al., 2019; Mremi et al., 2021), making it difficult to establish causation and
increased the risk of confounding bias (Sterne et al., 2024). Tamalet et al. (2016) employed a
descriptive quantitative design, which shares characteristics with a cross-sectional approach and
carries similar limitations, such as confounding bias and challenges in establishing causation

26
(Sterne et al., 2024). Three of the studies used randomized controlled trials (Brewer et al., 2021;
Molokwu et al., 2021; Pretsch et al., 2023), allowing the researchers to compare interventions
(Sterne et al., 2024). While varied methodologies are important for a comprehensive integrative
review, this diversity also contributes to significant heterogeneity in the study settings,
populations, and interventions, thereby limiting generalizability (Whittemore & Knafl, 2005).
Most of the studies used purposive sampling to recruit their participants, which enabled
the researchers to sample the target population but does carry the risk of self-selection bias
(Sterne et al., 2024). Further, most of the study sample sizes were small, contributing to the
increased risk of confounding bias and limited statistical power (Sterne et al., 2024).
Only one study identified a theoretical framework to inform their study, the Health Belief
Model (Molokwu et al., 2018). This framework is considered foundational in health behaviour
research, and it was created for deeper understanding of health prevention behaviour, such as
cancer screening (Alyafei & Easton-Carr, 2024). Incorporating a theoretical framework allows
researchers to ground their work in a logical framework that is linked to a wider body of
knowledge (Bomer-Norton, 2021). Without a theoretical framework, the findings of these studies
may lack connection to existing research within the field, increasing the risk of misinterpretation
or unintended application of results (Bomer-Norton, 2021).
The duration of the studies ranged from six months (Crosby et al., 2015), to 47 months
(Pretsch et al., 2023). The studies of shorter duration may have had limited capacity to assess
information about long-term adherence to follow-up recommendations. Most studies verified the
completion of follow-up recommendations through chart verification, thereby ensuring accurate
results. One exception was Lea et al. (2019), who relied on participant reporting, increasing the

27
risk of reporting bias. Tamalet et al. (2016) did not report the follow-up verification strategy
used, thereby reducing transparency of the research.
Six studies incorporated surveys, including four Likert scales and two questionnaires.
However, no study reported utilizing a validated questionnaire or tool to create their surveys,
raising concerns about data validity and measurement bias (Grove, 2021c).
Finally, the studies reviewed took place in both high-income and low-income countries,
which leads to marked heterogeneity of culture, health care settings, and participants. This
variability makes cross-study comparison more challenging.
Several strengths were identified in the studies reviewed. Most of the studies had clear
and consistent inclusion and exclusion criteria, improving comparability among studies. Only
one study, Dutton et al. (2020), did not provide detailed information about the inclusion and
exclusion criteria used. Across the studies, completion of a follow-up test or colposcopy was
consistently defined as adequate follow-up after a positive HPV self-sample, ensuring a uniform
outcome measure.

28
Chapter Four: Discussion
This integrative review evaluated different follow-up strategies to determine which are
effective in improving adherence to follow-up care after a positive HPV self-sample in lowincome women. The findings show inconsistent follow-up rates for HPV-positive participants.
Further, the findings indicate that achieving adequate follow-up in this population is resourceintensive and may require more thorough interventions to complete care recommendations.
Specifically, multiple communication modalities may be required to achieve adequate follow-up,
and the addition of patient navigation, HPV education, and the provision of a second HPV selfsample may be useful.
Follow-up rates were inconsistent between studies, ranging from 5.6% to 92% of HPVpositive participants successfully completing further recommendations for care. Several factors
may account for these inconsistent results, such as the diverse study settings, the varied
population, or the interventions themselves. In the literature, follow-up rates for abnormal CC
screening in diverse populations were also varied, with one systematic review reporting followup rates between 25-96% (Martinez-Gutierrez et al., 2023). These inconsistent results underline
the importance of further research on effective ways to follow-up with this population.
Multi-follow-up Strategy
A crucial follow-up strategy identified in the studies was phone follow-up; all studies
contacted their participants via phone call at some point in the result notification process.
Employing a second result notification strategy improved adherence to follow-up, with follow-up
rates ranging from 66%-92% in studies that used more than one method (Brewer et al., 2021;
Molokwu et al., 2018; Mremi et al., 2021; Tamalet et al., 2016). These results are significant as
they demonstrate that continued follow-up attempts with HPV-positive individuals are effective

