i

PRIMARY CARE PROVIDER PERSPECTIVES ON
SPECIMEN SELF-COLLECTION FOR CERVICAL CANCER SCREENING

by

Joanna Marie Paterson
B.A.Sc., Toronto Metropolitan University, 2010
M.Sc., University of Northern British Columbia, 2014
B.S.N., University of British Columbia, 2020

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

© Joanna M. Paterson, 2025

ii
Abstract
Cervical cancer incidence continues to rise across Canada. Unlike some other cancers,
cervical cancer is largely preventable through a combination of vaccination and routine
screening. Cervical cancer screening was introduced in British Columbia in 1955 using the
Papanicoulau smear which requires a cervical specimen be obtained during a pelvic exam.
However, the pelvic exam has been identified by patients as a barrier to participation in cervical
cancer screening. Today, vaginal human papillomavirus testing provides a safe, validated
alternative to the Papanicoulau smear. Importantly, the human papillomavirus specimen can be
collected by patients themselves using a vaginal swab, thereby removing pelvic exam-related
barriers to cervical cancer screening. Specimen self-collection tends to be preferred by patients,
however primary care providers9 perspectives on its use are not known. Primary care providers,
including nurse practitioners, have the potential to impact their patients9 health behaviours, and
as such, understanding providers9 perspectives on the use of self-collection is an important
consideration in order to reduce the burden of cervical cancer.

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TABLE OF CONTENTS
Abstract

ii

List of Tables

iv

List of Figures

v

Glossary

vi

Acknowledgements

vii

Chapter One: Introduction

1

Chapter Two: Background and Context
Cervical Cancer Epidemiology
Human Papillomavirus
Prevention of Cervical Cancer
Specimen Self-Collection
Provider Perspectives

2
2
2
3
7
10

Chapter Three: Methods
IR Framework
Author Positionality

11
11
16

Chapter Four: Findings
Description of Dataset
Provider Perspectives

17
17
20

Chapter Five: Discussion
Guidelines and Resources
Capacity Considerations
Resource Allocation
Limitations

29
30
32
34
35

Chapter Six: Conclusion

37

References

38

Appendix A: Search Concepts and Terms

48

Appendix B: Search Results using CINAHL (via EBSCO)

49

Appendix C: Search Results using MEDLINE (via EBSCO)

51

Appendix D: PRISMA Flow Diagram

53

Appendix E: Data Appraisal Summaries

54

Appendix F: Data Extraction Summaries

67

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List of Tables
Table 1: Cervical Cancer Screening Methods: Cytology-based Pap Test vs. HPV Test

5

Table 2: Health Care Providers Represented in Dataset

17

Table 3: Practice Settings Represented in Dataset

18

Table 4: Provider Outcomes Measured and Corresponding Studies

19

v
List of Figures
Figure 1: Approaches to Cervical Cancer Screening Described in Dataset

19

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Glossary
Pap test (Papanicoulau smear): screening test for cervical cancer, in use since 1928, that
involves the microscopic examination of cervical epithelial cells for cellular abnormalities,
which may or may not be precancerous (National Cancer Institute, 2024).
Primary care provider: in British Columbia, health care professionals, such as family
physicians and nurse practitioners who serve as the first point of contact between a patient
and the healthcare system, and who tend to provide longitudinal care including prevention,
diagnosis, and treatment of acute and chronic conditions (Ministry of Health, 2025).
Self-collection: process by which an individual collects their own vaginal sample using a swab
or brush and submits the specimen to be tested for the presence of human papillomavirus
for the purpose of cervical cancer screening (Brennan et al., 2024).
Self-testing: process by which an individual collects their own vaginal sample using a swab or
brush and completes point-of-care testing for the presence of human papillomavirus for the
purpose of cervical cancer screening (Brennan et al., 2024).
Screening: medical testing undertaken to detect health concerns or diseases in individuals
without symptoms of the disease of interest. With respect to cervical cancer, screening can
<prevent cancer or help catch it in its earliest stages, allowing more treatment options and a
better chance of recovery= (Provincial Health Services Authority; 2025b, para. 2).
Testing: also known as diagnostic testing, process in which symptomatic individuals or those
who screen positive for a given condition undergo further assessment to confirm or exclude
a diagnosis (Guidelines and Protocols Advisory Committee, 2016).
Additional note about language: Any individual with a uterine cervix, regardless of their gender,
is at risk for cervical cancer. In an effort to use inclusive language that reflects biological risk for
cervical cancer, I have avoided references to women and men, and instead used gender neutral
terms, such as patient or individual, whenever possible.

vii
Acknowledgements
I would like to express my sincere gratitude to Dr. Catharine Schiller for her patient guidance
and feedback throughout this process. To my classmates, thank you for your input in clarifying
early ideas, helping me to refine my focus, and for your encouragement throughout our time
together in this program. To the many NPs who have shaped my journey, thank you for your
dedication to excellence in healthcare, for inspiring and encouraging me to keep going, and for
helping me to recognize where I belong. I do not think I would have made it to this point without
the strong shoulders of my friends and family, whose generosity, reassurance, and humour have
helped me to find balance over the last few years; I promise I will stop going back to school
…one day. Lastly, to my favourite person, I doubt I will ever be able to articulate how much
your unwavering patience, loving support, and commitment to fun have allowed me to grow and
embrace the challenges brought by this season of life. Here9s to more adventures and
opportunities to chase steelhead along the way!

Chapter One: Introduction
Cervical cancer screening (CCS) is an effective, longstanding practice for preventing
cervical cancer; it is also a clinical practice area that is undergoing significant transformation in
British Columbia (BC) and globally. Until recently, CCS required a Pap test, which involves the
collection of a cervical specimen during a pelvic exam. Recent advances in CCS have enabled
specimen self-collection, which allows patients the option of collecting their own vaginal
specimen and does not require a pelvic exam. Previous studies have suggested that selfcollection is widely preferred by patients over clinician-collected specimens for CCS. However,
provider perspectives are not well-researched. Given the potential impacts on their patients9
health behaviours, primary care provider (PCP) perspectives on the use of self-collection for
CCS may provide valuable insights into best practices and implementation strategies.
The integrative review (IR) that follows was undertaken to answer the question <What
are the perspectives of primary care providers towards specimen self-collection for cervical
cancer screening?=. Chapter Two provides an overview of each component of the research
question, such as CCS, self-collection, and PCPs, as well as background and context to situate
the research question and subsequent analysis. Chapter Three describes the application of the
Whittemore and Knafl (2005) IR framework to the research question, including processes and
key decision points related to problem identification, literature search, data evaluation, and data
analysis. Chapter Four begins with a description of the dataset and presents the findings from the
literature. Chapter Five synthesizes these findings, discussing their implications for clinical
practice, health policy, and future research endeavours. Finally, Chapter Six offers a conclusion,
summarizing the principal insights and recommendations derived from this IR.

2
Chapter Two: Background and Context
This chapter introduces key concepts and context that informed this IR, which sought to
answer the question, <What are the perspectives of primary care providers towards specimen
self-collection for cervical cancer screening?=. Relevant foundational concepts related to CCS
practices and emerging approaches to specimen self-collection are presented. Additionally,
temporal and geographic aspects of the study context are described to situate the IR.
Cervical Cancer Epidemiology
According to the Canadian Partnership Against Cancer (CPAC, 2024), cervical cancer
incidence has been increasing across Canada since 2013. In 2023, 400 people in Canada died of
cervical cancer, and 1550 people were diagnosed (CPAC, 2024). Within BC, approximately 200
individuals are diagnosed with cervical cancer annually, and of these, approximately 50
individuals will die from it (HealthLinkBC, 2024).
In 2020, the World Health Organization (WHO) announced a strategic initiative to
eliminate cervical cancer by 2030 (Davies-Oliviera, 2021). Their three-pronged strategy involves
identifying targets for vaccination, screening, and treatment, all with the aim of reducing the
global burden of cervical cancer (Davies-Oliviera, 2021). Evidence to guide best practices in all
three areas is evolving. Recently, in the province of BC, efforts have focused on increasing
participation in CCS, with significant changes in how patients access this service and how testing
is performed (Provincial Health Services Authority [PHSA], 2025b).
Human Papillomavirus
The human papillomavirus (HPV) is a common sexually transmitted infection that can be
spread through oral, genital, and anal sexual contact (HealthLinkBC, 2024). An estimated 75%
of unvaccinated sexually active individuals will contract HPV in their lifetime (Public Health

3
Agency of Canada [PHAC], 2024). One reason that HPV is so prevalent is that HPV infections
are often asymptomatic and, if a person is unaware they have contracted the virus, they can
unknowingly spread the virus to others.
Human papillomavirus often does not require treatment and will typically clear on its
own in healthy individuals (PHAC, 2024). Most types of HPV are considered 8low-risk9; these
genotypes may cause genital warts but are otherwise not considered to be harmful (PHSA,
2025d). However, some HPV genotypes, if left untreated, may eventually lead to cervical or
other cancers (WHO, 2024; PHSA, 2025d). Seventy percent of cervical cancers are caused by
two 8high-risk9 types of HPV: 16 and 18 (WHO, 2024), and approximately 95% of all cervical
cancers are caused by persistent HPV infection of the cervix (WHO, 2024).
Non-Cervical Human Papillomavirus-associated Cancers
While the focus of this IR is cervical cancer prevention and screening, it is important to
note that HPV infection can also cause cancers of the mouth and oropharynx in males and
females, as well as anal and penile cancers in males (PHAC, 2012). In fact, the majority of
cancers caused by HPV are non-cervical (PHAC, 2024). According to PHAC (2024), <Globally,
it is estimated that 620,000 new cancer cases in women and 70,000 new cancer cases in men
were caused by HPV in 2019= (PHAC, 2024, Epidemiology sect.). As a result, vaccination
against HPV is an important consideration for males and females, as will be examined in the next
section.
Prevention of Cervical Cancer
Like other types of cancer, cervical cancer negatively impacts individuals and their
families, and places a significant burden on the health care system. However, unlike other types

4
of cancer, cervical cancer is largely preventable through a combination of vaccination and
routine screening.
Vaccination
Stopping the transmission of HPV infection is the most effective way to prevent it from
causing harm, and therefore, vaccination against HPV is a strategy for primary prevention of
cervical cancer. In Canada, two vaccines against HPV have been approved: Gardasil protects
against nine types of HPV (including types 16 and 18) and Cervarix is specifically targeted to
protect against HPV types 16 and 18 (PHAC, 2024).
Because vaccination prevents HPV infection but does not clear it, HealthLinkBC (2024)
recommends that individuals be immunized prior to becoming sexually active and potentially
being exposed to HPV. When the Gardasil vaccine was first introduced in BC in 2008 (PHAC,
2012), cervical cancer prevention was the priority and vaccination efforts were initially targeted
at female children in Grade 6, a time that is generally considered to be prior to HPV exposure
(HealthLinkBC, 2024). In 2010, access to Gardasil to was expanded to include females and
males aged nine to twenty-six years and, in 2011, Gardasil became available to females up to the
age of 45 years (PHAC, 2012). By contrast, Cervarix is only approved for use in females
(HealthLinkBC, 2024). In BC, Gardasil is provided free to eligible individuals, whereas Cervarix
can be purchased from pharmacies (HealthLinkBC, 2024).
Because vaccination against HPV is still a relatively new intervention, a significant
proportion of the population remains unvaccinated and therefore at increased risk for HPV
infection and potential progression to cervical cancer.

5
Screening
Early diagnosis and treatment of precancerous cervical lesions, known as secondary
prevention of cervical cancer, is associated with better outcomes, including reduced risk for
developing invasive cancer and increased likelihood of cure (Brennan et al., 2024; WHO, 2020).
The BC Cancer Agency (BCCA) recommends CCS for all people with a cervix between the ages
of 25 and 69 years (PHSA, 2025b). In BC, two methods of CCS are currently available:
cytology-based Pap test and HPV testing (see Table 1).
Table 1
Cervical Cancer Screening Methods: Cytology-based Pap Test vs. HPV Test
Cytology-based Pap test

HPV test

Specimen collection

Cervical cells collected using
brush or spatula

Vaginal cells collected using
swab

Collected by

Clinician only

Patient or clinician (based on
patient preference)

Pelvic exam required?

Yes

No

Positive result indicates

Precancerous changes to cells
visualized under microscope

Presence of HPV viral DNA

Testing frequency

Once every 3 years

Once every 5 years

(PHSA, 2025c; PHSA, 2025d)
Cytology-based screening. Cervical cancer screening using the Papanicoulau smear
(commonly known as a Pap test) was introduced in 1928 (Rajaram & Gupta, 2021; Vilos, 1998).
The Pap test involves the collection of cervical epithelial cells during a pelvic exam in which the
clinician uses a speculum to visualize the cervix and obtains a scraping of cells (Shaw, 2000).
These cells are then placed on a slide and examined under a microscope to look for visible
lesions, including precancerous changes or dysplasia that may not be visible without
magnification, a process called cytology (Rajaram & Gupta, 2021). A positive Pap test result

6
indicates the presence of abnormal cervical cells, which may or may not be precancerous and
requires follow-up including monitoring, further testing, or treatment (National Cancer Institute,
2024).
The patient experience of Pap testing has been extensively described in the literature.
Pain, distress, embarrassment, fear, and humiliation were terms used by patients in a recent
Canadian study of barriers to CCS (King & Busolo, 2022). Similarly, in their study of CCS in
rural Ontario, Racey and Gesink (2016) described <procedural barriers= (p. 138) that patients can
encounter, such as emotional discomfort, physical discomfort, embarrassment, and lack of
privacy, and that can lead to avoidance of CCS. Not surprisingly, many patients decline CCS
altogether due to these and other concerns. Exploration of the patient experience of CCS, and the
resulting impact on their willingness to undergo screening, has led to an understanding that new,
innovative alternatives to Pap tests are needed.
Additional barriers to Pap-based CCS have also been described in the literature, including
inconvenience and logistical considerations such as time constraints, transportation, related costs
(Brennan et al., 2024; Fontenot et al., 2024; Le Goff et al., 2023). Lower CCS rates by racial and
ethnic minorities have also been observed, and tend to be attributed to health literacy challenges,
language barriers, cultural beliefs, and structural barriers to health care access (Rodriguez et al.,
2023; Xiong et al., 2022). Increasing CCS rates in these 8under-screened9 populations will also
require innovative solutions to address and overcome these and other barriers.
HPV-based screening. Unlike cytology, in which a sample of cervical cells is directly
examined under a microscope to identify visible precancerous changes or dysplasia (Rajaram &
Gupta, 2021), HPV testing is used to detect the presence or absence of the HPV viral DNA
(Brennan et al., 2024). Multiple laboratory tests are available to analyze vaginal swabs for the

7
presence of viral DNA, including polymerase chain reaction (PCR) and nucleic acid-based
amplification (NAAT), both of which are widely used for other screening and diagnostic
applications (Rajaram & Gupta, 2021). A positive HPV test result indicates the presence of a
high-risk HPV genotype, which, if left untreated, may eventually develop into cervical or other
cancers (National Cancer Institute, 2024; WHO, 2024). Patients who test positive for high-risk
HPV require follow-up, such as monitoring, further testing, or treatment, the course of which is
determined by factors including previous CCS results, history of precancerous cervical lesions,
and personal health factors including age and family history (National Cancer Institute, 2024).
Local Context. According to a recent environmental scan of CCS in Canada, nine out of
ten provinces offer organized CCS programs (CPAC, 2024). At the time of publication of the
environmental scan, Quebec, Yukon, and Northwest Territories were in the process of
developing structured CCS programs with subsequent implementation planned, while Nunavut
had no organized CCS screening program in development (CPAC, 2024).
BC has offered CCS since 1955, which makes it the longest standing program in Canada
(CPAC, 2024). In January 2024, the BCCA introduced <HPV self-screening= (Ministry of
Health, 2024, para. 1) as a province-wide alternative to clinician-collected, cytology-based CCS.
Both cytology and HPV-based testing are currently available in BC; patients may have the option
to undergo Pap testing or a self- or clinician-collected HPV test depending on their health history
(Ministry of Health, 2024).
Specimen Self-Collection
The pelvic exam has been identified as a significant barrier to CCS (Hawkes et al., 2020;
King & Busolo, 2022). Unlike cytology-based Pap tests, HPV testing does not require the
collection of cervical cells, which means that the specimen does not need to be collected by a

8
clinician and the patient does not require a full pelvic exam. Thus, one important advantage of
the use of HPV testing for CCS is that the vaginal swab used for HPV testing can be collected by
a clinician or by patients themselves.
Self-collection of an HPV specimen for CCS is a validated tool, and its use is already
established in other jurisdictions, including Australia, New Zealand, Denmark, Scotland, and the
Netherlands (Bohn et al., 2019; Polman et al., 2019). A randomized non-inferiority trial
compared the accuracy of self- and clinician-collection for HPV testing and found self-collected
samples to be not inferior to the standard of care (i.e., clinician-collected samples) for CCS
(Polman et al., 2019). Variability in the implementation of self-collection protocols persists
despite the WHO9s endorsement of HPV self-collection and evidence that confirms HPV selfcollection provides comparable accuracy to clinician-collected samples (Gentile et al., 2024; Le
Goff et al., 2023; Polman et al., 2019).
In some jurisdictions, only patients who are overdue for CCS or those who decline
clinician-collected screening are offered the possibility of self-collecting their sample (Bohn et
al., 2019). In other settings, self-collection is the primary method for CCS (Ministry of Health,
2024). Since 2024, self-collection for CCS has been available in BC for:
Anyone aged 25 to 69 who has a cervix, is due for screening, has ever had sexual contact
(intercourse or digital or oral sexual contact involving the genital area with a person of
any gender), is asymptomatic, and is registered with the Medical Services Plan or has
their health care covered by a federal program. (PHSA, 2024a, para. 4)
However, the BCCA recommends against self-collection for those who are currently pregnant or
experiencing symptoms such as post-coital bleeding or persistent abnormal bleeding (PHSA,
2024a).