29
in ensuring adherence to care recommendations, suggesting that a successful follow-up strategy
requires multiple methods of communication.
Several other studies reproduced these results in the literature (Arrossi et al., 2022;
Sultana et al., 2022; Varon et al., 2024). Sultana et al. (2022) notified their participants with a
letter and a reminder phone call by a physician liaison, resulting in 84% follow-up for HPVpositive participants. Arrossi et al. (2022) implemented a multi-component intervention of text
messages and a home visit by a community health worker that achieved successful follow-up of
70.5% of participants. Varon et al.’s (2024) systematic review found that participants were more
likely to complete follow-up recommendations when multiple interventions were incorporated,
such as combining patient education with patient navigation. While the participants in these
studies were not entirely low-income, Sultana et al. (2022) did focus on never-and underscreened individuals, and Arrossi et al.’s (2022) population was from a country with an overall
low adherence to follow-up, making their findings relevant to population included in this
integrative review. Additionally, 1/3 of the studies reviewed by Varon et al. (2024) used
interventions specific to low-income populations.
Home Visits
Two studies used home visits as part of the intervention strategy, with one study
achieving a high follow-up rate and one study not reaching the 60% follow-up threshold (Brewer
et al., 2021; Dutton et al., 2020). This strategy has been used in other studies with promising
results in a variety of contexts (Arrossi et al., 2022; Martinez-Gutierrez et al., 2023). While some
countries use home visits routinely as part of their health care system, this may not be a feasible
strategy for middle-to high-income countries. In the Canadian context, home visits are reserved
mostly for those with extensive needs, such as bathing and dressing, or for palliative care

30
(Government of British Columbia, 2025). As such, utilizing home care nurses to encourage
effective CC screening follow-up in certain populations would constitute a significant shift in the
allocation of resources and is likely not feasible in a public health care system.
Mobile Health Interventions
Mremi et al. (2021) was the only study that utilized mobile health (mHealth)
interventions (text messages) as their primary method of communication, and successfully
achieved follow-up in 82% of participants. The results of their study may indicate that using
mHealth interventions to communicate with patients is an effective way to ensure follow-up in
this population. As mentioned previously, an Argentinian study employed a similar mHealth
strategy and achieved high rates of follow-up (Arrossi et al., 2022). Additionally, a 2021 scoping
review examining mHealth strategies to improve CC screening rates found that mHealth
interventions were associated with an increased uptake of screening (Bhochhibhoya et al., 2021).
Despite the apparent effectiveness of this follow-up strategy, the use of mHealth interventions is
currently under-explored in low-income populations as a follow-up strategy, and further research
is needed in a variety of settings to assess its applicability and usefulness. Interestingly, none of
the studies included in this integrative review, nor encountered in the literature, reporting using
email to contact patients. Email communication may represent an additional underexplored
resource for communicating with patients and supporting appropriate follow-up after an HPVpositive result.
Patient Navigation
Patient navigation is a follow-up strategy known to be effective in improving screening
rates and follow-up in cancer care in general (Chen et al., 2024). This strategy was used in three
studies with mixed results (Crosby et al., 2015; Mremi et al., 2021; Pretsch et al., 2023). This

31
review showed that patient navigation via text message resulted in adequate follow-up in one
study (Mremi et al., 2021), but not in the two other studies employing patient navigation by
phone call (Crosby et al., 2015; Pretsch et al., 2023). A recent systematic review showed that
patient navigation was found to be statistically significant with follow-up for an abnormal
cervical screening result, compared with studies that did not use patient navigation (Varon et al.,
2024). Moreover, it has been shown to reduce time between diagnosis and treatment in other
cancers (Chen et al., 2024). Despite patient navigation being successful in only one study in this
review, this evidence reinforces the importance of continuing to explore the effect of patient
navigation via different modalities on improving follow-up care in this population.
Education
HPV education was provided in three studies with varying degrees of effectiveness
(Crosby et al., 2015; Molokwu et al., 2018; Mremi et al., 2021). Two studies delivered HPV
specific education prior to self-sample collection, and both achieved adequate rates of follow-up
(Molokwu et al., 2018; Mremi et al., 2021). The third study only provided education to
participants who tested positive for HPV and only during their follow-up calls; they did not
achieve adequate follow-up rates (Crosby et al., 2015). Additionally, the content of the education
delivered was varied, where one study provided high-intensity patient education by a health
worker, and the others provided less detailed education. This suggests that the timing of HPV
education delivery, as well as the content of the education, is important and may contribute to
higher rates of follow-up if it is utilized.
Lack of education or misinformation regarding HVP and CC has been identified as a
barrier to cervical screening and follow-up adherence (Victoria et al., 2020). Further, Sossauer et
al. (2014) found that high-intensity education was positively correlated with higher knowledge

32
regarding HPV and CC. However, only one study in two systematic reviews examining factors
influencing follow-up care included education as an intervention (Martinez-Gutierrez et al.,
2023; Varon et al., 2024). This lack of information represents a significant gap in the literature
and requires further study on the effect of HPV-specific education on follow-up rates and,
specifically, the timing and intensity of such education.
Provision of Additional Self-Sample
Sending a second HPV self-sample was a novel intervention only implemented in one
study, Tamalet et al. (2016). This intervention recovered 50% of HPV-positive participants who
did not attend follow-up recommendations (Tamalet et al., 2016). Comparable results were found
by an Australian randomized controlled trial, where never-and under-screened HPV-positive
participants not attending recommended follow-up were mailed a second HPV self-sample kit
(Sultana et al., 2022). This additional intervention re-captured 37/108 participants who had been
lost to follow-up and resulted in an overall follow-up rate of 59.3%. This particular intervention
is rarely seen in the literature and may represent an understudied strategy to improve follow-up
rates in this population.
Time Consideration
Only one study quantified the amount of time researchers spent delivering results to
ensure adequate follow-up for HPV-positive participants (Brewer et al., 2021). None of the other
studies reported this variable, which may be an important factor to consider in this population.
Nevertheless, most of the studies employed at least two follow-up strategies, implying that
delivering results requires intensive human resources, regardless of whether adequate follow-up
is achieved. This variable may be an important outcome for further research to examine, as

33
resources in most health care settings are already limited. Further, this may represent an area in
which mHealth interventions could be useful in reducing human resource expenditure.
Implications for Research and Policy
Effective follow-up strategies for HPV-positive low-income women that result in further
care remain inconsistent. The literature has shown that using multiple communication strategies
is important in achieving follow-up in this population. MHealth, patient navigation, and HPVspecific education may be effective interventions and are key areas for further research. This
review found that Canadian studies in this discipline are sparse: therefore, conducting
longitudinal research in the form of randomized controlled trials to assess the effectiveness of
multi-modal strategies is necessary to improve the generalizability of results within the Canadian
context.
While low-income women have been named a vulnerable population in several important
practice documents (BC Cancer, 2024; CPAC, 2019), Current Oncology guidelines on
management of a positive HPV self-sample have excluded this important population (Zigras et
al., 2023). For outcomes to improve in low-income individuals, all major guidelines must
consistently define vulnerable populations to offer actionable practice recommendations for
policy makers and health care providers. Further research is essential to develop evidence-based
strategies that address the specific needs of this group.
Strengths and Limitations of this Integrative Review
There are several limitations in this integrative review. Despite effort to include all
relevant studies, some research may have been missed. The small number of studies reviewed is
a limitation, further narrowed by the focus on self-sampling, as significant data exists for followup after a positive Pap test. While the U.S. has a substantial amount of research on low-income

34
women, no studies specifically examining effective follow-up strategies for low-income women
in Canada were found. Additionally, including studies from both high-income and low-income
countries, and with varied healthcare systems and cultures, limits the generalizability of the
results, despite the focus on low-income populations.
However, this review has notable strengths. It was guided by an established framework
(Whittemore & Knafl, 2005) and by the validated CASP tool (CASP, 2025), which enhances the
rigor of the review. Furthermore, as Canada is currently shifting to self-sampling as the primary
method of CC screening, this review is timely and relevant.