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Advantages of Self-Collection
Previous studies suggest that self-collection is a potential solution to multiple barriers to
CCS participation discussed above. Many patients have become familiar with other forms of
specimen self-collection, including COVID-19 testing, home pregnancy tests, and vaginal swabs
for bacterial vaginitis and sexually transmitted infections (Fontenot et al., 2024; Rodriguez et al.,
2023). Zelli et al. (2022) argue that self-collection increases participation in CCS among
individuals who previously declined clinician-collected CCS due to embarrassment, fear, and
discomfort, as self-collection allows patients to have more control over their experience.
Another important advantage of self-collection is that it can be completed outside of a
clinical setting. Winer et al. (2023) found that targeted mailing of self-collection kits to under
screened individuals increased their likelihood of completing CCS. Similarly, Brennan et al.
(2024) demonstrated that mail-based self-collection programs reduce geographic barriers to CCS
and may help to address CCS and cervical cancer prevalence disparities in rural and remote
communities.
In BC, the introduction of HPV self-collection has also changed the recommended
frequency for CCS; Pap tests are currently recommended to occur once every three years,
whereas the recommendation for HPV-based screening, and therefore self-collection, is once
every five years (PHSA, 2025b). As explained by Delpero and Selk (2022), HPV testing has
higher sensitivity than cytology-based CCS and <decisions to lengthen the cervical screening
interval … are based on the strong negative predictive value of HPV testing= (p. 614). Given
pervasive and persistent shortages of PCPs, such as family physicians (FPs) and nurse
practitioners (NPs), across Canada (Canadian Institute for Health Information, 2024), the

10
potential for self-collection to reduce the burden on primary care services (Xiong et al., 2022)
should not be overlooked.
Provider Perspectives
Self-collection has the potential to improve CCS patient experiences and outcomes; it is
important that barriers to its implementation are identified and addressed. Understanding health
care providers9 perspectives on HPV self-collection for CCS is vital to ensure that best practice
is aligned with the growing evidence in support of self-collection.
Health care providers have the potential to significantly impact the health practices of the
patients they serve. Because self-collection remains a relatively new approach to CCS, patients
may not be aware of this option, or they may have questions about it. Primary care providers,
including NPs, should understand the available options for CCS so they can support patients in
making informed decisions that meet their health care needs. Le et al. (2022) assert that provider
bias has a direct impact on patient health care decision-making, including whether and how
patients engage in CCS. Similarly, Mao et al. (2017) found that patients were more likely to
engage in CCS practices that are <endorsed by clinicians= (p. 609). In many contexts, CCS is
facilitated through PCPs (Creagh et al., 2021), which means that a patient9s access to CCS is
fully dependent upon the beliefs, attitudes, and practices of their health care provider (Brennan et
al., 2024).
Regardless of their level of involvement in arranging CCS, exploring PCP perspectives
on self-collection for CCS may identify facilitators and barriers to its uptake, which can then
inform approaches to ensuring equitable access to CCS.

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Chapter Three: Methods
This chapter presents the methods that were used to conduct this IR, which aimed to
answer the question, <What are the perspectives of primary care providers toward specimen selfcollection for cervical cancer screening?=. The general approach to undertaking an IR, as well as
key methodological decision points that informed data collection, analysis, and conclusions, are
presented herein.
IR Framework
The IR framework encompasses five components: problem identification, literature
search, data evaluation, data analysis, and presentation (Whittemore & Knafl, 2005). Whittemore
and Knafl (2005) recommend that each of these components be well-defined, ensuring that key
decision points are clearly articulated in order to enhance rigour and overall strength of the
resulting conclusions.
Problem Identification
The <population/situation= (P/S) strategy (Health Evidence, 2021, p. 4) was used to
develop a searchable research question. The population identified was PCPs and the situation
was patient use of self-collection for CCS.
The use of specimen self-collection in health care is becoming more widespread. For
example, the extensive use of point-of-care COVID-19 testing has resulted in <growing
consumer demand= (Rodriguez et al., 2023, p. 1) for home-based screening and diagnostic tests
in other areas of healthcare. Patient preference for self-collection for the purpose of CCS has
been well-documented in the literature (e.g., Barger et al., 2023; Fullerton et al., 2024).
However, the acceptability of self-collection for CCS amongst PCPs has not been widely
studied. The target population for this IR had initially been restricted to nurse practitioners

12
(NPs). However, a preliminary literature scan completed in November 2024 found no studies on
this topic that had been conducted solely with NPs. As a result, the research question was revised
to include other PCPs, such as FPs, midwives, and physician assistants (PAs). It is worth noting
that different primary care roles exist in different jurisdictions; for example, the NP role has not
been integrated in France in the way that it currently exists in Canada and the United States (US;
Devictor et al., 2023). While an international comparison of PCP roles is beyond the scope of
this IR, it is important to recognize that the overall dataset reflects a range of PCP roles,
including but not limited to NPs.
Literature Search
A combination of comprehensive search and purposive sampling strategies were used to
identify and retrieve relevant literature (Whittemore & Knafl, 2005). Preliminary search terms
reflected the P/S criteria described previously. Based on early unstructured searches, three
searchable concepts were identified that would ensure that subsequent searches combined the
same P/S criteria, regardless of the specific search vocabulary used by different databases (see
Appendix A). Two online EBSCO databases, CINAHL and MEDLINE, were accessed through
the library of the University of Northern BC. CINAHL, which stands for <Cumulative Index to
Nursing and Allied Health Literature= (Geoffrey R. Weller Library, 2025) was selected because
it includes nursing, medicine, and allied health publications and practice resources, all of which
are relevant to the population, intervention, and outcome of interest specified in the research
question. Based on familiarity with the EBSCO platform developed through CINAHL searching,
the MEDLINE database, also hosted by EBSCO, was selected as the second database.
MEDLINE is also relevant to the research question because it indexes publications on nursing,
medicine, and the health care system (Geoffrey R. Weller Library, 2025).

13
Structured database searching took place in December 2024. Search terms were then
further refined based on heading suggestions from each database (see Appendices B and C). By
reviewing the reference lists of relevant articles, 8snowball9 results were also collected for
subsequent screening; one additional article was identified this way. Finally, Google Scholar was
used to capture relevant articles that were not indexed in the databases or had not been retrieved
using the selected search terms (see Appendices B and C). Eleven potentially relevant articles
were identified via Google Scholar, of which four were duplicates that had already been
identified through database searching. Twenty-five records were identified, and four duplicates
were removed prior to additional screening.
The twenty-one unique articles were downloaded and bibliographic information was
entered into an excel spreadsheet. Abstracts were reviewed to ensure relevance to the P/S
specified in the research question. At this point, two articles were removed because they were
about colorectal cancer screening, not CCS (Gupta et al., 2023; Nitkowski et al., 2024), and one
article did not include provider perspectives as an outcome variable (Huntington et al., 2023).
Eighteen articles underwent full-text reviews and additional spreadsheet columns were
created to document decisions related to inclusion and exclusion criteria, including the types of
health care providers, practice settings, and outcome measures for study. Two studies were
excluded because they assessed provider knowledge of HPV, not provider perspectives on its
application for CCS (Garcia et al., 2016; Ignamells et al., 2024). An additional two studies were
excluded because they included results from non-clinicians that could not be differentiated or
isolated from provider perspectives (Creagh et al., 2024; Danan et al., 2024). Finally, one article
was excluded because it was an editorial, not primary research (Senkomago & Saraiya, 2017).

14
As shown in the PRISMA flow diagram (Page et al., 2021; Appendix D), thirteen articles
were included in the IR. Of these, eight were qualitative studies, three were mixed methods
studies, and two were quantitative studies.
Note about search timeline. In December 2024, when the initial comprehensive online
database searches were run using the search terms and combined concepts described (see
Appendices A, B, and C), CINAHL returned nine articles and MEDLINE returned four articles.
The dataset that was subsequently analyzed reflects these search results from December 2024.
Upon repeating the original database searches in February 2025, substantially more articles were
retrieved; CINAHL retrieved 75 articles and MEDLINE retrieved 50 articles. It is possible that
these additional 112 results reflected a combination of new publications and/or changes to
database indexing or subject headings. These additional results were not considered for inclusion
in the dataset because of timing and the feasibility restrictions of completing this IR within the
context of a graduate course.
Data Evaluation
Three critical appraisal tools were used to evaluate the quality of the thirteen articles that
met inclusion criteria. The appropriate tool was selected based on the study design. Eight studies
were appraised using the Critical Appraisal Skills Programme (CASP) <CASP checklist for
qualitative research,= (CASP, 2024b), two studies were appraised using the <CASP checklist for
descriptive/cross-sectional studies= (CASP, 2024a), and three studies were appraised using the
<mixed methods appraisal tool (MMAT) version 2018= (Hong et al., 2018). A data appraisal
summary for each study can be found in Appendix E. Each study was subjectively determined to
be high, medium, or low quality by the IR author based on results from application of each
appraisal tool, as suggested by CASP (2024c).

15
Data Analysis
Data analysis began with descriptive data extraction. Data categories were developed so
that study characteristics could be compared directly. For example, provider type(s), practice
setting(s), and implementation stage were assessed for each study. A template was developed to
facilitate data extraction and to ensure that, whenever possible, the same data points were
extracted from each study. The quality designation that was determined based on critical
appraisal in the data evaluation step was also included in the data extraction template.
Study findings were grouped into categories of overall impressions, benefits and risks of
self-collection, facilitators and barriers to self-collection implementation, and recommendations.
Important contextual factors were also summarized to ensure that findings could be situated
appropriately. For example, because of the international scope of this IR, it was important to
differentiate between Canadian and US studies because health insurance coverage can be an
important determinant of patient engagement in CCS and Canada has a publicly-funded
healthcare system (Fuzzell et al., 2021). Finally, preliminary comments on connections between
each study and the overarching IR research question were included in the data extraction
template. These comments were used as starting points for the Discussion chapter that follows. A
completed data extraction summary for each study can be found in Appendix F.
Presentation
Overall findings were grouped into themes that represented areas of consideration across
studies. Themes evolved based on similarities and differences across the studies and they became
the basis for the Findings chapter that follows. A visual model was created to organize the data
(see Figure 1). Interpretation and implications of these findings, within the BC primary care
context is presented in the Discussion chapter.

16
Author Positionality
As a registered nurse (RN) and future NP, who practices in BC and who identifies as a
cis-gendered woman, I am interested in this topic for multiple reasons. When I first learned that
HPV self-collection would replace the need for Pap testing for CCS, I was both relieved and
skeptical; the idea that patients could engage in CCS without the need for pelvic exams seemed
too good to be true. Pap testing was part of the care that I offered as an RN who holds certified
practice standing in reproductive health (British Columbia College of Nurses and Midwives,
n.d.), and in this role I witnessed firsthand both physical and emotional discomfort that pelvic
exams caused in patients. I also witnessed the importance that patients placed on CCS, as
evidenced by their willingness to undergo Pap testing despite anxieties and hesitations.
As a future NP, I see it as my responsibility to understand current evidence-based best
practice so that I may support patients in making informed decisions about their health care.
When the BCCA introduced <HPV self-screening= (Ministry of Health, 2024, para. 1) over one
year ago, I chose to explore the evidence behind this novel approach to CCS so that I would be
prepared to answer patient questions and feel confident in recommending this modality. Since
then, I have also taken it upon myself to inform colleagues and share resources from BCCA
about its availability and validity. Thus, this IR was undertaken, in part, as a means to better
understand barriers to and facilitators of successful implementation of self-collection, a practice
that I believe will result in meaningful benefits for people who undergo CCS.

17
Chapter Four: Findings
According to Whittemore and Knafl (2005), the IR data analysis process involves data
extraction, reduction, display, and comparison. A description of the dataset, including study
designs, contexts, and outcomes follows. A visual summary of the dataset is included, as well as
key themes that emerged from the literature.
Description of Dataset
Of the thirteen articles included in this IR, eight were qualitative studies, three were
mixed methods studies, and two were cross-sectional quantitative studies. The majority of
studies were conducted in the US (n=8) while two Australian studies, two French studies, and
one Canadian study were also included.
The dataset reflected a wide range of provider types; all thirteen articles included PCP
perspectives, and eleven studies included NP perspectives specifically (Table 2). As shown in
Table 2, most studies included multiple provider types.
Table 2
Health Care Providers Represented in Dataset
Provider type
Family Physician
Nurse Practitioner
Obstetrician/Gynecologist
Midwife
Physician Assistant
Nurse
Other:
• Internist
• Oncologist

Number of studies
13
11
8
6
3
2
4
1

The dataset also reflected a wide range of practice settings (Table 3). Multiple studies
included participants who practiced in more than one type of clinical setting. Three studies did

18
not specify the practice settings of their research participants. Of the ten studies that did specify,
the most common practice setting was a community health center.
Table 3
Practice Settings Represented in Dataset
Practice setting
Community health center
General practice
Private practice
Hospital
Academic health center
Aboriginal health organization
Gender-diverse clinic
Correctional center

Number of studies
10
7
7
6
5
3
2
1

Most studies (n=9) did not specify details about the patient population for whom the
research participants provided care. Of those studies that did specify, three collected perspectives
from providers who serve patients in geographic regions with notable socioeconomic
disadvantage, geographic isolation and/or poor access to health care, and one study involved
providers who serve patients living with HIV.
The dataset reflects a spectrum of approaches to CCS, and each study explored provider
perspectives on different testing modalities. Figure 1 presents a visual summary of key
characteristics of CCS interventions along with the identification of those studies that
commented on each different approach. It is worth noting that only Creagh et al. (2021), Le Goff
et al. (2023), and Zammit et al. (2023) explored provider perspectives on HPV self-collection
post-implementation. Conversely, the other eleven studies sought to determine providers9
perspectives on self-collection for CCS prior to it becoming available in their jurisdictions.
As described in the Methods chapter, all articles included in this IR explored provider
perspectives on the use of HPV self-collection for CCS. However, the primary outcome

19
described by authors varied across the dataset (Table 4); the most common outcome was
provider 8acceptability9 (n=4).
Figure 1
Approaches to Cervical Cancer Screening Described in Dataset
Clinician-led

Patient-led
Cervical cancer screening

Type of test

Cytology (Pap)

Collector

Clinician-collected

Clinician-collected

In-clinic

In-clinic

Collection setting

HPV

Self-collected

In-clinic

Pick-up/ return via
clinic

Access to kit

Relevant studies

At home

Bohn et al. (2022);
Brennan et al. (2024);
Creagh et al. (2021);
Fontenot et al. (2024);
Katz et al. (2017);
Le et al. (2022);
Le Goff et al. (2023);
Mao et al. (2017);
Pourette et al. (2022);
Rodriguez et al. (2023);
Xiong et al. (2022);
Zammit et al. (2023);
Zelli et al. (2022)

Rodriguez et al. (2023)

Bohn et al. (2022);
Fontenot et al. (2024);
Le et al. (2022);
Le Goff et al. (2023);
Rodriguez et al. (2023);
Xiong et al. (2022);
Zammit et al. (2023);
Zelli et al. (2022)

Brennan et al. (2024);
Creagh et al. (2021);
Fontenot et al. (2024);
Le et al. (2022);
Le Goff et al. (2023);
Mao et al. (2017);
Pourette et al. (2022);
Rodriguez et al. (2023);
Xiong et al. (2022);
Zammit et al. (2023)

Mail-based

Brennan et al. (2024);
Creagh et al. (2021);
Katz et al. (2017);
Mao et al. (2017);
Pourette et al. (2022);
Rodriguez et al. (2023);
Xiong et al. (2022)

Table 4
Provider Outcomes Measured and Corresponding Studies
Provider outcome measured
Acceptability (n=4)

Study
Creagh et al. (2021); Katz et al. (2017); Le et al. (2022);
Zelli et al. (2022)

Attitudes (n=3)

Bohn et al. (2022); Fontenot et al. (2024); Mao et al.
(2017)

Willingness to adopt (n=2)

Brennan et al. (2024); Rodriguez et al. (2023)

Opinions (n=2)

Le Goff et al. (2023); Pourette et al. (2022)

Views (n=1)

Xiong et al. (2022)

Experiences (n=1)

Zammit et al. (2023)

20
Provider Perspectives
The thirteen studies selected for inclusion in this IR presented diverse provider
perspectives on the use of self-collection for CCS. Perceived advantages and disadvantages of
the self-collection option, as well as potential impacts of self-collection on providers9 practices
and the wider healthcare system, are discussed in this section. Finally, providers9 reflections
regarding their role in CCS are presented.
Advantages of Self-Collection
Providers identified numerous benefits of self-collection for CCS. The potential for selfcollection to increase overall CCS rates was seen as beneficial by providers (Rodriguez, 2023;
Zelli et al., 2022). In fact, Zelli et al. (2022) found that the potential to increase CCS rates was
the most important benefit of self-collection identified by providers. Although some researchers
differentiated between efforts to reengage patients who were overdue for screening and the
ability to engage never-screened patients, self-collection was viewed by providers as a valuable
strategy for achieving both goals (Bohn et al., 2022; Creagh et al., 2021; Pourette et al., 2022,
Zammit et al., 2023).
From a provider perspective, self-collection is considered to be more convenient for
patients than clinician-collected methods for CCS (Le et al., 2022; Rodriguez et al., 2023; Xiong
et al., 2022). By reducing transportation challenges (Le Goff et al., 2023) and travel-related costs
incurred by patients as part of going to and from their provider9s clinic (Mao et al., 2017),
providers identified the potential for self-collection to reduce geographic barriers to care (Bohn
et al., 2022; Katz et al., 2017; Pourette et al., 2022). Zelli et al. (2022) also found that providers
associated self-collection with efficiency and time savings for patients, and Le Goff et al. (2023)

21
highlighted the benefit described by providers of reduced wait times for patients who wish to
access CCS.
Self-collection was described by providers as both patient-centred (Fontenot et al., 2024)
and trauma-informed (Xiong et al., 2022). Importantly, self-collection offers patient choice in
how they engage in CCS (Bohn et al., 2022; Zammit et al., 2023) and increases the level of
control that patients have over their CCS experience (Xiong et al., 2022). Providers identified the
potential for patient empowerment (Le Goff et al., 2022; Zammit et al., 2023) and <proaction in
their own health= (Xiong et al., 2022, p. 6) as consequences of participation in self-collection.
Providers asserted that self-collection would improve the patient experience of CCS by
offering increased privacy (Le et al., 2022; Le Goff et al., 2023; Xiong et al., 2022), and
decreased pain and discomfort (Xiong et al., 2022; Zelli et al., 2022). Providers predicted that
patients would experience less fear (Le Goff et al., 2022) and less embarrassment (Zelli et al.,
2022) because self-collection is less invasive and less intrusive than clinician-collected CCS
(Brennan et al., 2024; Fontenot et al., 2024; Le Goff et al., 2023; Xiong et al., 2022). Two
studies highlighted the perception held by providers that patients prefer female providers for
pelvic exams, suggesting that self-collection would be preferred by patients who have male
primary care providers and by the male providers themselves (Brennan et al., 2024; Le Goff et
al., 2023).
Three studies reported the strategic advantages that providers associated with selfcollection; when patients contacted their PCPs to seek self-collection for CCS, this provided an
opportunity for providers to address other health concerns or screening needs (Katz et al., 2017).
Similarly, when patients sought other forms of healthcare from their provider, the provider could
take the opportunity to offer self-collection to those due for CCS because specimen collection

22
could be completed without the need for a separate appointment (Brennan et al., 2024; Xiong et
al., 2022).
Several studies highlighted the importance that providers placed on self-collection for
specific patient populations. Fontenot et al. (2024) reported that some providers would support
self-collection only in special patient populations for whom traditional Pap tests had proven
challenging. For example, providers supported self-collection for patients with histories of sexual
or other trauma (Fontenot et al., 2024; Le et al., 2022), gender diverse populations (Fontenot et
al., 2024; Le et al., 2022), and those with anatomical variations such as vulvar structural
abnormalities or imperforate hymens (Fontenot et al., 2024; Xiong et al., 2022). Providers also
perceived that younger patients may prefer self-collection and saw it as strategy to promote CCS
in the younger population (Bohn et al., 2022; Xiong et al., 2022).
Interestingly, providers had divergent views with respect to self-collection for patients
with low literacy or language barriers. Some providers believed self-collection would increase
engagement in this population (Xiong et al., 2022) and that self-collection could be used as a tool
to increase health literacy regarding the connection between HPV and cervical cancer (Le et al.,
2022). Conversely, other providers saw low literacy as a barrier to patients engaging in selfcollection and did not think that pursuing self-collection would be worthwhile in this population
since those patients would not be motivated to participate in CCS (Katz et al., 2017). For
example, in one study, providers thought that low educational attainment among their patients
would result in a patient preference for clinician-collected CCS, due to discomfort with their own
anatomy (Pourette et al., 2022).
Similarly, there were disparate provider views on the use of self-collection among
patients with mobility or dexterity challenges. Some providers saw self-collection as reducing

23
barriers for patients with physical disabilities or mobility challenges (Fontenot et al., 2024),
while other providers thought that requiring patients to collect their own samples would increase
health disparities experienced by those for whom self-collection would be physically challenging
(Xiong et al., 2022).
Disadvantages of Self-Collection
Providers also identified a number of related concerns and risks associated with selfcollection. One of the most common provider concerns associated with self-collection was the
potential for missed opportunities to provide care. Providers were concerned that they would not
be able to conduct other components of a physical exam that would typically be included at the
same time as a Pap test (Bohn et al., 2022; Brennan et al., 2024) and that they would not have the
opportunity to visualize pathology (Brennan et al., 2024; Fontenot et al., 2022; Rodriguez et al.,
2023; Zelli et al., 2022). Additionally, providers noted they would have fewer opportunities to
review other health concerns with their patients or recommend other types of health screening
(Brennan et al., 2024; Mao et al., 2017; Rodriguez et al., 2023; Zelli et al., 2022).
Providers identified potential risks to patients associated with self-collection. According
to Le Goff et al. (2023), providers believed that self-collection would unduly increase the burden
on the patient, especially for those models that would require patients to complete self-collection
at home and return samples by mail. Providers also raised concerns related to patients being
unable to collect an adequate sample (Fontenot et al., 2024; Mao et al., 2017), which may require
them to undergo repeat testing (Xiong et al., 2022). Katz et al. (2017) also reported provideridentified risks for physical harm to patients due to the potential for kits breaking and the patient
unknowingly retaining a foreign body in their vagina.

24
Providers worried that the availability of self-collection for CCS would change the health
care behaviours and expectations of patients. Some providers anticipated that self-collection
would make patients more reluctant to receive other care in-person (Mao et al., 2017) and that
patients might feel that other important physical exams or screening were unnecessary (Le Goff
et al., 2023). Some providers believed that self-collection would also make patients less likely to
complete necessary follow-up, such as further testing and treatment related to cervical cancer
(Fontenot et al., 2024; Mao et al., 2017).
Reluctance from Providers
Providers reported that there is insufficient awareness amongst their colleagues of the
availability of self-collection for CCS (Creagh et al., 2021; Zammit et al., 2023; Zelli et al.,
2022). While providers were familiar with other applications of patient self-collection, such as
colorectal cancer screening (Le et al., 2022), Group B Strep in pregnancy (Fontenot et al., 2024),
bacterial vaginitis (Rodriguez et al., 2023), and COVID-19 testing (Rodriguez et al., 2023), the
availability of self-collection for CCS remained largely unknown and providers were therefore
skeptical of its use.
Despite published evidence to the contrary, providers believed that self-collection
methods are less reliable than clinician-collected CCS (Le Goff et al., 2023). Providers expected
that results from self-collected tests would be less accurate due to user error (Katz et al., 2017;
Le et al., 2022; Mao et al., 2017). Additionally, providers believed that patients would not
perceive self-collection as being 8as valid9 as clinician-collected testing (Xiong et al., 2022), and
that patients simply would not wish to engage with a self-collection option (Fontenot et al.,
2024). Providers also questioned specific aspects of the test9s validity, including sensitivity,
specificity, and accuracy of the result (Bohn et al., 2022; Creagh et al., 2021; Fontenot et al.,

25
2024; Xiong et al., 2022). According to Bohn et al. (2022), providers believed that more
evidence demonstrating the validity and accuracy of self-collection would improve uptake. Two
articles discussed the erroneous comments made by providers about the use of self-collection for
CCS; Fontenot et al. (2024) and Le Goff et al. (2023) highlighted providers9 concerns about the
patient successfully reaching their own cervix. However, as the authors pointed out, HPV selfcollection involves a vaginal swab, not a cervical specimen for cytology, suggesting that the
concerns of those providers were likely based on incorrect assumptions or misinformation
(Fontenot et al., 2024; Le Goff et al., 2023); this finding reinforced concerns related to lack of
provider knowledge about self-collection (Creagh et al., 2021; Zammit et al., 2023; Zelli et al.,
2022).
Providers identified ambiguity and confusion as barriers to their adoption of selfcollection for CCS (Creagh et al., 2021; Le et al., 2022). According to Xiong et al. (2022),
providers did not demonstrate a clear understanding of the intention or scope of self-collection,
such as whether it could be used for all persons with a cervix or whether it would only be
appropriate for those who had declined a Pap test. Similarly, Bohn et al. (2022) reported that
providers did not feel confident about their interpretation of patient eligibility criteria for selfcollection, and Creagh et al. (2021) found that, according to providers, the eligibility criteria
were too inflexible and too narrow. Overall, providers expressed confusion with existing
guidance on the use of self-collection for CCS (Creagh et al., 2021; Le et al., 2022). One
provider stated that, while they were able to recognize the benefits of self-collection, they would
not use it yet and would instead <wait for further guidance= (Fontenot et al., 2024, p. 513).
Providers noted that national guidelines (Bohn et al., 2022) and recommendations from

26
professional organizations (Fontenot et al., 2024) would be needed to support their acceptance of
self-collection as a reliable and safe tool for CCS.
Workflow and Logistical Considerations
Many providers described concerns related to the ways in which introduction of selfcollection for CCS could change the workflow of their practices. Some providers perceived
workflow benefits associated with self-collection, such as reducing stress on clinicians (Xiong et
al., 2022) and improved efficiency and time savings (Zelli et al., 2022). Conversely, Creagh et al.
(2021) and Zammit et al. (2023) reported concerns expressed by providers that self-collection for
CCS would increase workload for clinic staff. Providers in the Le at el. (2022) study expressed
concern that the coordination of self-collection kit pick-up, drop-off, and processing (for patients
who preferred to collect their sample at home), and scheduling clinic space to allow patients to
self-collect their sample in the clinic, all had the potential to cause significant disruption to their
existing practices. The additional burden on clinic support staff who would likely become
responsible for determining patient eligibility for self-collection was identified by providers in
two articles (Creagh et al., 2021; Zammit et al., 2023). Providers also expressed concerns related
to patients not returning their self-collected specimens and suggested that competing priorities
within their clinical practices would make it unreasonable for staff to follow-up with patients
individually to remind them to return their specimens (Fontenot et al., 2024; Rodriguez et al.,
2023).
Providers identified challenges related to the costs associated with self-collection. While
some providers suggested that self-collection would be more cost-effective than cliniciancollected CCS (Mao et al., 2017), other providers worried that self-collection would increase
system-level costs. Some providers anticipated that patients would request self-collection kits,

27
but would not return the sample, thereby increasing costs due to waste. Other providers
suggested that self-collection would result in increased rates of user error and the need for repeat
collection, which would increase the cost per completed screen (Xiong et al., 2022).
Unlike clinician-collected approaches to CCS, it was unclear to some providers if and
how they would be compensated for facilitating self-collection and who would be responsible for
the costs of the self-collection kits (Xiong et al., 2022). In providing context for their study,
Xiong et al. (2022) pointed out that, at the time their article was published, self-collection was
not covered by the US National Breast and Cervical Cancer Early Detection Programs or health
insurance plans. Providers identified this as a barrier to CCS because patients would need to pay
out-of-pocket for this service (Xiong et al., 2022). According to Bohn et al. (2022) and Fontenot
et al. (2024), providers described existing compensation models for self-collection as inadequate;
as one provider explained, <our practice only gets paid when we see patients face to face= (Bohn
et al., 2022, p. 1521), and suggesting that facilitating self-collection would not become a priority
until <it9s part of the basic way that primary care clinicians are paid= (p. 1521).
Provider Influence
Several studies highlighted the impact that PCPs have on patient health behaviours and
explored how providers9 beliefs about self-collection may influence patient participation in CCS.
For example, a provider9s endorsement of self-collection had a positive impact on an individual
patient9s decision to participate in CCS (Le et al., 2022). Similarly, a provider9s previous
experience with self-collection has the potential to shape their attitudes towards other selfcollection applications, which could in turn affect whether or not they offered self-collection to
other patients (Brennan et al., 2024). Specifically, Brennen et al. (2024) found that providers
who had previous positive experiences with self-collection for COVID-19 or colorectal cancer

28
screening, for example, were more likely to support self-collection for CCS. Conversely,
providers who had had previous negative experiences <had more reservations= (Brennan et al.,
2024, p. 9) about the use of self-collection for CCS.
As described by Zammit et al. (2023), the former Australian <practitioner-supported
model= (p. 2) required that a PCP facilitate access to CCS. Under this model, the provider was
responsible for determining eligibility for self-collection based on guidelines published by the
National Cervical Screening Program (NCSP; Zammit et al., 2023). Despite revisions to the
NCSP guidelines in 2022 that increased eligibility for self-collection, Zammit et al. (2023)
highlighted the important role that providers assume in settings where self-collection is only
available to specific patient subpopulations. Similarly, in their study of the former Australian
NCSP, Creagh et al. (2021) described the advocacy role that PCPs took on in promoting the use
of self-collection and calling for expanded access to self-collection as an option for CCS.
PCPs have the opportunity to shape how health care is delivered through advocacy and
health system leadership. Similarly, as trusted health experts, PCPs can significantly influence
how individual patients receive care and what care they access. Understanding the provider
perspective on self-collection for CCS has the potential to inform practice, policy, and future
research, as will be discussed in the next chapter.

29
Chapter Five: Discussion
Building on the themes identified in Chapter Four, this chapter relates the findings back
to important contextual elements in order to synthesize implications for practice, policy, and
further research. Each section concludes with a commentary on local implications, in which
findings from the literature are briefly discussed relative to BC9s self-collection-based model for
CCS. Finally, the limitations of this IR are discussed.
The results of this IR indicate that, in many jurisdictions, the use of self-collection for
CCS remains a controversial aspect of care. Overall, there is interest from providers in learning
how self-collection may benefit providers and patients, with the clear goal of increasing CCS
rates and early diagnosis and treatment of precancerous cervical lesions. However, many
providers remain skeptical about the role of self-collection. Several studies described providers9
concerns about the accuracy of self-collection as compared to clinician-collected samples
(Fontenot et al., 2024; Katz et al., 2017; Le et al., 2022; Rodriguez et al., 2023; Xiong et al.,
2022). In addition, some providers were reluctant to support self-collection because it would
eliminate the opportunity to visualize pathology during a pelvic exam (Bohn et al., 2022;
Brennan et al., 2024; Fontenot et al., 2024; Zelli et al., 2022). Providers worried that selfcollection would lead to fewer direct patient-provider interactions and could lead to less inperson care overall (Le Goff et al., 2023). Despite widespread systemic shifts towards health care
delivery models that are integrating virtual and telehealth options, as well as other applications of
specimen self-collection, there continues to be a preference for in-person patient visits expressed
by many PCPs and there are concerns about the risk associated with missed opportunities for
physical assessment (Mao et al., 2017; Rodriguez et al., 2023).

30
When the literature search for this IR was conducted, only three eligible studies reported
on provider perspectives from jurisdictions actively using self-collection for CCS (Creagh et al.,
2021; Le Goff et al., 2023; Zammit et al., 2023). The other ten studies included in this IR
reported providers9 perspectives on the potential use of HPV testing, and thus self-collection for
CCS, if and when it were to become available in their jurisdiction. Many of these studies
specified that a key barrier to self-collection was that this modality had not yet received
regulatory approval in their practice locations (Bohn et al., 2022; Fontenot et al., 2024; Mao et
al., 2017; Xiong et al., 2022). Despite this significant obstacle, study participants shared valuable
insights regarding the perceived benefits and risks of self-collection and highlighted important
clinical practice considerations. By identifying and addressing provider needs proactively, health
system leaders are likely to be more successful in implementing or expanding self-collection
programs.
Guidelines and Resources
Providers who work in areas with established self-collection services articulated a need
for additional practice resources to support them in offering this new approach to CCS. Specific
provider needs included clarification of the provider9s responsibility when facilitating selfcollection. For example, providers were unsure whether specimen self-collection had to be
completed in the clinic or whether patients could take their kit home and return it later (Creagh et
al., 2021). This perspective was also shared by pre-implementation providers; updated national,
provincial, or state guidelines were seen as a necessity for provider buy-in (Bohn et al., 2022),
and targeted provider education to support the transition from Pap testing to HPV self-collection
was identified as a priority (Le et al., 2022; Mao et al., 2017). In addition to clear clinical
guidance for providers, they also anticipated the need for patient-specific materials that would

31
provide simple illustrated instructions for successful sample collection (Katz et al., 2017; Le
Goff et al., 2023; Xiong et al., 2022).
In BC, the BCCA coordinates <the full spectrum of cancer care from prevention,
screening, diagnosis and treatment, to research and education, to supportive and palliative care=
(PHSA, 2025a, para. 1). With respect to CCS, the BCCA establishes and updates provincial
clinical guidelines (Gentile et al., 2024). In support of the January 2024 launch of BC9s <HPV
self-screening= program (Ministry of Health, 2024, para. 1), the BCCA developed print resources
including posters, pamphlets, and written instructions for both patient and provider audiences
(PHSA, 2025b). These resources are gender-inclusive, published in multiple languages, and are
available free, either as virtual resources that can be downloaded from the BCCA website or as
print resources that can be ordered by mail. Additionally, a series of videos was created to
provide further details about CCS, including who should be screened, how to request and return
a self-collection kit, how to collect a sample, and how to follow-up for results (ScreeningBC,
2024).
In order to support primary care practice change across BC, the BCCA has also published
care pathways for a number of different CCS scenarios, including patients who are
immunocompromised and those who have had cervical cancer before (PHSA, 2025c). These
pathways consist of step-by-step algorithms that inform clinical decision making based on
individual patient needs (PHSA, 2024b). Within their online resource library, the BCCA also
lists relevant scientific publications that provide informed updates about the provincial CCS
program so that evidence that supports practice change is readily available to providers (PHSA,
2025d).

32
As a result of the coordinated provincial approach to cancer screening and the practice
resources developed by BCCA, many of the gaps identified by providers in the literature are
unlikely to be perceived as challenges in the BC context. However, provider perspectives on the
use of self-collection in BC as well as early provider experiences have not yet been published. It
remains possible that, despite the BCCA9s best efforts, implementation of the provincial selfcollection program for CCS may still not meet providers9 needs or may cause unforeseen
challenges in PCP practices. Recently, Gentile et al. (2024) reported that, between February 1
and June 30, 2024, 1100 practices across BC ordered self-collection kits to have available for
their patients. While the authors do not differentiate between primary care and speciality
practices, this early finding suggests that there is interest in offering self-collection for CCS.
Ongoing evaluation of the BC CCS program will hopefully include provider experiences and
perspectives on self-collection.
Capacity Considerations
Logistical considerations related to the implementation of self-collection for CCS also
caused concerns for some providers. Even those providers who identified myriad benefits of selfcollection expressed hesitation in offering it due to an anticipated increased workload for
themselves and their teams (Le et al., 2022; Zammit et al., 2023). This concern is somewhat
paradoxical given that, with self-collection, the act of collecting the specimen is shifted from the
provider to the patient, which would potentially free up providers to provide those aspects of care
that patients cannot complete themselves (Xiong et al., 2022; Zelli et al., 2022). However,
studies that explored this challenge identified administrative tasks, such as identifying eligible
patients and coordinating self-collection kit pick-up and return, as most burdensome for PCP

33
practices (Bohn et al., 2022; Creagh et al., 2021; Le et al., 2022; Le Goff et al., 2023; Zammit et
al., 2023).
One area that was largely unaddressed in the literature was CCS result follow-up.
Multiple studies highlighted the need for clear processes to guide the distribution and return of
self-collection kits; however, less attention was paid to how results from self-collection would be
handled by PCPs and whether this new approach to CCS would require different care pathways.
When a clinician collects a specimen for CCS, that provider assumes the responsibility for the
follow-up of results (Le et al., 2022). However, providers expressed concern that, when a patient
engages in self-collection, who holds the responsibility for follow-up becomes less clear (Le et
al., 2022; Zammit et al., 2023). Two articles identified specific provider concerns related to
follow-up of screening results. The possibility of increased access to screening without a
corresponding increase in follow-up or treatment was identified by providers as decreasing
barriers to CCS, but not the full spectrum of cancer care (Le et al., 2022). In discussing existing
self-collection methods for CCS in Australia, providers described a well-established screening
pathway and an unsolved need to ensure follow-up for positive HPV results (Zammit et al.,
2023).
As previously discussed, the BCCA coordinates the provincial CCS program in BC and
works in collaboration with the patient9s PCP, if they have one (PHSA, 2025a; 2025e). In BC,
patients may self-refer to BCCA to determine eligibility for CCS and can receive a selfcollection kit by mail if they are due for CCS, all without the need for a PCP appointment
(PHSA, 2025e). Additionally, the BCCA maintains a provincial database for CCS, and
proactively sends reminders to patients when they are due for screening (PHSA, 2025e). Based
on the provider perspectives captured in the literature, this approach seems desirable because it

34
shifts the tasks of determining patient eligibility, coordinating specimen collection, and
following-up on results from individual providers to a provincial agency. This approach is
particularly important in the current climate of PCP shortages across BC and Canada because it
decreases demands on PCPs and it allows all BC residents to access CCS if they need it, even if
they do not have a regular PCP (Canadian Institute for Health Information, 2024; PHSA, 2025e).
In situations where unattached patients require follow-up based on screening results, BCCA will
connect the patient with a clinic in their home community (PHSA, 2025e).
Resource Allocation
Cost considerations were cited by providers as potential barriers to successful
implementation of self-collection for CCS. For example, uncertainty around insurance coverage
for self-collection (Fontenot et al., 2024; Xiong et al., 2022) and a lack of a clear compensation
model for providers who facilitate self-collection (Bohn et al., 2022), were of particular concern
in the US, where there is no universal healthcare coverage system (Fuzzell et al., 2021).
Conversely, in Canada, CCS is universally available to eligible patients at no cost (CPAC, 2024).
In BC specifically, self-collection supplies are provided to eligible patients free of charge, along
with a prepaid return envelope so that patients can mail the sample back for analysis (PHSA,
2025e). However, Canadian PCP perspectives on compensation for clinician-collected versus
self-collected CCS specimens remains unknown.
Resource allocation and policy considerations for CCS will need to evolve alongside
HPV vaccination patterns. Prior to widespread availability of HPV vaccination, CCS was the
primary strategy to prevent cervical cancer-related morbidity and mortality (CPAC, 2024).
Theoretically, as HPV vaccination coverage increases, rates of HPV infection will decrease, as
will resultant cervical cancer. With this in mind, it is possible that patients could overestimate the

35
protection conferred by the HPV vaccine and then not see the need for CCS. Public health
messaging will need to continue to be responsive to such trends and will likely rely on PCPs to
support health promotion activities. Currently, PHAC (2024) continues to recommend CCS for
both vaccinated and unvaccinated individuals:
While HPV vaccine has been shown to be highly effective against cervical cancer caused
by the HPV types contained within the vaccine, vaccine recipients remain susceptible to
infection from other high-risk HPV types. In addition, sexually active [individuals] may
have been infected with the HPV types contained within the HPV vaccine prior to
receiving the vaccine. (<Cervical Cancer Screening in Women= section)
As a result, CCS remains a priority strategy to prevent cervical cancer. The BCCA has
successfully established coordinated and comprehensive clinical guidelines, logistical supports,
and policy frameworks to support the implementation of self-collection for CCS. Many of the
barriers identified by providers in the literature have been addressed by the BCCA9s CCS
program, and future research into provider perspectives on its implementation is needed to
provide local data.
Limitations
In their discussion of the IR method, Whittemore and Knafl (2005) described its value as
well as the complexities of including diverse methodologies for informing evidence-based
nursing practice. The challenges of combining studies that employed different methodologies
and made different comparisons led to limitations in this IR. As was introduced in Chapter Four
(Figure 1), while all thirteen articles explored health care providers9 perspectives on the use of
self-collection for CCS, the variables and research methods differed. As a result, it was difficult
to determine which specific variables contributed to providers9 perspectives and in what ways.