35
Chapter Five: Conclusion
Adequate follow-up after a positive HPV self-sample result is crucial in reducing
morbidity and mortality of CC, particularly in low-income women who often face significant
barriers to care. This review identified several promising interventions, including multi-method
communication strategies (phone call, text message, mail, home visits), patient navigation, HPV
education, and mHealth interventions, all of which improved adherence to follow-up
recommendations. Additionally, sending a second HPV self-sample emerged as a potentially
effective but currently underexplored intervention that warrants further investigation.
Despite these findings, gaps remain in understanding the most effective approaches for
follow-up in low-income women, particularly in Canada, where no studies specifically examine
follow-up strategies after a positive HPV self-sample in this population. As Canada is currently
undergoing policy and practice changes regarding HPV self-sampling (CPAC, n.d.) in response
to the World Health Organization global strategy, there is an opportunity to explore and evaluate
effective interventions in vulnerable groups to reduce the disparities in CC outcomes (World
Health Organization, 2020). Future research should focus on resource-sparing equitable
strategies that ensure all individuals, regardless of socioeconomic status, receive timely followup care and treatment for CC.

36
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https://doi.org/10.3390/curroncol30060425

43

Appendix A
Detailed Search Strategy
Search Date

Database

November 6,
2024

CINAHL

Search Terms
((cervix or cervical) N4 (self-screen* or
7
“self screen*” or self-collect* or “self
collect*” or self-sampl* or “self sampl*” or
self test* or self-test*) OR ((HPV or
“Human papillomavirus”) N4 (self-screen*
or “self screen*” or self-collect* or “self
collect*” or self-sampl* or “self sampl*” or
self-test* or self test)) OR
((MH cervical smears) or (MH
papillomavirus infections) or (MH Human
papillomavirus Viruses) or (MH Cancer
Screening) or (MH Early Detection of
Cancer)) AND (self-screen* or “self
screen*” or self-collect* or “self collect*” or
self-sampl* or “self sampl*” or self test* or
self-test*) AND
(MH “Socioeconomic Factors”) OR (MH
“Poverty”) OR (MH “Working Poor”) OR
(MH “Social Class”) OR (MH “Medically
Underserved”) OR (MH “Healthcare
Disparities”) OR (low* N3 (income OR
socioeconomic* OR “social class” OR SES
OR “social status”)) OR (poverty OR
impoverished OR disadvantaged OR
“working poor”) OR (economic* N3
(isadvantage* OR hardship* OR deprive*))
OR (underserved OR “under served” OR
underresourced) OR (vulnerab* N3
(population* OR group* OR communit*))
AND
(MH “Follow-Up Studies” OR MH “Patient
Follow-Up” OR MH “Continuity of Patient
Care” OR MH “Aftercare” OR follow-up
OR “post-treatment care” OR monitoring
OR tracking OR “continuity of care” OR
recall OR “recall system” OR reengagement OR “retention in care”)

Articles
Retrieved

44
November 6,
2024

Medline
with
OVID

November 6,
2024

Google
Scholar

November 6,
2024November 11,
2024

Ancestry
Searching

((cervix or cervical) adj4 (self-screen* or
23
“self screen*” or self-collect* or “self
collect*” or self-sampl* or “self sampl*” or
self test* or self-test)) OR ((HPV or
“Human papillomavirus”) adj4 (self-screen*
or “self screen*” or self-collect* or “self
collect*” or self-sampl* or “self sampl*” or
self-test* or self test*)) OR
((MH isadvantage test/ or MH vaginal
smears/ or MH Papillomavirus Infections/ or
MH “Early Detection of Cancer”) AND
((self-screen* or “self screen*” or selfcollect* or “self collect*” or self-sampl* or
“self sampl*” or self test* or self-test))
AND
(“MH Socioeconomic Factors” or “MH
Poverty” or “MH Working Poor” or “MH
Social Class” or “MH Medically
Underserved” or “MH Healthcare
Disparities” or (low* adj3 (income or
socioeconomic* or “social class” or SES or
“social status”)) or (poverty or impoverished
or disadvantaged or “working poor”) or
(economic* adj3 (isadvantage* or hardship*
or deprive*)) or (underserved or “under
served” or underresourced) or (vulnerab*
adj3 (population* or group* or
communit*)))
AND
(“Follow-Up Studies/” or “Patient FollowUp/” or “Continuity of Patient Care/” or
“Aftercare/” or follow-up or “post-treatment
care” or monitoring or tracking or care
continuity or recall or re-engagement or
retention in care)
(hpv-self sampling or cervical cancer
21
screening) and (hpv positive or abnormal
result) and (low-income or underscreened)
and (follow-up)
37

45
Appendix B
Review Matrices
Article:
Brewer, N., Bartholomew, K., Grant, J., Maxwell, A., McPherson, G., Wihongi, H., Bromhead,
C., Scott, N., Crengle, S., Foliaki, S., Cunningham, C., Douwes, J., & Potter, J. D. (2021).
Acceptability of human papillomavirus (HPV) self-sampling among never- and underscreened Indigenous and other minority women: A randomised three-arm community trial in
Aotearoa New Zealand. The Lancet Regional Health - Western Pacific, 16, Article 100265.
https://doi.org/10.1016/j.lanwpc.2021.100265
Objective: To evaluate whether invitation for self-sampling methods could increase
screening participation and to seek information on resources required to achieve 90%
follow-up if HPV+
Setting, sampling technique and sample size: Auckland, New Zealand, purposive
sampling, N: 3550 (actual participation: 545)
Type of study and design: Open-label, three-armed RTC with non-random sub-study
1.
2.
3.
4.

Offered clinic based self-sampling
Offered home based self-sampling
Usual care (offered cytology at PCP office with GP or nurse)
Sub study: non-responders informed they could self-sample at home/clinic

Findings:
• Highest participation in home-based group (14%, p<0.0001)
• All ethnicities were more likely to participate in home-based group than usual care
• Previous screening did not have large impact on participation
• High follow-up if HPV + (92%) with mean time to achieve follow-up 2.5 hours
• Sub-study yielded further 6.9% of non-responders
Strengths and limitations:
Strengths: RTC measuring different HPV testing locations, attempt to capture more
participants with offer of second HPV self-sample at home, high follow-up for HPV +
participants with intensive follow-up strategy
Limitations: achieved low overall participation (15%), study may not be generalizable as it
did not include rural women, short study return time (6 months) may have impacted followup rates

46
Implications + CASP rating
•
•
•
•

Patients more likely to perform CC screening if home self-sample provided
Low participation rate may highlight need to focus resources on low-income
population
Large burden on health care system to achieve adequate follow-up with human
resource intensive strategy
CASP: moderate

47
Article: Crosby, R. A., Hagensee, M. E., Vanderpool, R., Nelson, N., Parrish, A., Collins, T.
& Jones, N. (2015). Community-based screening for cervical cancer: A feasibility
study of rural Appalachian women. Sexually Transmitted Diseases, 42(11), 607-611.
https://doi.org/10.1097/OLQ.0000000000000365
Objective: To describe women’s comfort and perceptions of their experience of selfcollection HPV tests, to determine whether nurse guided patient navigation increase the rate
of women receiving a Pap test after being screened for HPV, and to test the hypothesis that
women testing positive for HPV would be more likely to have a subsequent pap test than
those who test negative
Setting, sampling technique and sample size: Kentucky, USA, purposive and convenience
sampling, N: 400
Type of study and design: Cross sectional study
Self-sampling occurred at recruitment venue. Research nurses provided results to all
participants over the phone or face to face with patient navigation to schedule follow-up Pap
test. HPV + participants received HPV education. Up to three navigation attempts were
made for participants. Survey for demographics and attitudes on HPV and sexual health.
Findings
•
•
•
•
•