36
For example, if all of the articles had compared at-home versus in-clinic HPV self-collection, it
would be relatively straightforward to draw conclusions about how independent variables, such
as collection setting, may have impacted the outcome of interest, namely provider perspectives.
Conversely, it was much more challenging to compare providers9 perspectives on traditional Pap
testing with perspectives on mail-based HPV self-collection, for example, because there were so
many variables that differed between studies. As a result, it is much more likely that confounding
variables may have obscured true relationships between conditions and outcomes. As the
familiar idiom illustrates, we cannot compare apples and oranges. In some cases, the
characteristics were too dissimilar to allow for meaningful comparison across studies. This is not
a reflection of the quality of each individual study; rather, it is a reflection of the breadth of
potential approaches to studying this topic.
Additionally, the current literature lacks perspectives specific to Canadian NPs. The
dataset included only one Canadian study, and while other Canadian research informed the
background of the IR, overall conclusions cannot be directly applied to Canadian NP role in
CCS. While it was necessary to include international literature, important jurisdictional
differences in NP scope may have confounded the findings.
Finally, because the studies included in the dataset employed non-experimental designs,
the conclusions presented by the researchers were necessarily based on their interpretations, and
thus are impacted by their biases. The narrative analysis undertaken for this IR involved
secondary analysis of the published data, and the conclusions presented herein are subject to the
author9s own biases and frames of reference (Whittemore & Knafl, 2005). While the author has
endeavoured to position herself relative to the research question (see Chapter Three), this IR
represents only one interpretation of the available data.

37
Chapter Six: Conclusion
This review sought to answer the question <What are the perspectives of PCPs toward
specimen self-collection for CCS?= using the Whittemore and Knafl (2005) IR methodology.
Previous studies have suggested that, by eliminating the need for a pelvic exam, self-collection
has the potential to improve CCS rates, especially amongst patients who are unwilling or
reluctant to undergo a pelvic exam. Given the potential impacts on their patients9 health
behaviours, PCP perspectives on self-collection for CCS are critical factors in informing best
practices and implementation strategies to support the expansion of this evidence-based and
patient-centred aspect of preventative healthcare.
Findings from the thirteen studies reviewed suggest that PCPs have identified a mix of
advantages and disadvantages associated with self-collection for CCS, and thus, hold both
positive and negative perspectives on self-collection for CCS. However, in many contexts, PCPs
remain unfamiliar with self-collection for CCS. This suggests that further research is needed to
identify facilitators and barriers related to PCP knowledge of self-collection.
The scope of this IR did not allow for in-depth analysis of similarities and differences
across international healthcare contexts reflected in the dataset. Differences in healthcare
provider roles across study contexts, along with a deficit of NP-specific literature, limited
conclusions pertaining to NP practice. Additionally, themes related to healthcare access and
patient-centre care were identified and warrant more fulsome investigation.

38
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Appendix A
Search Concepts and Terms
Concepts
Health care
providers9
perspectives

•
•
•
•
•
•
•

CINAHL Subject Heading*
attitudes or perceptions or opinions
or thoughts or feelings or beliefs
Attitude of Health Personnel
Nurse Attitudes
Physician Attitudes
Midwife Attitudes
Physician Assistant Attitudes
Attitude to Medical Treatment

•
•
•
•
•
•
•
•
•
•
•

Specimen selfcollection

•
•
•
•

Cervical cancer
screening

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Search Results
Removal of
Duplicates
Additional Hand
Searching
Results to be
Screened

self-sampling or hpv testing or home
or kit
Self-testing
Home diagnostic tests
Diagnostic test kits approval

screening or early detection or early
diagnosis or early identification
Cancer Screening
Health Screening
Early detection of cancer
Early diagnosis
Early intervention
hpv or humanpapillomavirus or
human papilloma virus
Human Papillomavirus Viruses
pap smear screening or cervical
cancer screening
Cervical smears (Cervical smears,
automated)
Papanicolau
Papillomavirus infections
cervical cancer screening or cervical
screening or smear test or pap smear
cervix cancer or cervix neoplasm or
cervical cancer
cervical cancer or cervical neoplasm
or cervical carcinoma
Cervix neoplasms
9 articles

•
•
•
•
•
•
•
•
•
•
•
•

•
•
•

MeSH (Medline)+
primary care provider or pcp or
practitioner or nurse practitioner
providers of health care or
physicians or advance practice
nurses
Nurse Practitioners
Family Nurse Practitioners
General Practitioners
Physicians, Primary Care
Access to Primary Care
Health Personnel
attitude or health personnel or
experiences or perspective or nurse
attitudes
Attitude of Health Personnel
Health Knowledge, Attitudes,
Practice
self-sampling or hpv testing or home
or kit
self-sampling hpv testing
Self-Testing
Specimen Handling
Human Papilloma Viruses
Human Papillomavirus DNA Tests
cancer screening or early detection
Early Detection of Cancer
Early Diagnosis
human papillomavirus or human
papilloma virus or hpv
Human Papillomavirus Viruses
cervical cancer screening or cervical
screening or cervical screening
programme or smear test or pap
smear
Papanicolaou Test
Uterine Cervical Neoplasms
Diagnostic Screening Programs

4 articles

•
•
•
•

Google Scholar
<HPV self-testing
provider perspectives=
<primary care provider
self-testing cervical
cancer=
<physician perspectives
self-testing cervical
cancer=
<nurse practitioner
perspectives self-testing
cervical cancer=

11 articles

-4 duplicates
+1 articles
21 articles

*Bolded terms are exact subject headings (MH); non-bolded terms are keyword searches (as suggested by
CINAHL via EBSCO)
+Bolded terms are medical subject headings (MeSH); non-bolded terms are keyword searches (as suggested by
MEDLINE via EBSCO)

49
Appendix B
Search Results using CINAHL (via EBSCO)

Tue, February
25, 2025
1:22:13 PM

#

Query

S11

S1 AND S9 AND S10

Limiters/Expanders

Last Run Via

Results
75

Expanders - Apply equivalent

Interface - EBSCOhost Research

subjects

Databases

Search modes - Proximity

Search Screen - Advanced Search
Database - CINAHL Complete

S10

S6 OR S7

Expanders - Apply equivalent

Interface - EBSCOhost Research

subjects

Databases

Search modes - Proximity

Search Screen - Advanced Search

19,273

Database - CINAHL Complete
S9

S2 OR S3 OR S4

Expanders - Apply equivalent

Interface - EBSCOhost Research

subjects

Databases

Search modes - Proximity

Search Screen - Advanced Search

126,779

Database - CINAHL Complete
S8

(MH "Physician Assistant

Expanders - Apply equivalent

Interface - EBSCOhost Research

Attitudes") OR "attitudes or

subjects

Databases

perceptions or opinions or

Search modes - Proximity

Search Screen - Advanced Search

120,399

Database - CINAHL Complete

thoughts or feelings or beliefs"
OR (MH "Attitude of Health
Personnel") OR (MH
"Physician Attitudes") OR (MH
"Midwife Attitudes") OR (MH
"Nurse Attitudes")
S7

(MH "Cervix Neoplasms") OR

Expanders - Apply equivalent

Interface - EBSCOhost Research

"cervix cancer or cervix

subjects

Databases

neoplasm or cervical cancer"

Search modes - Proximity

Search Screen - Advanced Search

19,273

Database - CINAHL Complete
S6

(MH "Cervix Neoplasms") OR

Expanders - Apply equivalent

Interface - EBSCOhost Research

"cervix cancer or cervix

subjects

Databases

neoplasm or cervical cancer"

Search modes - Proximity

Search Screen - Advanced Search

0

Database - CINAHL Complete
S5

(MH "Cervical Smears") OR

Expanders - Apply equivalent

Interface - EBSCOhost Research

"papanicolaou"

subjects

Databases

Search modes - Proximity

Search Screen - Advanced Search

7,507

Database - CINAHL Complete
S4

(MH "Cancer Screening") OR

Expanders - Apply equivalent

Interface - EBSCOhost Research

(MH "Cervical Smears") OR

subjects

Databases

(MH "Cervical Smears,

Search modes - Proximity

24,196

50

51
Appendix C
Search Results using MEDLINE (via EBSCO)

Tue, February
25, 2025
1:54:29 PM

#

Query

S14

S4 AND S12 AND S13

Limiters/Expanders

Last Run Via

Results

Expanders - Apply equivalent

Interface - EBSCOhost Research

50

subjects

Databases

Search modes - Proximity

Search Screen - Advanced Search
Database - MEDLINE with Full Text

S13

S5 OR S6

Expanders - Apply equivalent

Interface - EBSCOhost Research

subjects

Databases

Search modes - Proximity

32,687

Search Screen - Advanced Search
Database - MEDLINE with Full Text

S12

S7 OR S8 OR S9 OR S10 OR

Expanders - Apply equivalent

Interface - EBSCOhost Research

S11

subjects

Databases

Search modes - Proximity

431,456

Search Screen - Advanced Search
Database - MEDLINE with Full Text

S11

(MH "Health Personnel") OR

Expanders - Apply equivalent

Interface - EBSCOhost Research

"providers of health care or

subjects

Databases

physicians or advance practice Search modes - Proximity

Search Screen - Advanced Search

nurses" OR (MH "Attitude of

Database - MEDLINE with Full Text

320,779

Health Personnel") OR (MH
"Physicians, Primary Care")
OR (MH "Health Knowledge,
Attitudes, Practice")
S10

(MH "Attitude of Health

Expanders - Apply equivalent

Interface - EBSCOhost Research

Personnel") OR "attitude of

subjects

Databases

health personnel or

Search modes - Proximity

137,501

Search Screen - Advanced Search
Database - MEDLINE with Full Text

experiences or perspective or
nurse attitudes"
S9

(MH "Nurse Practitioners") OR

Expanders - Apply equivalent

Interface - EBSCOhost Research

(MH "Family Nurse

subjects

Databases

Practitioners") OR (MH

Search modes - Proximity

"Primary Health Care") OR

126,715

Search Screen - Advanced Search
Database - MEDLINE with Full Text

"primary care provider or pcp
or practitioner or nurse
practitioner" OR (MH "General
Practitioners") OR (MH
"Physicians, Primary Care")
S8

"health professionals or

Expanders - Apply equivalent

Interface - EBSCOhost Research

healthcare professionals or

subjects

Databases

health personnel or healthcare

Search modes - Proximity

201,882

52

53
Appendix D
PRISMA Flow Diagram

Included

Screening

Identification

Identification of studies via databases and other methods
Records identified through:
Database searching (n= 25)
CINHAL (EBSCO): 9
Medline (EBSCO): 4
Google Scholar: 11
Citation Searching: 1

Records removed before screening:
Duplicate records removed (n = 4)
Records removed for other reasons (n = 0)

Abstracts/Records screened
with inclusion criteria (n =
21)

Articles/records excluded (n = 3)
Reason 1: two articles were about
colorectal cancer screening (not cervical
cancer)
Reason 2: one article was about evaluation
of implementation, not provider

Full-text articles sought for
retrieval (n = 18)

Articles not retrieved (n = 0)

Full-text articles assessed
for eligibility (n = 18)

Records included in review
(n = 13)
Qualitative: 8
Mixed Methods: 3
Quantitative: 2

(adapted from Page et al., 2021)

Records excluded:
Reason 1: two studies assessed provider
knowledge of HPV, not perspectives on its
application for cervical cancer screening (n
= 2)
Reason 2: two studies included results from
non-clinicians that could not be
differentiated or isolated from clinician
perspectives (n = 2)
Reason 3: one article was an editorial, not
primary research (n = 1)

54
Appendix E
Data Appraisal Summaries

Article

Bohn, J. A., Fitch, K. C., Currier, J. J., & Bruegl, A. (2022). HPV self-collection: What are we waiting for? Exploration of
attitudes from frontline healthcare providers. International Journal of Gynecological Cancer, 32(12), 1519–1523.
https://doi.org/10.1136/ijgc-2022-003860

Study Location

Oregon, USA

Sample Size

Study Design

Qualitative

Implementation Stage

N=18
Pre

Post

1. Was there a clear
statement of the aims of the
research?

Yes

No

Can9t tell

Goal of research is to examine Oregon provider attitudes towards HPV selfcollection in order to increase uptake/availability of cervical cancer screening.
Authors clearly state context, including need for low barrier method for
cervical cancer screening, and this method's proven clinical effectiveness,
cost-effectiveness.

2. Is a qualitative
methodology appropriate?

Yes

No

Can9t tell

Authors sought to examine attitudes held by a group of health care providers.

3. Was the research design
appropriate to address the
aims of the research?

Yes

No

Can9t tell

Observational study. Authors used semi-structured focus groups and individual
interviews. Grounded theory for analysis.

4. Was the recruitment
strategy appropriate to the
aims of the research?

Yes

No

Can9t tell

Authors invited all members of Oregon Rural Practice-based Research
Network via email. State-wide Network was intentionally used to include
providers from varied geographic locations within state.
However, it is unclear whether providers in urban areas were included as well.

Can9t tell

The preferred data collection method was via focus groups, but individual
interviews were arranged for participants who could not attend 1 of 3 FGs. The
authors do not address whether/how participation in a focus group versus
individual interview may have impacted data collected. Additionally, the
authors intended to examine providers' "knowledge" of HPV self-collection (p.
1519), but only assessed for familiarity using Likert scale, which may or may
not equate to their knowledge.

Can9t tell

Authors were obstetrician/gynecologist (n=2), gynecologic oncologist, health
services researcher (p. 1520). All authors were affiliated with the Department
of Obstetrics & Gynecology and/or Knight Cancer Institute in Portland. It is
unclear how the authors' own perspectives on the topic may have impacted the
research design or results.

Can9t tell

Ethics approval was granted. "Study participants gave informed consent to
participate in the study before taking part" (p. 1523). The study topic relates to
health equity and health care access, however the ethical implications of the
research itself are not discussed.

Can9t tell

The authors describe the "comparative, iterative, and interactive" (p. 1520)
phases of data collection and analysis, and the component steps involved in
grounded theory. The whole study team was involved in coding data, and
together identified themes (sub-, meta-, macro- and overarching themes).

Can9t tell

Findings include a "strong desire" (p. 1521) to implement HPV self-collection,
as well as multiple concerns held by health care providers. However, the
authors did not present the themes clearly. For example, they identified
barriers to cervical cancer screening broadly, not only specific to HPV selfcollection (i.e., theme #5 identified barriers to current standard practice, not
the proposed change to practice, which was the purpose of the study).

5. Was the data collected in a
way that addressed the
research issue?

6. Has the relationship
between researcher and
participants been adequately
considered?
7. Have ethical issues been
taken into consideration?

8. Was the data analysis
sufficiently rigorous?

9. Is there a clear statement
of findings?

Yes

Yes

Yes

Yes

Yes

No

No

No

No

The study is valuable because it suggests an overall willingness to embrace
this new practice, as well as ambivalence towards change. The results of this
study include provider concerns as well as barriers to implementation that are
concordant with the wider literature on this topic. For Oregon, this study
provides local perspectives on potential challenges for implementation.

10. How valuable is the
research?
Overall Appraisal
(CASP, 2024b)

No

Low quality

Medium quality

High quality

55
Article

Brennan, L., Adekunle, T., Kasting, M., Forman, M. R., Champion, V., & Rodriguez, N. M. (2024). Factors associated with
clinician willingness to adopt HPV self-sampling and self-testing for cervical cancer screening. Journal of Clinical and
Translational Science, 8(1), Article e118. https://doi.org/10.1017/cts.2024.604

Study Location

"Midwest" USA

Sample Size

Study Design

Mixed methods

Implementation Stage

248 surveys, 23 interviews
Pre

Post

5.1. Is there an adequate
rationale for using a mixed
methods design to address the
research question?

Yes

No

Can9t tell

<convergent mixed-methods approach that included a survey and in-depth
interviews= (p. 2)

5.2. Are the different
components of the study
effectively integrated to
answer the research
question?

Yes

No

Can9t tell

Qualitative data collection tool developed based off of quantitative tool "to
contextualize and provide reasoning behind the findings from the quantitative
survey." (p. 3)

5.3. Are the outputs of the
integration of qualitative and
quantitative components
adequately interpreted?

Yes

No

Can9t tell

Clear presentation of results, and integrated discussion as related to
topics/themes.