All participants successfully contacted for patient navigation
5.6% of HPV positive participants had follow-up Pap test
Those contacted for a 2nd navigation attempt were less likely to have a follow-up
Pap test at 6 months
Participants testing positive were not more likely to have follow-up Pap test
High acceptability of HPV self-sampling (89.2%)

Strengths and limitations
Strengths: successfully recruited adequate sample size in target population, up to 3
navigation attempts made with participants, multiple data analysis techniques used to
interpret findings
Limitations: no power analysis done, 6-month study duration may not have been long
enough for follow-up, no validated tool used for questionnaire
Implications + CASP rating
•
•
•
•

Findings contradict other research on positive effect of patient navigation
Patient navigation proved human resource heavy
Further research could focus on mHealth interventions for patient navigation
CASP: moderate

48
Article: Dutton, T., Majoram, J., Burgess, S., Montgomery, L., Vail, A., Callan, N., Jacob,
S., Hawkes, D., Saville, M., & Bailey, J. (2020). Uptake and acceptability of human
papillomavirus self-sampling in rural and remote Aboriginal communities:
Evaluation of a nurse-led community engagement model. BMC Health Services
Research, 20, Article 398. https://doi.org.10.1186/s12913-020-05214-5
Objective: To determine whether community-based HPV self-sampling model effectively
recruited never-and under-screened Aboriginal women in CC screening, to assess clinical
outcomes including follow-up, assess acceptability of the model by participants
Setting, sampling technique and sample size: 8 rural and remote communities in New
South Wales, Australia, convenience and snowball sampling, N: 215
Type of study and design: Cross sectional study design
Community health workers recruited participants at community events and home visits +
provided kits. Self-sampling was completed at home. Results returned by mail to participants
and GP, results and follow-up explained to participants by community nurses either face to
face or by phone. Evaluation questionnaire on service elicited during follow-up.
Findings
•
•
•

46% of participants had follow-up after 20 months
13.2% of participants reported difficulty understanding test + relied on nurses to
explain results
Unexpected outcome of participants who presented for follow-up cytology with GP
sought care for other health conditions

Strengths and limitations
Strengths: high community engagement between public health and local aboriginal land
council, triangulation of qualitative results between 2 researchers to ensure validity of
findings
Limitations: convenience and snowball sampling could have resulted in selection bias, no
eligibility criteria, inclusion/exclusion criteria or demographic data included, did not specify
how many participants required home visit for follow-up
Implications + CASP rating
•
•
•

Demonstrates high burden on health care system for result delivery to ensure followup
High reliance on nurses to explain results may indicate low health literacy,
underlying importance of education on HPV and CC
CASP: moderate

49
Article: Lea, C. S., Perez-Heydrich, C., Des Marais, A. C., Richman, A. R., Barclay, L.,
Brewer, N. T., & Smith, J. S. (2019). Predictors of cervical cancer screening among
infrequently screened women completing human papillomavirus self-collection: My
Body My Test 1. Journal of Women’s Health, 28(8), 1094-1104.
https://doi.org/10.1089/jwh.2018.71.41
Objective: To identify barriers, knowledge, attitudes, and predictors of cervical cancer
screening among low-income women. To assess predictors of longer time since last Pap test
and of completing in clinic Pap test after receiving HPV results from self-sample.
Setting, sampling technique and sample size: North Carolina, USA, purposive sampling,
N: 230
Type of study and design: Cross sectional study design
Participants mailed HPV self-sample, contacted by American Sexual Health Association for
result notification, followed by 3 questionnaires. Information provided on low-cost or free
Pap tests in their region. Participants self-reported completing Pap test.
Findings
•
•
•
•
•

Participants who tested positive for HPV on self-sample more likely to report
completing follow-up Pap test (OR=5.1, 95% CI: 1.4-25.7)
Travel >11 miles associated with completing follow-up Pap test (OR 3.6, 95% CI
1.0-14.2)
Many participants unaware of programs that offer free or low-cost Pap tests
Cost and lack of health insurance most frequent barrier for completing CC screening
cited by participants
Participants with high school education or less were more likely to have longer time
intervals between screening than those with more education

Strengths and limitations
Strengths: findings generalizable to local low-income population, multiple recruitment
strategies used to identify and recruit hard to reach population, fulsome questionnaires used
to collect data on attitudes and barriers to screening
Limitations: purposive sampling may have resulted in self-selection bias, small sample size,
self-reported Pap tests may have led to overreporting, no validated tool used for
questionnaire
Implications + CASP rating
•
•
•

USA policy should focus on informing women of low cost or free Pap tests to ensure
access to recommendations for care
Under-educated women should be a focus for targeted screening and follow-up
CASP: high

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Article: Molokwu, J. C., Penaranda, E., Dwivedi, A., Mallawaarachchi, I., & Shokar, N.
(2018). Effect of educational intervention on self-sampling acceptability and followup Paps in border dwelling Hispanic females. Journal of Lower Genital Tract
Disease, 22(4), 295-301. https://doi.org/10.1097/LGT.0000000000000424
Objective: To evaluate the effect of a community outreach-led education intervention
compared with education pamphlet on cervical cancer screening preferences and the effect
on subsequent screening for predominantly Hispanic women living on the US-Mexican
border who are overdue for CC. Secondary outcomes: acceptability of test, HPV knowledge.
Setting, Sampling Technique and Sample Size: Border of US and Mexico in Texas, USA,
purposive sampling, N: 202
Type of study and design: Randomised control trial
Intervention arm: education from outreach worker using PowerPoint presentation +
provision of educational material for participants to keep. Education materials at Grade 6
reading level including severity of hrHPV, cervical cancer screening with instruction for
HPV self-sampling. Self-sampling completed after the education session
Control arm: leaflet provided with the educational materials described above + self-sampling
kit with instructions
Findings
•
•
•

High intensity intervention significantly improved post-survey HPV knowledge (0.74
vs 0.09, p: <0.001)
HPV knowledge improvement was significantly associated with a follow-up Pap test
(p=0.033)
Participants testing positive for HPV were more likely to seek follow-up Pap, but
result was not statistically significantly

Strengths and limitations
Strengths: Community recruitment allows for generalizability to local population, only study
comparing intervention in RTC, used HBM theoretical framework to guide study
Limitations: Results may not be generalizable to other cultures, races or non-border
populations, small size sample, purposive sampling may have resulted in self-selection bias
Implications + CASP rating
•
•
•

Highlighted that education on HPV important in increasing screening and follow-up
Demonstrates that policy should be focused on increasing education on HPV and CC
CASP: moderate

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Article: Mremi, A., Linde, D. S., Mchome, B., Mlay, J., Schledermann, D., Blaakaer, J., &
Rasch, V. (2021). Acceptability and feasibility of self-sampling and follow-up
attendance after text message delivery of human papillomavirus results: A crosssectional study nested in a cohort in rural Tanzania. Acta Obstetricia et Gynecologica
Scandinavica, 100(4), 802-810. https://doi.org/10.1111/aogs.14117
Objective: To explore the acceptability and feasibility of HPV self-sampling among
Tanzanian women living in rural areas, and to assess the attendance rate of follow-up
screening appointments for hrHPV positive women
Setting, sampling technique and sample size: Kilimanjaro region of Northern Tanzania,
purposive sampling, N: 1108
Type of study and design: Cross sectional study in a cohort
Study nurses gave participants instructions for self-sampling with individual counseling
regarding the implication of receiving a positive test. If positive, 4 text messages over 1
month were sent to participants with appointment date for follow-up Pap test. Phone call if
did not present for follow-up.
Findings
•
•
•

82% of participants presented for follow-up
16% required phone call to attend follow-up
High acceptability of self-sampling among participants