5.4. Are divergences and
inconsistencies between
quantitative and qualitative
results adequately addressed?

Yes

No

Can9t tell

Multiple examples in which quant/qual results diverged, which were
elaborated upon in discussion section. Some hypotheses presented, in addition
to highlighting areas for future study.

5.5. Do the different
components of the study
adhere to the quality criteria
of each tradition of the
methods involved?

Yes

No

Can9t tell

Adequate description of data analysis for each type of data. Inclusion of raw
data and syntehsized data in results and discussion sections, respectively.

Overall Appraisal
(Hong et al., 2018)

Low quality

Medium quality

High quality

56
Article

Creagh, N. S., Zammit, C., Brotherton, J. M., Saville, M., McDermott, T., Nightingale, C., & Kelaher, M. (2021). Self‐collection
cervical screening in the renewed National Cervical Screening Program: A qualitative study. Medical Journal of
Australia, 215(8), 354–358. https://doi.org/10.5694/mja2.51137

Study Location

Victoria, Australia

Sample Size

Study Design

Qualitative

Implementation Stage

N=18
Pre

Post

1. Was there a clear
statement of the aims of the
research?

Yes

No

Can9t tell

Goal of study was to evaluate implementation of self-collection and assess
acceptability of the new practice according to both patients and providers.

2. Is a qualitative
methodology appropriate?

Yes

No

Can9t tell

Authors sought to understand the experiences of participants.

3. Was the research design
appropriate to address the
aims of the research?

Yes

No

Can9t tell

Semi-structured individual interviews were conducted.

4. Was the recruitment
strategy appropriate to the
aims of the research?

Yes

No

Can9t tell

Providers were contacted by mail via registry held by the lab that tests selfcollected specimens. Follow-up phone calls were made to those who had not
opted-out following initial contact. Recruitment was ongoing throughout the
data collection phase.

5. Was the data collected in a
way that addressed the
research issue?

Yes

No

Can9t tell

Limited information is provided about the semi-structured interviews; the
interview guide was not provided, and information about the interviews (e.g.,
duration) were not included in the article.

6. Has the relationship
between researcher and
participants been adequately
considered?

Yes

No

Can9t tell

Author affiliations are included, but individual author professions (i.e.,
clinician vs. academic) are not included and the article does not describe
individual author contributions. Interestingly, the publication was dedicated to
a deceased member of the research team. However, there is no discussion of
potential for bias, etc.

7. Have ethical issues been
taken into consideration?

Yes

No

Can9t tell

REB, informed consent, funding disclosure. Additional consent was sought to
audio record the interview, and the authors describe accommodations that were
made for one participant who did not consent to recording.

8. Was the data analysis
sufficiently rigorous?

Yes

No

Can9t tell

NVivo software used for template analysis. Initial thematic codes based in
literature, then revised multiple times by research team, with cross-checking
for consistency amongst individual researchers.

9. Is there a clear statement
of findings?

Yes

No

Can9t tell

Article concludes that self-collection is "feasible and acceptable" (p. 357).
Additionally, the authors highlight priority barriers to implementation.
The research is valuable because it builds on a prior pilot study. Importantly, it
demonstrates feasibility outside of the pilot context (i.e., without the additional
supports that were available to implement the practice). It also highlights
barriers to success and identifies resources that are needed to support success
of this practice change.

10. How valuable is the
research?
Overall Appraisal
(CASP, 2024b)

Low quality

Medium quality

High quality

57
Article

Fontenot, H. B., Fuzzell, L., Brownstein, N. C., Lake, P., Michel, A., Vadaparampil, S. T., & Perkins, R. B. (2024). Health care
provider willingness to recommend self-collected tests for human papillomavirus: A mixed methods examination of
associated factors. Women’s Health Issues, 34(5), 506–517. https://doi.org/10.1016/j.whi.2024.05.005

Study Location

USA (national)

Sample Size

Study Design

Mixed methods

Implementation Stage

1251 surveys, 51 interviews
Pre

Post

5.1. Is there an adequate
rationale for using a mixed
methods design to address the
research question?

Yes

No

Can9t tell

Sought to identify provider and practice characteristics, preferences (quant)
and provider attitudes, perceived concerns and perceived benefits (qual).

5.2. Are the different
components of the study
effectively integrated to
answer the research
question?

Yes

No

Can9t tell

<Quantitative measures included provider and practice characteristics,
willingness to recommend, and preferences related to self-collection.
Qualitative interviews further elucidated provider perspectives.= (p. 506)

5.3. Are the outputs of the
integration of qualitative and
quantitative components
adequately interpreted?

Yes

No

Can9t tell

Survey questions and results, along with analysis in Results section. Interview
themes and subthemes, as well as quotations (raw data) included in Results
section. Integrated discussion, drawing on quant/qual sources.

5.4. Are divergences and
inconsistencies between
quantitative and qualitative
results adequately addressed?

Yes

No

Can9t tell

Good discussion of both convergence and divergence between qual/quant data.
Interesting analysis of divergence in 'special populations' vs general
population.

5.5. Do the different
components of the study
adhere to the quality criteria
of each tradition of the
methods involved?

Yes

No

Can9t tell

Appropriate smapling strategies, efforts to minimize bias/confounding.

Overall Appraisal
(CASP, 2024a)

Low quality

Medium quality

High quality

58
Article

Katz, M. L., Zimmermann, B. J., Moore, D., Pasket, E. D., & Reiter, P. L. (2017). Perspectives from health-care providers and
women about completing human papillomavirus (HPV) self-testing at home. Women & Health, 57(10), 1161–1177.
https://doi.org/10.1080/03630242.2016.1243608

Study Location

Oregon, USA

Sample Size

Study Design

Qualitative

Implementation Stage

N=28
Pre

Post

1. Was there a clear
statement of the aims of the
research?

Yes

No

Can9t tell

Goal of research is to examine provider perspectives on the practice of mailing
HPV self-collection kits to rural patients.

2. Is a qualitative
methodology appropriate?

Yes

No

Can9t tell

Authors sought to examine attitudes held by a group of health care providers.

3. Was the research design
appropriate to address the
aims of the research?

Yes

No

Can9t tell

Conducted focus groups; intention to "foster dynamic group discussions and a
broader range of themes" than individual interviews (p. 3). Individual
interviews used if only one participant available.

4. Was the recruitment
strategy appropriate to the
aims of the research?

Yes

No

Can9t tell

Convenience sample intended to provide local, non-generalizable findings.

5. Was the data collected in a
way that addressed the
research issue?

Yes

No

Can9t tell

Extensive description of data collection protocols.

6. Has the relationship
between researcher and
participants been adequately
considered?

Yes

No

Can9t tell

Author affiliations are included, but individual author professions (i.e.,
clinician vs. academic) are not included. The article does describe individual
author contributions to data analysis.

7. Have ethical issues been
taken into consideration?

Yes

No

Can9t tell

REB, informed consent, funding disclosure.

8. Was the data analysis
sufficiently rigorous?

Yes

No

Can9t tell

Article includes appendices with themes and data to support transparency in
how themes were developed.

9. Is there a clear statement
of findings?

Yes

No

Can9t tell

Overall acceptance of the use of mail-in HPV self-testing for rural patients.
Extensive "Results" section consisted of 9 themes; may have been clearer or
more effective to group these into a smaller number of total themes.
This research is valuable for program planning purposes. The FGs showed
participants multiple potential devices and sought perspectives on a range of
hypothetical options. Seeking perspectives prior to implementation has the
potential to mitigate challenges and increase engagement/buy-in.
The research is conducted in a particularly underserved population with high
disease burden.

10. How valuable is the
research?

Overall Appraisal
(CASP, 2024b)

Low quality

Medium quality

High quality

59
Article

Le, D., Ciceron, A. C.., Jeon, M. J., Gonzalez, L. I., Jordan, J. A., Bordon, J., & Long, B. (2022). Cervical cancer prevention and
high-risk HPV self-sampling awareness and acceptability among women living with HIV: A qualitative investigation from
the patients9 and providers9 perspectives. Current Oncology, 29(2), 516–533. https://doi.org/10.3390/curroncol29020047

Study Location

Washington DC, USA

Sample Size

Study Design

Qualitative

Implementation Stage

N=10
Pre

Post

1. Was there a clear
statement of the aims of the
research?

Yes

No

Can9t tell

Yes, 2 interrelated research questions (patient perspectives, provider
perspectives), but unclear links between findings.

2. Is a qualitative
methodology appropriate?

Yes

No

Can9t tell

Objective is to identify perspectives of patients and providers. Involves
exploration of individual experiences.

3. Was the research design
appropriate to address the
aims of the research?

Yes

No

Can9t tell

"In-depth interviews with providers" (p. 518)

4. Was the recruitment
strategy appropriate to the
aims of the research?

Yes

No

Can9t tell

Purposive sampling of healthcare providers who serve women living with
HIV.

5. Was the data collected in a
way that addressed the
research issue?

Yes

No

Can9t tell

Interview questions based on theoretical model (Health Belief Model).

6. Has the relationship
between researcher and
participants been adequately
considered?

Yes

No

Can9t tell

Followed principles of "community-engaged research" (p. 519), including
community advisory board and member checks throughout process.
Acknowledgment that academic researchers as outsiders, relying on
community members.

7. Have ethical issues been
taken into consideration?

Yes

No

Can9t tell

REB, informed consent, funding disclosure. Remuneration for participants.

8. Was the data analysis
sufficiently rigorous?

Yes

No

Can9t tell

Specific description "goal of this study was to achieve thematic saturation" (p.
519). Described analysis process and researcher roles therein.

9. Is there a clear statement
of findings?

Yes

No

Can9t tell

Clear statement of findings related to the patient perspectives, but less clear
with respect to providers.
Valuable because of specific patient sub-population (women living with HIV)
and health care providers who care for them.

10. How valuable is the
research?
Overall Appraisal
(CASP, 2024b)

Low quality

Medium quality

High quality

60
Article

Le Goff, J., Le Duc-Banaszuk, A.-S., Lefeuvre, C., Pivert, A., Ducancelle, A., De Pauw, H., Arbyn, M., Vinay, A., & RexandGalais, F. (2023). Acceptability to healthcare professionals of home-based HPV self-sampling for cervical screening: A
French qualitative study conducted in an area with low access to health services. Cancers, 15(21), Article 5163.
https://doi.org/10.3390/cancers15215163

Study Location

Mayenne & Sarthe, Pays de la Loire, France

Sample Size

Study Design

Qualitative

Implementation Stage

N=59
Pre

Post

1. Was there a clear
statement of the aims of the
research?

Yes

No

Can9t tell

Exploring perspectives in effort to improve access in underserved geographic
areas. "Although healthcare professionals play a major role, little is known
about their opinions on cervical screening and self-sampling" (p. 2)

2. Is a qualitative
methodology appropriate?

Yes

No

Can9t tell

Aim of study: "explore viewpoints of health professionals" (p. 3)

3. Was the research design
appropriate to address the
aims of the research?

Yes

No

Can9t tell

This is part of a larger mixed methods study.

4. Was the recruitment
strategy appropriate to the
aims of the research?

Yes

No

Can9t tell

All eligible providers were invited via public cancer screening organization.
Invitations send via email, with spaced reminder emails sent.

5. Was the data collected in a
way that addressed the
research issue?

Yes

No

Can9t tell

Profession-specific interview guides developed by local affiliate Dept of
Psychology. Data collected by 1 trained interviewer (assuming good
consistency). Interview guides included in publication, available to reader.

6. Has the relationship
between researcher and
participants been adequately
considered?

Yes

No

Can9t tell

Author affiliations are included, but individual author professions (i.e.,
clinician vs. academic) are not included.The article does describe individual
author contributions to data analysis. Conflict of interest statement (negative).

7. Have ethical issues been
taken into consideration?

Yes

No

Can9t tell

REB, informed consent, funding disclosure.

8. Was the data analysis
sufficiently rigorous?

Yes

No

Can9t tell

"Constant comparison" (p. 4) method used to identify saturation. However,
insufficient description of how saturation was identified, how themes were
identified/developed

9. Is there a clear statement
of findings?

Yes

No

Can9t tell
Valuable because offers international perspective. Attuned to "low physician
density … medical deserts" (p. 2).

10. How valuable is the
research?
Overall Appraisal
(CASP, 2024b)

Low quality

Medium quality

High quality

61
Article

Mao, C., Kulasingam, S. L., Whitham, H. K., Hawes, S. E., Lin, J., & Kiviat, N. B. (2017). Clinician and patient acceptability of
self-collected human papillomavirus testing for cervical cancer screening. Journal of Women’s Health, 26(6), 609–615.
https://doi.org/10.1089/jwh.2016.5965

Study Location

Washington, USA

Sample Size

Study Design

Quantitative (cross-sectional)

Implementation Stage

N=118
Pre

Post

1. Did the study address a
clearly focused issue?

Yes

No

Can9t tell

Study sample inclusion criteria were specific enough to clearly focus the
question. The study sought the perspectives of specific health professions
employed within a specified healthcare system who had performed Pap exams
within specified timeframe and had publicly listed email address.

2. Did the authors use an
appropriate method to
answer their question?

Yes

No

Can9t tell

The authors used a type of cross-sectional study (online survey), which
provides a one-time 8snapshot9 of the participants9 opinions and perspectives
and is an appropriate method to answer their research question.

Can9t tell

The authors recruited participants via email, which is a common and widely
accepted practice to invite participation in an online survey. This approach
allows the researchers to quickly target all members of a specified group.
However, there are potential drawbacks to this approach given that individuals
may have multiple email addresses and may not actively check their employerassigned address, or high email volume may results in messages being missed
or ignored.

Can9t tell

Both objective and subjective data were collected. Participant demographics
including age, gender, profession, type of clinical practice/specialty were
collected. Additionally, the study sought participants9 perspectives on various
clinical situations and characteristics, which was appropriate to answer the
research question. However, the survey itself was not published, so it is
impossible to fully assess the potential for measurement or classification bias
(i.e., the wording of survey questions cannot be assessed).

Can9t tell

Data collection setting (online) and method (survey) are justified. While the
specific wording of survey questions is unknown, the results suggest that
participants had the option to select multiple pre-populated responses and
could indicate <Other= if their desired answer was not available. However, it is
unclear whether indicating <Other= would prompt or permit the participant to
type an explanation.

Can9t tell

The relatively small sample size (n=118) is appropriate to answer the question
given the specific inclusion criteria for the study population. The response rate
(49.6%) is sufficient to minimize the impact of chance. However, the response
rates for subgroups varied considerably, suggesting that a number of
likeminded participants may have skewed the results disproportionately.

3. Were the subjects
recruited in an acceptable
way?

4. Were the measures
accurately measured to
reduce bias?

5. Were the data collected in
a way that addressed the
research issue?

6. Did the study have enough
participants to minimize the
play of chance?

Yes

Yes

Yes

Yes

No

No

No

No

The results are presented as the proportion of respondents with
shared/differing perspectives. Some data points are further analyzed for
subgroups based on linked demographic data, however this is not reported
consistently, which makes interpretation of the findings challenging.
The main result is that the majority of respondents "would recommend a selfcollected HPV test" (p. 609) if specific criteria were met.

7. How are the results
presented and what is the
main result?

8. Was the data analysis
sufficiently rigorous?

9. Is there a clear statement
of findings?

10. Can the results be applied
to the local population?

Yes

Yes

Yes

No

No

Can9t tell

The majority of results are descriptive statistics. The data analyzed via Chi
square and Mantel-Haenszel tests are not included in the article; the authors
include three points of analysis, only one of which has p-value <0.05. There is
insufficient description of the analysis process.

Can9t tell

The findings are clearly stated and are informed by sufficient discussion.
However, because this study is based on a pre-implementation survey, the
findings are somewhat hypothetical. The main conclusion is: <Home selfcollected HPV screening tests are acceptable to … clinicians if the test is
shown to be accurate, cost effective, and does not impact access to a healthcare
provider for other health concerns.= (p. 614).

Can9t tell

In their discussion of the methodological limitations of their study, the authors
describe the study population as mostly <academic clinicians who may be
more willing to adopt new approaches to cervical cancer screening than those
outside of an academic setting= (p. 613). The authors caution that the results
are unlikely to be generalizable.
The authors assert that their study is <one of the first studies to also determine
acceptability in clinicians= (p. 613) (i.e., in addition to patient perspectives).
However, they also acknowledge that additional research is needed to inform
implementation at the system and individual provider levels.

11. How valuable is the
research?
Overall Appraisal
(CASP, 2024a)

No

Low quality

Medium quality

High quality

62
Article

Pourette, D., Cripps, A., Guerrien, M., Desprès, C., Opigez, E., Bardou, M., & Dumont, A. (2022). Assessing the acceptability of
home-based HPV self-sampling: A qualitative study on cervical cancer screening conducted in Reunion Island prior to the
RESISTE trial. Cancers, 14(6), Article 1380. https://doi.org/10.3390/cancers14061380

Study Location

Reunion Island (French territory in Indian
Ocean)

Sample Size

Study Design

Qualitative

Implementation Stage

N=20
Pre

Post

1. Was there a clear
statement of the aims of the
research?

Yes

No

Can9t tell

Pre-implementation assessment of knowledge and perspectives. Part or larger
program of research.

2. Is a qualitative
methodology appropriate?

Yes

No

Can9t tell

Seeking to explore awareness, interest, perceptions of barriers, etc. led to
results related to knowledge, attitudes, practices, past experiences .

3. Was the research design
appropriate to address the
aims of the research?

Yes

No

Can9t tell

Sought perspectives of health professionals (and patients).

4. Was the recruitment
strategy appropriate to the
aims of the research?

Yes

No

Can9t tell

Authors state that "a diverse sample of health professionals" (p. 4) was
"selected", but provide no details about approach to sampling.

5. Was the data collected in a
way that addressed the
research issue?

Yes

No

Can9t tell

Interview guides included in publication with relevant/ appropriate questions.

6. Has the relationship
between researcher and
participants been adequately
considered?

Yes

No

Can9t tell

7. Have ethical issues been
taken into consideration?

Yes

No

Can9t tell

REB, informed consent, funding disclosure. Interviews conducted in multiple
languages appropriate to context.

8. Was the data analysis
sufficiently rigorous?

Yes

No

Can9t tell

Discussion focused on data from patient interviews, not providers. Reader to
assume that similar approach to analysis for provider interviews, but unclear.

9. Is there a clear statement
of findings?

Yes

No

Can9t tell

<The professionals interviewed were unanimous in recognizing that sending a
selfsampling kit to women9s homes should make it possible to reach women
whom they are unable to screen= (p. 13)
International perspectives in context with diverse cultures (language, "medical
pluralism" (p. 3), history), increased disease burden, inadequate access to
health services.

10. How valuable is the
research?
Overall Appraisal
(CASP, 2024b)

Low quality

Medium quality

High quality

63
Article

Rodriguez, N. M., Brennan, L. P., Claure, L., Balian, L. N., Champion, V. L., & Forman, M. R. (2023). Leveraging COVID-era
innovation for cervical cancer screening: Clinician awareness and attitudes toward self-sampling and rapid testing for HPV
detection. PLoS ONE, 18(3), Article e0282853. https://doi.org/10.1371/journal.pone.0282853

Study Location

Indiana, USA

Sample Size

Study Design

Mixed methods

Implementation Stage

5.1. Is there an adequate
rationale for using a mixed
methods design to address the
research question?

Yes

No

224 surveys, 20 interviews
Pre

Post

Can9t tell

<This convergent mixed-methods study was designed as an online crosssectional survey and in-depth interviews with clinicians who conduct cervical
cancer screening in Indiana. (p. 3)

5.2. Are the different
components of the study
effectively integrated to
answer the research
question?

Yes

No

Can9t tell

Quant (survey) to explore "clinician awareness, perceived benefit, and
willingness to adopt" (p. 3)
Qual (interviews) sought additional depth on perceptions of
benefits/limitations, reasons individual providers were un/willing to adopt, and
"whether COVID pandemic influenced their overall perspective of rapid
testing as a screening modality" (p. 3)

5.3. Are the outputs of the
integration of qualitative and
quantitative components
adequately interpreted?

Yes

No

Can9t tell

The way the results section was organized (qualitative theme with quant data
to support/expand) demonstrates thoughtfulness towards how data was
integrated to paint comprehensive picture.

5.4. Are divergences and
inconsistencies between
quantitative and qualitative
results adequately addressed?

Yes

No

Can9t tell

Some discordance within quant data (i.e., think it's beneficial, but not willing
to adopt), which was then interpreted using qual.

5.5. Do the different
components of the study
adhere to the quality criteria
of each tradition of the
methods involved?

Yes

No

Can9t tell

Largely, yes, it seems that there was good adherence. However, missing from
the methods section is a comment on response rate for survey data. We know
224 surveys were completed, but it is not clear how many were eligible.

Overall Appraisal
(Hong et al., 2018)

Low quality

Medium quality

High quality

64
Article

Xiong, S., Lazovich, D. A., Hassan, F., Ambo, N., Ghebre, R., Kulasingam, S., Mason, S. M., & Pratt, R. J. (2022). Health care
personnel9s perspectives on human papillomavirus (HPV) self-sampling for cervical cancer screening: A preimplementation, qualitative study. Implementation Science Communications, 3(1), Article 130.
https://doi.org/10.1186/s43058-022-00382-3

Study Location

"Midwest" USA

Sample Size

Study Design

Qualitative

Implementation Stage

N=30
Pre

Post

1. Was there a clear
statement of the aims of the
research?

Yes

No

Can9t tell

Description of current challenges; seeking perspectives on proposed solution.

2. Is a qualitative
methodology appropriate?

Yes

No

Can9t tell

Seeking perspectives of "health care personnel (providers, leaders, and clinic
staff)" (p. 1)

3. Was the research design
appropriate to address the
aims of the research?

Yes

No

Can9t tell

Qualitative key informant interviews to seek participants' "views" on potential
implementation (p. 1)

4. Was the recruitment
strategy appropriate to the
aims of the research?

Yes

No

Can9t tell

Recruited via email plus snowball sampling. Screened with pre-interview
survey.

5. Was the data collected in a
way that addressed the
research issue?

Yes

No

Can9t tell

Pre-interview demographics survey plus individual interviews.

6. Has the relationship
between researcher and
participants been adequately
considered?

Yes

No

Can9t tell

7. Have ethical issues been
taken into consideration?

Yes

No

Can9t tell

REB, informed consent, funding disclosure. Remuneration for participants.

8. Was the data analysis
sufficiently rigorous?

Yes

No

Can9t tell

Publication includes detailed description of analysis process, as well as
references to theoretical model used to develop data collection instrument.

9. Is there a clear statement
of findings?

Yes

No

Can9t tell

Provides nuanced but clear conclusions, which inform recommendations for
future directions.
Provides good 'snapshot in time' of pre-implementation concerns, need for
information, and considerations to support implementation success. Also
identifies future research needs.

10. How valuable is the
research?
Overall Appraisal
(CASP, 2024b)

Low quality

Medium quality

High quality

65
Article

Zammit, C., Creagh, N., Nightingale, C., McDermott, T., Saville, M., Brotherton, J., & Kelaher, M. (2023, April 27). 8I9m a bit
of a champion for it actually9: Qualitative insights into practitioner-supported self-collection cervical screening among early
adopting Victorian practitioners in Australia. Primary Health Care Research & Development, 24, Article e31.
https://doi.org/10.1017/S1463423623000191

Study Location

Victoria, Australia

Sample Size

Study Design

Qualitative

Implementation Stage

N=18
Pre

Post

1. Was there a clear
statement of the aims of the
research?

Yes

No

Can9t tell

"This study aimed to describe the experiences of practitioners in Victoria,
Australia, who used human papillomavirus (HPV)-based self-collection
cervical screening during the first 17 months of its availability" (p. 1)

2. Is a qualitative
methodology appropriate?

Yes

No

Can9t tell

Seeking to "describe experiences" (p. 1).

3. Was the research design
appropriate to address the
aims of the research?

Yes

No

Can9t tell

Individual interviews using guide (published) that had been piloted.
Purposive sampling of healthcare providers who were actively providing this
service. Providers were contacted by mail via registry held by the lab that tests
self-collected specimens. Follow-up phone emails/calls were made to those
who had not opted-out following initial contact. Total of 3 rounds of
communication. Interesting, third round of recruitment "over sampled male
practitioners to maximize their representation as study participants." (p. 2)

4. Was the recruitment
strategy appropriate to the
aims of the research?

Yes

No

Can9t tell

5. Was the data collected in a
way that addressed the
research issue?

Yes

No

Can9t tell

6. Has the relationship
between researcher and
participants been adequately
considered?

Yes

No

Can9t tell

Author affiliations are included, but individual author professions (i.e.,
clinician vs. academic) are not included.The article does describe individual
author contributions to data analysis. Conflict of interest statement indicated
that authors' employer received free test kits from manufacturer.

7. Have ethical issues been
taken into consideration?

Yes

No

Can9t tell

REB, informed consent, funding disclosure. Incentive (movie voucher) for
participants. Statement re: conflict of interest (researchers had previously
received free kits from manufacturers).

8. Was the data analysis
sufficiently rigorous?

Yes

No

Can9t tell

Authors state that Nvivo software used. Description of "thematic template
analysis" approach included (p. 2), as well as development of coding
framework, iterative revisions, efforts to ensure consistency.

9. Is there a clear statement
of findings?

Yes

No

Can9t tell

"Practitioners were overwhelmingly supportive of self-collection cervical
screening because it was acceptable to their patients and addressed patients9
barriers to screening." (p. 1)
Potentially very limited application given:
1) includes perspectives of early adopters (those who have used in first 17
months of availability), therefore introduces (self-)selection bias;
2) availability of self-testing very limited to specific population (e.g., "only
available to those aged 30 years <, who were overdue for cervical screening
and refused practitioner-collected test." (p. 2)

10. How valuable is the
research?

Overall Appraisal
(CASP, 2024b)

Low quality

Medium quality

High quality

66
Article

Zelli, J., Hum, S., Lofters, A., & Dunn, S. (2022). Clinician acceptability of self-collected human papillomavirus swabs as a
primary cervical cancer screening method. Canadian Family Physician, 68(2), e31–e38.
https://doi.org/10.46747/cfp.6802e31

Study Location

Toronto, Canada

Sample Size

Study Design

Quantitative (cross-sectional)

Implementation Stage

N=58
Pre

Post

1. Did the study address a
clearly focused issue?

Yes

No

Can9t tell

The study was focused based on participants (primary care providers and
obstetrician-gynecologists) at two urban hospitals.

2. Did the authors use an
appropriate method to
answer their question?

Yes

No

Can9t tell

The authors describe the study design as "descriptive, cross-sectional,
anonymous, online pilot survey" (p. 31), which is an appropriate method to
answer their research question.

Can9t tell

The authors specify that they used the Dillman et al. (2014) approach to survey
recruitment, which is a validated comprehensive approach to virtual survey
recruitment. The authors invited all "staff physicians and nurse practitioners"
(p. 34) in the relevant departments at the two participating hospital sites within
a defined time frame (2 months). Additionally, the authors specify that
"residents and trainees were excluded" (p. 34) because they were seeking only
the perspectives of experienced clinicians.

Can9t tell

Objective data were collected using a 5-point Likert scale, which is an
appropriate measurement tool for the research question. The survey design is
adequately described (i.e., wording of questions) in the narrative, and the
authors note that the survey tool is available upon request.

Can9t tell

Data collection setting (online) and method (survey) are justified. The data
collection tool was reviewed and piloted prior to implementation. The results
section (pp. 34-35) provides a fulsome representation of the data collected,
supporting transparency.

Can9t tell

The authors acknowledge their findings are not generalizable due to small
sample size (n=58), low response rate (30.9%) and selection bias (based on
urban academic hospital setting only). As a result, they were unable to identify
statistically significant differences between groups, which limits the
conclusions that can be drawn from this study. However, because the study
was framed as an "online pilot study" (p. 31), this suggests that subsequent
studies may be planned to contribute to the knowledge base.

3. Were the subjects
recruited in an acceptable
way?

4. Were the measures
accurately measured to
reduce bias?
5. Were the data collected in
a way that addressed the
research issue?

6. Did the study have enough
participants to minimize the
play of chance?

Yes

Yes

Yes

Yes

No

No

No

No

7. How are the results
presented and what is the
main result?

Demographic data were summarized. The remaining results are presented in
two ways: (1) the relative importance of different features of HPV selfscreening; (2) comparison between different clinical specialties (i.e., PCP vs.
OB-GYN). The main result is that most respondents would offer their patients
"HPV self-sampling for cervical cancer screening" (p. 38). There are
statistically significant differences between PCPs' and OB-GYNs' opinions on
HPV self-swabbing vs. Pap testing.

8. Was the data analysis
sufficiently rigorous?

Yes

No

Can9t tell

Descriptive analyses of the study sample are presented. Additionally, Chisquare testing was used to assess differences between clinician characteristics
(specialty, age, etc.) and their perspectives on HPV self-sampling. All p-values
are reported (p < 0.05 considered statistically significant).

9. Is there a clear statement
of findings?

Yes

No

Can9t tell

There is a clear statement of findings, which reflects the results as well as the
limitations of the study (i.e., poorly generalizable due to selection bias).

10. Can the results be applied
to the local population?

Yes

No

Can9t tell

The authors adapted the original survey tool developed by Mao et al. (2017)
for the Canadian context. However, importantly, the study site was two large
urban hospitals in Toronto. It is unlikely that this study reflects the experiences
and perspectives of clinicians in northern BC.
The authors piloted the use of an adapted survey tool for use in a Canadian
context. They also acknowledge that additional research (i.e., with a larger,
more diverse sample) is needed.

11. How valuable is the
research?
Overall Appraisal
(CASP, 2024a)

Low quality

Medium quality

High quality

Appendix F
Data Extraction Summaries

Article

Bohn, J. A., Fitch, K. C., Currier, J. J., & Bruegl, A. (2022). HPV self-collection: What are we waiting for? Exploration of attitudes from frontline healthcare providers. International
Journal of Gynecological Cancer, 32(12), 1519–1523. https://doi.org/10.1136/ijgc-2022-003860

Study Location

Oregon, US

Provider Types

FP
Midwife
NP
Nurse

Screening Modalities Discussed

Traditional Pap
HPV, clinician-collected
HPV, self-collected, in-clinic
HPV, self-collected, at home, kit pick-up in-person
HPV, self-collected, at home, kit pick-up via mail
Other:

Study Design

Qualitative

Relevant Context

•
•

Findings

Significance to RQ

N=18

Sample Size
OB-GYN
PA
Other:

Practice Setting(s)

Specific Patient Population
Implementation Stage
Primary Outcome
Overall Appraisal

1

Aboriginal health organization
Academic health center
Community health center
Gender-diverse clinic

General practice
Hospital
Private practice
Other:

Unspecified
Pre

Post

Provider knowledge and attitudes
Medium quality

At the time of publication, American guidelines were available to support HPV testing for CCS, but only for provider-collected specimens, not self-collected.
In Canada, CCS is universally available to eligible patients at no cost. However, in the US, health insurance coverage and out-of-pocket payment are important determinants of
patient engagement in CCS.

Overall: <Nearly all providers stated they will offer HPV self-collection to most of their patients once available" (p. 1519)
Benefits of self-collection
•
Effective for reaching <inadequately screening populations= (p. 1519).
•
Preferred by patients (especially younger patients).
•
Increased access for geographically isolated patients.
•
Potential value in sustaining CCS in the context of disruptions to health care, as was seen with the COVID-19 pandemic.
Risks of self-collection
•
Concerns related to accuracy and sensitivity of test, and validity of results.
•
Missed opportunity for other components of a physical exam.
•
Confusion regarding patient eligibility criteria.
•
Insufficient infrastructure (e.g., kit availability, lab processing availability/readiness, clinical and administrative support for patient and provider questions).
Facilitators of implementation
•
Additional evidence demonstrating non-inferiority of self-collection.
•
National guidelines would support provider confidence in use of self-collection.
Barriers to implementation
•
Practice culture: some providers expressed <hesitation to relinquish control of cervical cancer screening= (p. 1521).
•
Competing interests: time constraints, prioritization of other acute care concerns (including patient priorities and provider priorities).
•
Compensation model: <Our practice only gets paid when we see patients face to face. And so, until the payment structure is such that there9s infrastructure payments that come
in on a regular basis to do all of the work that9s not fee for service, face-to-face work, then this will always sit on the back burner. And we9ll get to it when we get to it, but it
won9t be front and center until it9s part of the basic way that primary care clinicians are paid.= (p. 1521)
•

Providers have mixed views of how they think patients will perceive self-collection (i.e., some think that patients will be keen to have an alternative to Pap tests, others think
patients will still prefer clinician-collected samples). This relates to a theme in this IR related to perceived patient concerns that become articulated as provider concerns.

67

Article

Brennan, L., Adekunle, T., Kasting, M., Forman, M. R., Champion, V., & Rodriguez, N. M. (2024). Factors associated with clinician willingness to adopt HPV self-sampling and
self-testing for cervical cancer screening. Journal of Clinical and Translational Science, 8(1), Article e118. https://doi.org/10.1017/cts.2024.604

Study Location

Indiana, Kentucky, Ohio, Michigan, US (collectively referred
to as <Midwest=)

Provider Types

FP
Midwife
NP
Nurse

Screening Modalities Discussed

Traditional Pap
HPV, clinician-collected
HPV, self-collected, in-clinic
HPV, self-collected, at home, kit pick-up in-person
HPV, self-collected, at home, kit pick-up via mail
Other: HPV point-of-care testing (<self-testing=)

Study Design

OB-GYN
PA
Other: Internist,
Oncologist

Mixed methods
•

Sample Size

Practice Setting(s)

Specific Patient Population
Implementation Stage

248 surveys, 23 interviews
Aboriginal health organization
Academic health center
Community health center
Gender-diverse clinic

General practice
Hospital
Private practice
Other: Unspecified

Unspecified
Pre

Post

Primary Outcome

<which clinician characteristics are associated with willingness to adopt HPV
self-sampling and self-testing?= (p. 2)

Overall Appraisal1

High quality

This study includes provider perspectives on HPV self-collection for CCS as well as <patient-operated rapid HPV tests (self-testing)= (p. 1), which, at the time of publication,
are currently under development.
In Canada, CCS is universally available to eligible patients at no cost. However, in the US, health insurance coverage and out-of-pocket payment are important determinants of
patient engagement in CCS.

Relevant Context

•

Findings

Overall: The majority of providers expressed support for using self-collection (83%) in the clinic or at home (52%).
Benefits of self-collection
•
Opportunistic CCS: providers can offer CCS to eligible patients when they present for different health needs.
•
Removes concern related to gender discordance previously documented in the literature (i.e., patients tend to prefer female providers for Pap tests). The authors suggest that this
would translate to increased access to CCS for patients of male providers who are able to access CCS without need for pelvic exam performed by male provider.
Risks of self-collection
•
There is the potential to miss lesions or other signs of pathology when a pelvic exam is not performed.
•
Missed opportunity for provider to perform a <complete physical exam and complete well-woman9s exam= (p. 5).
•
Missed opportunity for provider to gain more health history, identify other screening needs, and build therapeutic relationship/trust.
Facilitators of implementation
•
Male providers tended to be more supportive of self-collection than their female counterparts. The authors attribute this to discomfort experienced by male providers and female
patients undergoing pelvic exams.
Provider characteristics
•
Primary care providers were 3.16 times more likely to support self-collection than OB-GYN and internal medicine specialists.
•
Support for self-collection at home was positively associated with rural practice setting (as compared to urban setting).
•
Providers9 previous experience with self-collection for other applications (e.g., FIT, COVID testing) informed their attitudes towards self-collection. Providers who had
previous positive experiences were more likely to support self-collection for CCS. Conversely, providers who had previous negative experiences <had more reservations= (p. 9)
about the application of self-collection to CCS.

Significance to RQ

•
•

<Clinicians constitute a key group whose attitudes, beliefs, and practices are consequential for primary and secondary HPV prevention= (p. 2)
<Clinicians are a key stakeholder group for the implementation of novel approaches to screening= (p. 8)

68

Abbreviations: CCS = cervical cancer screening; FP = family physician; HPV = human papillomavirus; NP = Nurse Practitioner; OB-GYN = Obstetrician-Gynecologist; PA = Physician Assistant; US = United States
1

Please see critical appraisal summaries in Appendix E for explanation of quality rating.