Strengths and limitations
Strengths: large sample size, high follow-up rate, utilized education + mHealth intervention
Limitation: conducted in rural setting of low-income country, may have limited
generalizability to other settings, no validated tool used for questionnaire, purposive
sampling may have resulted in self-selection bias or courtesy bias leading to over estimation
of acceptance of self-sampling. ⅓ of participants were HIV positive, a population with high
awareness of importance of follow-up which might have contributed to results
Implications + CASP rating
•
•
•

Shows promise of mHealth to reduce human resources burden of CC screening
Demonstrates that policy should be focused on increasing education on HPV and CC
CASP: moderate

52
Article: Pretsch, P. K., Spees, L. P., Brewer, N. T., Hudgens, M. G., Sanusi, B., Rohner, E.,
Miller, E., Jackson, S. L., Barclay, L., Carter, A., Wheeler, S. B., & Smith, J. S.
(2023). Effect of HPV self-collection kits on cervical cancer screening uptake among
under-screened women from low-income US backgrounds (MBMT-3): A phase 3,
open-label, randomised controlled trial. Lancet Public Health, 8(6), e411-e421.
http://doi.org/10.1016/s2468-2667(23)00076-2
Objective: To identify whether mailing HPV self-collection kits to women’s home in
conjunction with providing appointment scheduling assistance resulted in increased uptake
of cervical cancer screening compared with offering scheduling assistance alone
Setting, sampling technique and sample size: North Caroline, USA, purposive sampling,
N: 665
Type of study and design: Randomised control trial
1. Intervention group: Self-sampling HPV test mailed to home + scheduling assistance
for follow-up Pap test
2. Control group: Scheduling assistance for Pap test
Both groups completed telephone questionnaires at 4 stages of study. Trained interviewer
provided results over the phone with brief counselling. Up to 3 calls made for scheduling
assistance.
Findings
•
•

Screening uptake higher in intervention group (72% and 37%)
Similar rates of follow-up for HPV positive participants in both groups (43%)

Strengths and limitations
Strengths: study exceeded power analysis, comprehensive statistical analysis, multiple
attempts to contact participants
Limitations: Purposive sampling may have resulted in self-selection bias, unable to say if
home HPV sampling vs scheduling assistance resulted in outcome or if follow-up due to
another variable
Implications + CASP Rating
•
•
•
•

Results demonstrate that further research is required to isolate variables responsible
for improving follow-up rates
Scheduling assistance via phone call is human resource intensive
Further research could focus on other mHealth interventions for scheduling
assistance
CASP: moderate

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Article: Tamalet, C., Halfon, P., Le Retraite, L., Grob, A., Leanri, F. X, Heid, P., SanchoGarnier, H., & Piana, L. (2016, May). Genotyping and follow-up of HR-HPV types
detected by self-sampling in women from low socioeconomic groups not
participating in regular cervical cancer screening in France. Journal of Clinical
Virology, 78, 102-107. https://doi.org/10.1016/j.jcv.2016.02.027
Objective: To describe hrHPV types in women ages 35-69 from low socioeconomic status
not attending regular cervical screening in Marseille, France
Setting, sampling technique and sample size: Marseille, France, purposive sampling,
N: 22,702 (Participation: 4245)
Type of study and design: Quantitative descriptive population-based intervention study
Participants received HPV self-sample in the mail with instructions to mail samples to lab.
Results communicated to participants and GPs but did not specify how. Reminder call and
letter sent at 3 and 6 months if no follow-up complete. HPV + Participants not completing
follow-up at 12 months were sent another HPV-self sample with results delivered by
phone/mail
Findings
•
•
•

Overall follow-up was 66% of HPV positive participants
Results from second HPV sample revealed that 43% had cleared the infection
Sending second HPV self-sample recovered 50% of participants lost to follow-up

Strengths and limitations
Strengths: large sample size, used novel strategy to recover participants lost to follow-up
Limitations: did not explicitly say how they followed-up with participants, did not describe
ethical considerations/approval by ethical body
Implications + CASP rating
•
•

Sending second HPV self-sample may be effective strategy to recover those lost to
follow-up; however, requires more research
CASP: moderate