Article

Creagh, N. S., Zammit, C., Brotherton, J. M., Saville, M., McDermott, T., Nightingale, C., & Kelaher, M. (2021). Self‐collection cervical screening in the renewed National Cervical
Screening Program: A qualitative study. Medical Journal of Australia, 215(8), 354–358. https://doi.org/10.5694/mja2.51137

Study Location

Victoria, Australia

Provider Types

FP
Midwife
NP
Nurse

Screening Modalities Discussed

Traditional Pap
HPV, clinician-collected
HPV, self-collected, in-clinic
HPV, self-collected, at home, kit pick-up in-person
HPV, self-collected, at home, kit pick-up via mail
Other:

Study Design

Qualitative

Relevant Context

•
•

Findings

Practice Setting(s)

Specific Patient Population
Implementation Stage

N=18
Aboriginal health organization
Academic health center
Community health center
Gender-diverse clinic

General practice
Hospital
Private practice
Other:

Unspecified
Pre

Post

Primary Outcome

<acceptability [among providers] of the self-collection cervical screening
pathway= (p. 354)

Overall Appraisal1

High quality

Shortly before data collection, national guidelines for cervical screening changed: from patients receiving a Pap once every 2 years to HPV-based screening once every 5 years.
In Australia, HPV self-collection must be facilitated by a primary care provider; the provider determines whether the patient meets eligibility criteria and arranges for specimen
self-collection. This workflow differs from other jurisdictions in which patients can request an HPV self-collection kit without needing to contact their primary care provider.

Overall: Self-collection was <highly acceptable= (p. 354) to most study participants.
Benefits of self-collection
•
<a progressive change= (p. 356) from traditional clinician-collected cytology (i.e., Pap smears).
•
effective way to reengage patients who had previously declined clinician-collected tests for CCS, or to engage new patients who have never completed CCS.
Barriers to implementation
•
Lack of awareness of self-screening amongst primary care providers, including evidence for validity of the test.
•
Belief that self-collection is inferior to traditional clinician-collected specimen.
•
Increased workload for providers/clinic staff to determine patient eligibility (i.e., change in screening frequency without consideration of administrative implications).
•
Eligibility criteria for self-collection was described as too <inflexible= and <narrow= (p. 357).
•
Ambiguity within existing clinical practice guidelines regarding provider responsibilities in facilitating self-collection (i.e., must collection be completed in-clinic or can
patients take kit home?).
Recommendations
•
Need resources for providers to support integration of self-collection into routine practice, including supports for identifying patients in need of CCS and clarity regarding
eligibility and provider responsibility.
•

Significance to RQ

Sample Size
OB-GYN
PA
Other:

•
•

Because all options for CCS (including self-collection) are facilitated through primary care providers in Australia, their knowledge and attitudes play an important role in
whether and how patients engage in CCS.
Providers who are not supportive of HPV self-collection for the purpose of CCS may limit the options available to their patients, while providers who are supportive of its use
are more likely to offer it as an option for eligible patients.
According to patients, the provider9s <approach= (p. 355) to discussing options for CCS was the strongest predictor of whether patients agreed to CCS and which modality they
preferred (i.e., clinician-collected or self-collected).

69

Abbreviations: CCS = cervical cancer screening; FP = family physician; HPV = human papillomavirus; NP = Nurse Practitioner; OB-GYN = Obstetrician-Gynecologist; PA = Physician Assistant; US = United States
1

Please see critical appraisal summaries in Appendix E for explanation of quality rating.

Article

Fontenot, H. B., Fuzzell, L., Brownstein, N. C., Lake, P., Michel, A., Vadaparampil, S. T., & Perkins, R. B. (2024). Health care provider willingness to recommend self-collected
tests for human papillomavirus: A mixed methods examination of associated factors. Women’s Health Issues, 34(5), 506–517. https://doi.org/10.1016/j.whi.2024.05.005

Study Location

US (national)

Provider Types

FP
Midwife
NP
Nurse

Screening Modalities Discussed

Traditional Pap
HPV, clinician-collected
HPV, self-collected, in-clinic
HPV, self-collected, at home, kit pick-up in-person
HPV, self-collected, at home, kit pick-up via mail
Other:

Study Design

Mixed methods
•

Relevant Context
•

Findings

Sample Size
OB-GYN
PA
Other: Internist

Practice Setting(s)

Specific Patient Population
Implementation Stage

1251 surveys, 56 interviews
Aboriginal health organization
Academic health center
Community health center
Gender-diverse clinic

General practice
Hospital
Private practice
Other:

Unspecified
Pre

Post

Primary Outcome

Provider <attitudes (perceived benefits and concerns) toward using human
papillomavirus self-collection for cervical cancer screening= (p. 506)

Overall Appraisal1

High quality

Data collection took place prior to regulatory approval of HPV self-collection for CCS in 2021. At the time of data collection, CCS guidelines were being revised. With this in
mind, survey questions were frames as hypothetical: <If HPV self-sampling were an available (FDA-approved) option for cervical cancer screening, would you recommend that
patients who are due for cervical cancer screening and do not have any gynecological symptoms, utilize self-sample HPV tests instead of undergoing a speculum examination?=
(p. 508)
In Canada, CCS is universally available to eligible patients at no cost. However, in the US, health insurance coverage and out-of-pocket payment are important determinants of
patient engagement in CCS.

Overall: 62% of survey respondents would potentially be willing to recommend self-collection (33.4% definitely or probably + 28.6% maybe; p. 510). Additionally, there was
overwhelming support of the use of self-collection in special populations (i.e., <persons with a history of trauma, gender minorities, and others for whom speculum examinations are
difficult= (p. 511)).
Benefits of self-collection
•
Seen as less invasive and more patient-centred.
•
Increased access to CCS for specific patient populations:
o
58.8% of providers think self-collection will increase access to CCS for those with geographic/travel barriers and those who cannot take time away from competing
priorities (e.g., stay at home moms).
o
63.7% […] with 8challenging9 pelvic exams (e.g., <with a health condition or trauma history=; p. 510).
o
59.2% […] who cannot tolerate speculum/pelvic exam due to anatomical variations (e.g., <vulvar or vaginal conditions=; p. 510).
o
60.0% […] with physical disability or mobility challenges.
o
50.2% […] who are uncomfortable with exam because they identify as nonbinary or transgender.
Risks of self-collection
•
59.6% of providers have concerns about accuracy and adequacy of specimens collected by patients.
•
Concern about missing pertinent exam findings due to not examining the patient.
•
Belief that patients cannot or will not engage in self-collection.
•
60.0% of providers believe that patients who participate in HPV self-collection at home would be less likely to return their specimen and/or follow-up after abnormal results.
•
Providers perceive increased workload without adequate compensation: <the prescription is being written by the provider, patients are being brought to by the provider, but the
revenue is being shifted to the pharmaceutical company= (p. 513).
Facilitators of implementation
•
Providers are already familiar with patient self-collection for vaginitis testing and testing for group B streptococcus in pregnancy.
•
Openness to adoption when guidelines are available: <I think it9s a great addition and whether it should be routinely used, I would wait for further guidance= (p. 513).
<Providers with ambivalent attitudes focused on educational factors, the need for and guidelines and protocols for practice, and national endorsements= (p. 511)
•
Location of specimen self-collection is an important consideration: 43.6% of survey respondents <would offer self-collection either at home or in the office, depending on
patient preference, 22.3% would offer self-collection only in the office, and 11.0% only at home= (p. 510).
•

70

Abbreviations: CCS = cervical cancer screening; FP = family physician; HPV = human papillomavirus; NP = Nurse Practitioner; OB-GYN = Obstetrician-Gynecologist; PA = Physician Assistant; US = United States
1

Please see critical appraisal summaries in Appendix E for explanation of quality rating.

Barriers to implementation
•
Providers may not understand technical aspects of the test and how it differs from clinician-collected cervical tests: <A few [providers] expressed that the patient would not be
able to reach the cervix, which underscored confusion related to the self-sample; reaching the cervix is not required because exfoliated cervical cells are collected from the
vagina= (p. 511).
Provider characteristics
•
Male providers were 1.53 times more likely than female providers to be willing to recommend self-collection.
•
OB-GYN were least likely to recommend self-collection:
o
<Advanced practice providers= (NP, Certified nurse midwife, PA) were 1.53 times more likely than OB-GYNs to be willing to recommend self-collection (p. 510)
o
Internal medicine physicians were 6.26 times more likely than OB-GYNs to be willing to recommend self-collection (p. 510)
o
Family medicine physicians were 5.83 times more likely than OB-GYNs to be willing to recommend self-collection (p. 510)
Recommendations
•
8Very important= considerations as reported by at least 70% of survey respondents:
o
Ability of patient to obtain adequate sample
o
Acceptability of self-collection to patients and providers
o
Insurance coverage
o
Recommendations from professional organizations (p. 510)
Significance to RQ

•

Widespread implementation of HPV self-collection will require practice-specific considerations and adaptations. This mixed methods study provides specialty-specific insights
into what information and infrastructure different providers are seeking.

71

Abbreviations: CCS = cervical cancer screening; FP = family physician; HPV = human papillomavirus; NP = Nurse Practitioner; OB-GYN = Obstetrician-Gynecologist; PA = Physician Assistant; US = United States
1

Please see critical appraisal summaries in Appendix E for explanation of quality rating.

Article

Katz, M. L., Zimmermann, B. J., Moore, D., Pasket, E. D., & Reiter, P. L. (2017). Perspectives from health-care providers and women about completing human papillomavirus
(HPV) self-testing at home. Women & Health, 57(10), 1161–1177. https://doi.org/10.1080/03630242.2016.1243608

Study Location

Ohio, US

Provider Types

Screening Modalities Discussed

Traditional Pap
HPV, clinician-collected
HPV, self-collected, in-clinic
HPV, self-collected, at home, kit pick-up in-person
HPV, self-collected, at home, kit pick-up via mail
Other:

Study Design

OB-GYN
PA
Other:

Qualitative
•

N=28

Sample Size

FP
Midwife
NP
Nurse

Practice Setting(s)

Specific Patient Population
Implementation Stage
Primary Outcome
Overall Appraisal

1

Aboriginal health organization
Academic health center
Community health center
Gender-diverse clinic

General practice
Hospital
Private practice
Other:

Residents of Appalachian Ohio county (a region notable for socioeconomic
disadvantage, geographic isolation).
Pre

Post

<perceived acceptability of mailed HPV self-tests= (p. 1)
High quality

Study participants were asked about the hypothetical use of mail-based self-collection because at-home HPV self-collection had not yet been approved in this jurisdiction at the
time of data collection. As a result, the study explores the proposed use of HPV self-collection in conjunction with Pap testing.
In Canada, CCS is universally available to eligible patients at no cost. However, in the US, health insurance coverage and out-of-pocket payment are important determinants of
patient engagement in CCS.

Relevant Context

•

Findings

Overall: Healthcare providers consider the use of HPV self-collection to be an acceptable approach to CCS for patients in Appalachian Ohio.
Benefits of self-collection
•
Self-collection could be used to reengage patients with health services, broadly. The approach described in this study would involve self-collection kits mailed to patients, and
interested patients bringint their completed kits to a clinical facility, which would provide an opportunity for addressing other health concerns.
•
Mail-based delivery of self-collection kits is a way to address geographic barriers to CCS access in rural areas.
Risks of self-collection
•
Potential for inaccurate screening results due to user error (i.e., patients not completing the test properly).
•
Pre-existing distrust of the medical system by patients in Appalachian Ohio; unexpectedly receiving a CCS kit in the mail may raise suspicion about purpose of the test.
•
Physical harm to patients: providers feared that part of the self-collection device would break off and be retained inside the patient.
Barriers to implementation
•
Low levels of health literacy in the target population.
Recommendations
•
To address concerns related to mistrust, low health literacy, and to prevent user error, the authors highlight the need for written resources that clearly articulate the importance of
CCS and explain how to complete the self-collection process.
•

Significance to RQ
•

While the distribution of self-collection kits by mail has the potential to reduce geographic barriers to CCS, the approach proposed herein is problematic and may be seen as
misleading and unethical. The proposed process requires that patients attend a clinic to complete a Pap test and receive their HPV results because HPV self-collection had not
yet been approved for CCS. It seems that having patients attend an in-person medical visit and Pap test negates the potential benefits of doing the test remotely. Additionally,
without knowing how the self-collection process is described to patients, the reader is unable to determine whether the practice is misleading patients (i.e., is it clear that patients
will need a Pap test in addition to the self-collected HPV test?).
The authors9 description of <withholding the HPV self-test results to capitalize on women9s related anxiety as a method to bring women into the office= (p. 7) is very concerning
and certainly not patient-centred.

72

Abbreviations: CCS = cervical cancer screening; FP = family physician; HPV = human papillomavirus; NP = Nurse Practitioner; OB-GYN = Obstetrician-Gynecologist; PA = Physician Assistant; US = United States
1

Please see critical appraisal summaries in Appendix E for explanation of quality rating.

Article

Le, D., Ciceron, A. C.., Jeon, M. J., Gonzalez, L. I., Jordan, J. A., Bordon, J., & Long, B. (2022). Cervical cancer prevention and high-risk HPV self-sampling awareness and
acceptability among women living with HIV: A qualitative investigation from the patients9 and providers9 perspectives. Current Oncology, 29(2), 516–533.
https://doi.org/10.3390/curroncol29020047

Study Location

Washington DC, US

Sample Size

Provider Types

FP
Midwife
NP
Nurse

Screening Modalities Discussed

Traditional Pap
HPV, clinician-collected
HPV, self-collected, in-clinic
HPV, self-collected, at home, kit pick-up in-person
HPV, self-collected, at home, kit pick-up via mail
Other:

Study Design

Qualitative

Relevant Context

•
•

Findings

Practice Setting(s)

Specific Patient Population
Implementation Stage

Aboriginal health organization
Academic health center
Community health center
Gender-diverse clinic

General practice
Hospital
Private practice
Other: Unspecified

Women living with HIV in urban Washington-Baltimore Metropolitan Area.
Pre

Post

Primary Outcome

Awareness; feasibility and acceptability of self-sampling

Overall Appraisal1

High quality

The use of HPV screening for the purpose of CCS in patients 25 years and older was approved in the US in 2014; however, this did not include HPV self-collection.
In Canada, CCS is universally available to eligible patients at no cost. However, in the US, health insurance coverage and out-of-pocket payment are important determinants of
patient engagement in CCS.

Overall: Providers expressed <mixed opinions= (p. 523) about the use of self-collection for CCS in women living with HIV.
Benefits of self-collection
•
Potential to increase patient knowledge of link between high risk-HPV and cervical cancer.
•
Seen as more convenient for patients.
•
Allows for CCS without compromising patient privacy.
•
Increase access to CCS for patients with <gender dysphoria or a history of sexual abuse= (p. 523)
Risks of self-collection
•
Inaccurate results due to <incorrect use of the kit= (p. 523).
•
For take-home kits, concern that patients would not return kit promptly or at all.
Facilitators of implementation
•
Providers have familiarity with <self-sampling= (p. 523) as it is used for STI testing and colorectal cancer screening (i.e., FIT test).
Barriers to implementation
•
Insufficient capacity for follow-up of abnormal test results (i.e., increase in access to screening without corresponding increase of available treatment).
•
Lack of guidance regarding processes: can patients take kits home or must they be completed in-clinic?, how long are kit valid?, how best to communicate results?
•
Increased administrative workload for clinic staff (i.e., coordinating kit pick-up and drop-off).
•

Significance to RQ

OB-GYN
PA
Other:

N=10

•

Providers recognized the impact of their role in recommending or endorsing screening practices. Providers also identified the potential for their bias on patients9 health practices
and decision-making.
The authors clearly describe the link between provider attitudes towards HPV self-collection and impacts on patient care: <Since providers of health care and social services
directly influence their patients9/clients9 decision making, health-seeking behaviors, and access, their perspectives will undoubtedly influence the acceptability and feasibility of
HR-HPV self-sampling.= (p. 524)

73

Abbreviations: CCS = cervical cancer screening; FP = family physician; HPV = human papillomavirus; NP = Nurse Practitioner; OB-GYN = Obstetrician-Gynecologist; PA = Physician Assistant; US = United States
1

Please see critical appraisal summaries in Appendix E for explanation of quality rating.

Article

Le Goff, J., Le Duc-Banaszuk, A.-S., Lefeuvre, C., Pivert, A., Ducancelle, A., De Pauw, H., Arbyn, M., Vinay, A., & Rexand-Galais, F. (2023). Acceptability to healthcare
professionals of home-based HPV self-sampling for cervical screening: A French qualitative study conducted in an area with low access to health services. Cancers, 15(21),
Article 5163. https://doi.org/10.3390/cancers15215163

Study Location

Mayenne & Sarthe, Pays de la Loire, France

Provider Types

FP
Midwife
NP
Nurse

Screening Modalities Discussed

Traditional Pap
HPV, clinician-collected
HPV, self-collected, in-clinic
HPV, self-collected, at home, kit pick-up in-person
HPV, self-collected, at home, kit pick-up via mail
Other: HPV urinary self-collection

Study Design
Relevant Context

Qualitative
•
•
•

Findings

Significance to RQ

OB-GYN
PA
Other:

N=59

Sample Size
Practice Setting(s)

Specific Patient Population
Implementation Stage
Primary Outcome
Overall Appraisal

1

Aboriginal health organization
Academic health center
Community health center
Gender-diverse clinic

General practice
Hospital
Private practice
Other: Unspecified

Residents of 2 geographic regions with low physician density and low
screening rates.
Pre

Post

<opinions of primary healthcare professionals on self-sampling= (p. 3)
Medium quality

Since 2019, the French National Authority for Health has recommended vaginal self-sampling (VSS) as an alternative to clinician-collected samples for the purpose of CCS.
In addition to VSS, this study also explores potential use of urinary self-sampling (USS), which has been demonstrated to be effective in detecting precancerous and cancerous
lesions of the cervix but was not being used in practice at the time of publication.
Providers who are involved in CCS in France include OB-GYNs, GPs), and midwives. At the time of publication, the NP role was not recognized nationally.

Overall: Health care providers consider self-collection to be an acceptable approach to CCS in geographic regions with low screening rates.
Benefits of self-collection
•
Increased access to CCS in geographically underserved areas (decreases transportation challenges, avoids wait times to see provider in-person).
•
Simpler, less medicalized approach that <avoids intrusive and invasive nature of [pelvic] examinations= (p. 9).
•
Less fear, embarrassment, and more privacy for patients.
•
Improves access for patients who are not comfortable with male provider doing Pap test.
•
Patient empowerment.
Risks of self-collection
•
Seen as less reliable test.
•
Patients will opt-out of other components of the physical exam or be more reluctant to receive other care in-person.
Facilitators of implementation
•
Familiarity with vaginal self-sampling (i.e., self-collection) as it is currently used for STI testing.
Barriers to implementation
•
Competing priorities in primary care practices: <There9s a distinction to be made between prevention, emergencies, and medical follow-up= (p. 6); <We9re very busy with other
issues; prevention takes second place= (p. 6).
•
No coordinated approach to self-collection kit distribution; patients may request kits from select labs only if they are aware of this option.
•
Low levels of health literacy in the target population.
•
Perception that some patient groups may not be able to complete test: older patients <just don9t have that knowledge of their anatomy= (p. 7), obese patients may not be able to
reach cervix (p. 8).
•
•

Perspectives from geographic context with low provider density outside of North America.
Concerns raised by providers regarding cervical vs. vaginal self-collection might illustrate a lack of familiarity or knowledge about self-collection for CCS (i.e., patients swab
vagina, not cervix). While this was not highlighted by Le Goff et al. (2023), other authors cited in this IR have pointed out the need for provider education so that they may
support patients in completing self-collection comfortably, effectively, and safely.

74

Abbreviations: CCS = cervical cancer screening; FP = family physician; HPV = human papillomavirus; NP = Nurse Practitioner; OB-GYN = Obstetrician-Gynecologist; PA = Physician Assistant; US = United States
1

Please see critical appraisal summaries in Appendix E for explanation of quality rating.

Article

Mao, C., Kulasingam, S. L., Whitham, H. K., Hawes, S. E., Lin, J., & Kiviat, N. B. (2017). Clinician and patient acceptability of self-collected human papillomavirus testing for
cervical cancer screening. Journal of Women’s Health, 26(6), 609–615. https://doi.org/10.1089/jwh.2016.5965

Study Location

Seattle, WA, USA

Provider Types

FP
Midwife
NP
Nurse

Screening Modalities Discussed

Traditional Pap
HPV, clinician-collected
HPV, self-collected, in-clinic
HPV, self-collected, at home, kit pick-up in-person
HPV, self-collected, at home, kit pick-up via mail
Other:

Study Design

Sample Size
OB-GYN
PA
Other: Internist

Cross-sectional
•

Practice Setting(s)

Specific Patient Population
Implementation Stage

N=118
Aboriginal health organization
Academic health center
Community health center
Gender-diverse clinic

General practice
Hospital
Private practice
Other:

Unspecified
Pre

Post

Primary Outcome

Provider attitudes towards home-based HPV self-collection for CCS.

Overall Appraisal1

Low quality

The shift from cytology-based CCS to primary HPV testing was supported by national guidelines in the US at the time of publication. However, only clinician-collected
samples were approved. The study explores HPV self-collection as a hypothetical area for expanding CCS.
In Canada, CCS is universally available to eligible patients at no cost. However, in the US, health insurance coverage and out-of-pocket payment are important determinants of
patient engagement in CCS.

Relevant Context

•

Findings

Overall: 78% of providers would recommend HPV self-collection but only <if the test had qualities such as high sensitivity and cost effectiveness= (p. 609).
Benefits of self-collection
•
Increase CCS rates.
•
Potential to reduce costs.
Risks of self-collection
•
Decrease opportunities to address other health concerns and decline in other preventative screening activities.
o
75.7% of providers indicated <missed opportunity to address other health issues= (p. 613, table 5) was a reason to not recommend home HPV testing.
o
Patients and providers worry that a shift away from in-clinic care will lead to patients having decreased access to their healthcare provider for other concerns.
•
Inability for patients to adequately collect sample.
•
Inaccurate test result.
•
Perception that patients will be less likely to complete necessary follow-up.
Facilitators of implementation
•
Providers indicated that patient acceptability is more important than clinician acceptability (93.2% vs 72.9%; p. 612).
•
Zero providers indicated that <provider should perform test= (p. 613, table 5) was a reason to not recommend home-based HPV self-collection.
Barriers to implementation
•
Recent changes to CCS frequency guidelines were met with <significant push back by clinicians= (p. 610). Revisions to CCS that further reduce face-to-face contact with
providers are likely to be met with additional skepticism.
Recommendations
•
The development of provider education, and clinical pathways to determine eligibility and coordinate follow-up are important considerations for providers.
•

Significance to RQ

As a seminal study into provider perspectives on HPV self-collection for CCS, this article provides insights into which test characteristics were most important to providers.
Subsequent efforts to implement self-collection have been impacted by these early findings. However, many of the concerns identified by providers persist into more recent
literature.

75

Abbreviations: CCS = cervical cancer screening; FP = family physician; HPV = human papillomavirus; NP = Nurse Practitioner; OB-GYN = Obstetrician-Gynecologist; PA = Physician Assistant; US = United States
1

Please see critical appraisal summaries in Appendix E for explanation of quality rating.

Article

Pourette, D., Cripps, A., Guerrien, M., Desprès, C., Opigez, E., Bardou, M., & Dumont, A. (2022). Assessing the acceptability of home-based HPV self-sampling: A qualitative
study on cervical cancer screening conducted in Reunion Island prior to the RESISTE trial. Cancers, 14(6), Article 1380. https://doi.org/10.3390/cancers14061380

Study Location

Reunion Island (French territory in Indian Ocean)

Provider Types

FP
Midwife
NP
Nurse

Screening Modalities Discussed

Traditional Pap
HPV, clinician-collected
HPV, self-collected, in-clinic
HPV, self-collected, at home, kit pick-up in-person
HPV, self-collected, at home, kit pick-up via mail
Other:

Study Design

OB-GYN
PA
Other:

Qualitative
•

Sample Size
Practice Setting(s)

Specific Patient Population
Implementation Stage

N=20
Aboriginal health organization
Academic health center
Community health center
Gender-diverse clinic

General practice
Hospital
Private practice
Other: Correctional Centre

Socioeconomically disadvantaged, geographically isolated
Pre

Post

Primary Outcome

Health professionals9 opinion and knowledge of HPV self-sampling

Overall Appraisal1

Medium quality

In 2020, clinician-collected HPV testing replaced Pap tests as the primary method for CCS screening in France. At the time of publication, HPV self-collection had been
proposed as an alternative to clinician-collection testing, but had not been widely implemented.
Reunion Island is a <French overseas department= (p. 2) where the prevalence of cervical cancer is 2-3 times higher than rates of mainland France. Cancer screening on Reunion
is described as fragmented, which the authors attribute to the territory9s <medical pluralism= (p. 3), a legacy of its history as a French colony.

Relevant Context

•

Findings

Overall: Providers are supportive of at-home HPV self-collection in particular patient populations (e.g., poorly connected to care, reluctant to undergo Pap test, geographically
isolated).
Benefits of self-collection
•
Increase access to CCS for some patient populations: poorly connected to care, reluctant to undergo Pap test, geographically isolated.
Barriers to implementation
•
Perceived disinterest from patients: <reluctance to touch one9s intimate parts amongst women, in particular those less educated.= (p. 13)
Facilitators of implementation
•
On-demand telephone or on-site support for patients when completing their self-collection may lead to better (i.e., more accurate) results and more efficient screening.
Recommendations
•
Need for outreach efforts to engage socially isolated patients.
•
Provider education about self-collection so that providers can (1) present all CCS options to patients and (2) teach patients how to complete self-collection.

Significance to RQ

•

Relevance to Indigenous communities in Canada who a history of colonization, experience poverty and socioeconomic disadvantages including insufficient access to medical
services, as well as disproportionately high rates of cervical cancer and low rates of screening.

76

Abbreviations: CCS = cervical cancer screening; FP = family physician; HPV = human papillomavirus; NP = Nurse Practitioner; OB-GYN = Obstetrician-Gynecologist; PA = Physician Assistant; US = United States
1

Please see critical appraisal summaries in Appendix E for explanation of quality rating.

Article

Rodriguez, N. M., Brennan, L. P., Claure, L., Balian, L. N., Champion, V. L., & Forman, M. R. (2023). Leveraging COVID-era innovation for cervical cancer screening: Clinician
awareness and attitudes toward self-sampling and rapid testing for HPV detection. PLoS ONE, 18(3), Article e0282853. https://doi.org/10.1371/journal.pone.0282853

Study Location

Indiana, USA

Provider Types

FP
Midwife
NP
Nurse

Screening Modalities Discussed

Traditional Pap
HPV, clinician-collected
HPV, self-collected, in-clinic
HPV, self-collected, at home, kit pick-up in-person
HPV, self-collected, at home, kit pick-up via mail
Other: HPV point-of-care testing

Study Design

Mixed methods

Relevant Context

•
•

Findings

Significance to RQ

Sample Size
OB-GYN
PA
Other: Internist

Practice Setting(s)
Specific Patient Population
Implementation Stage

224 surveys, 20 interviews
Aboriginal health organization
Academic health center
Community health center
Gender-diverse clinic

General practice
Hospital
Private practice
Other:

Unspecified
Pre

Post

Primary Outcome

clinician awareness, perceived benefits and limitations, and willingness to
adopt point-of-care HPV testing, patient self-sampling, and rapid HPV selftesting with self-collected samples

Overall Appraisal1

Medium quality

The use of HPV testing for CCS has been available in the US since 2018, however HPV self-collection was not widely implemented at the time of publication.
In Canada, CCS is universally available to eligible patients at no cost. However, in the US, health insurance coverage and out-of-pocket payment are important determinants of
patient engagement in CCS.

Overall: 50% of providers supported the adoption of HPV self-collection for CCS.
Benefits of self-collection
•
Increase CCS rates.
o
72% of respondents believed self-collection would <greatly or somewhat= improve CC screening <coverage= and/or follow-up (p. 10).
•
Increase patient comfort, convenience.
Risks of self-collection
•
Inaccurate results due to user error or faulty test kit.
•
Decreased opportunity to examine/discuss non-HPV concerns
Facilitators of implementation
•
74% of respondents were using (or had used) or were familiar with self-collection for other applications: FIT, STI, BV.
•
Post-COVID expanded telehealth infrastructure and increased patient/provider familiarity and comfort with virtual care.
•
Increased patient demand for self-collection options.
Barriers to implementation
•
Assumption that patients will not return kits.
•
•
•

This study connects patient expectations, provider perspectives, and diagnostic innovations with the undeniable impacts of the COVID-19 pandemic on health care delivery.
Lessons from COVID-19 testing may be applied to other screening or diagnostic testing, including both testing technology and workflow processes.
Providers9 previous experiences with COVID-19 point-of-care testing, whether positive or negative, shape their perspectives on other applications of self-collection and
emergent point-of-care testing for CCS.

77

Abbreviations: CCS = cervical cancer screening; FP = family physician; HPV = human papillomavirus; NP = Nurse Practitioner; OB-GYN = Obstetrician-Gynecologist; PA = Physician Assistant; US = United States
1

Please see critical appraisal summaries in Appendix E for explanation of quality rating.

Article

Xiong, S., Lazovich, D. A., Hassan, F., Ambo, N., Ghebre, R., Kulasingam, S., Mason, S. M., & Pratt, R. J. (2022). Health care personnel9s perspectives on human papillomavirus
(HPV) self-sampling for cervical cancer screening: A pre-implementation, qualitative study. Implementation Science Communications, 3(1), Article 130.
https://doi.org/10.1186/s43058-022-00382-3

Study Location

<Midwest= US

Provider Types

FP
Midwife
NP
Nurse

Screening Modalities Discussed

Traditional Pap
HPV, clinician-collected
HPV, self-collected, in-clinic
HPV, self-collected, at home, kit pick-up in-person
HPV, self-collected, at home, kit pick-up via mail
Other:

Study Design

Qualitative

Relevant Context

•
•

Findings

Sample Size
OB-GYN
PA
Other:

Practice Setting(s)

Specific Patient Population
Implementation Stage

N=30
Aboriginal health organization
Academic health center
Community health center
Gender-diverse clinic

General practice
Hospital
Private practice
Other:

Unspecified
Pre

Post

Primary Outcome

<views on HPV self-sampling and its potential implementation.= (p. 1)

Overall Appraisal1

High quality

The use of HPV screening for the purpose of CCS was approved in the US in 2018. The American Cancer Society published guidelines for CCS using HPV testing in 2020.
In Canada, CCS is universally available to eligible patients at no cost. However, in the US, health insurance coverage and out-of-pocket payment are important determinants of
patient engagement in CCS.

Overall: Perception that <support for HPV self-sampling is growing= (p. 1), but provider skepticism persists.
Benefits of self-collection
•
Higher patient acceptability: more convenient, less invasive, offers more comfort, privacy.
•
Perception that younger patients will readily adopt, therefore may increase CCS rates in younger population.
•
Patient-centred tool to reengage previously under-screened patients: <empower and cultivate diverse patients9 interest and proaction in their own health= (p. 6).
•
<Important trauma-informed CCS tool given the full control patients would be able to have over their own screening experiences= (p. 6)
•
<Potential to narrow racial and ethnic disparities in cervical cancer screening= (p. 6) by reducing barriers for those with <limited English proficiency, low health literacy, and/or
financial and structural barriers= (p. 5).
•
<Opportunistic advantage= (p. 6) of clinic-based self-collection: providers can readily offer CCS to patients when they may be in the clinic for a different purpose.
•
More efficient: <reducing [provider] stress and saving clinicians more time to conduct other clinical interaction= (p. 5)
Risks of self-collection
•
Concern that patient will not see self-collection as 8as valid9 as clinician-collected specimen.
•
User error would lead to repeat testing, increased patient burden, and increased cost.
•
Increases barriers to CCS, and therefore health disparities, in populations for whom self-collection is physically challenging: patients with <variable sexual anatomies, such as
those with circumcisions and imperforate hymens= (p. 7) or with limited dexterity or mobility.
•
Potential for over-testing or over-screening leading to increased costs.
Barriers to implementation
•
Lack of regulatory approval was the biggest barrier to implementation identified by providers.
•
Perceived lack of evidence around test9s validity (sensitivity and specificity; accuracy of result) and viability.
•
Unclear who would be responsible for cost: not covered by the National Breast and Cervical Cancer Early Detection Programs or health plans at the time of publication.
•
Disparate opinions on role of self-collection: is it an alternative to Pap test for all patients, or should it only be used for those that decline/refuse Pap?
Recommendations
•
Print or multimedia resources to support patient use of self-collection kits must be available for those with low literacy and non-English speakers. Otherwise, there is a risk for
exacerbating existing CCS disparities based on race/ethnicity.

78

Abbreviations: CCS = cervical cancer screening; FP = family physician; HPV = human papillomavirus; NP = Nurse Practitioner; OB-GYN = Obstetrician-Gynecologist; PA = Physician Assistant; US = United States
1

Please see critical appraisal summaries in Appendix E for explanation of quality rating.

•

The study presents a variety of pros and cons of HPV self-collection for CCS without clear consensus on whether providers support its use. This may reflect the breadth of
modalities discussed. Each variation in CCS has its own benefits and drawbacks, so by comparing four different approaches to testing, the strength of the overall conclusion is
diluted.
This article highlights the need for systems-level buy-in to ensure the successful implementation of HPV self-collection for CCS. While provider perspectives can directly
impact patient interactions, endorsement from other parts of the healthcare system is also required. For example, regulating bodies, laboratory facilities, and clinical/practice
organizations (e.g., American Cancer Society) must align to facilitate the use of self-collection.

Significance to RQ

•

Article

Zammit, C., Creagh, N., Nightingale, C., McDermott, T., Saville, M., Brotherton, J., & Kelaher, M. (2023, April 27). 8I9m a bit of a champion for it actually9: Qualitative insights
into practitioner-supported self-collection cervical screening among early adopting Victorian practitioners in Australia. Primary Health Care Research & Development, 24,
Article e31. https://doi.org/10.1017/S1463423623000191

Study Location

Victoria, Australia

Provider Types

FP
Midwife
NP
Nurse

Screening Modalities Discussed

Traditional Pap
HPV, clinician-collected
HPV, self-collected, in-clinic
HPV, self-collected, at home, kit pick-up in-person
HPV, self-collected, at home, kit pick-up via mail
Other:

Study Design

Qualitative
•
•

Relevant Context
•

Findings

Practice Setting(s)

Specific Patient Population
Implementation Stage

N=18
Aboriginal health organization
Academic health center
Community health center
Gender-diverse clinic

General practice
Hospital
Private practice
Other:

Unspecified
Pre

Post

Primary Outcome

<experiences of practitioners … who offered self-collection to their patients= (p.
1)

Overall Appraisal1

High quality

Australia has a coordinated National Cervical Screening Program (NCSP) that was established in 1991.
In 2017, national guidelines introduced HPV testing as the primary means of CCS for patients aged 25 years and up. However, at the time of data collection, self-collection was
<only available to people ≥ 30 years who were overdue for screening by ≥ 2 years or had never-screened and declined a clinician-collected test= (p. 1).
Australia has a <practitioner-supported model= (p. 2) of HPV self-collection for CCS, in which <[the test] must be ordered by a doctor or nurse practitioner who is responsible
for follow-up= (p. 2).

Overall: <Practitioners were overwhelmingly supportive of self-collection cervical screening= (p. 1)
Benefits of self-collection
•
Patient-centred approach:
o
Patient choice: <Practitioners saw their role as providing eligible participants with a choice between a clinician-collected or self-collected test, noting that the
availability of self-collection centred around 8participant9s choice9= (p. 3).
o
Empowering for patients (perhaps particularly for those who identify as Aboriginal and Torres Strait Islander; p. 3).
•
Potential to increase engagement of patients who were previously resistant/reluctant to engage in CCS.
•
Builds trusting therapeutic relationship by proactively determining the patient9s eligibility for preventative CCS and offering choice, the provider demonstrates commitment to
patient wellbeing
Risks of self-collection
•
Relative to clinician-collected specimen, self-collection is seen as <lesser alternative= and <less optimal= (p. 3).
•
Increased burden on providers to determine eligibility for self-collection (i.e., because only approved for under-screened patients, onus is on provider to access CCS histories via
national registry to determine eligibility).
•
Potential for waste based on prior experience with sub-optimal kit return when using mail-based delivery.
Barriers to implementation
•
Lack of knowledge and awareness of self-collection among providers.
•
Concern regarding capacity for follow-up (i.e., have a well-established screening pathway, but now need to invest in expanding follow-up).
•

Significance to RQ

Sample Size
OB-GYN
PA
Other:

While self-collection may be seen as desirable by many patient groups, its availability is limited to under-screened patients. There is potential for providers, who recognize
benefits of self-collection, to advocate for increased access. Provider attitudes are particularly in the Australian context due to their <practitioner-supported model= (p. 2) of
accessing HPV self-collection.

79
Abbreviations: CCS = cervical cancer screening; FP = family physician; HPV = human papillomavirus; NP = Nurse Practitioner; OB-GYN = Obstetrician-Gynecologist; PA = Physician Assistant; US = United States
1

Please see critical appraisal summaries in Appendix E for explanation of quality rating.

Article

Zelli, J., Hum, S., Lofters, A., & Dunn, S. (2022). Clinician acceptability of self-collected human papillomavirus swabs as a primary cervical cancer screening method. Canadian
Family Physician, 68(2), e31–e38. https://doi.org/10.46747/cfp.6802e31

Study Location

Toronto, Canada

Provider Types

FP
Midwife
NP
Nurse

Screening Modalities Discussed

Traditional Pap
HPV, clinician-collected
HPV, self-collected, in-clinic
HPV, self-collected, at home, kit pick-up in-person
HPV, self-collected, at home, kit pick-up via mail
Other:

Study Design

Cross-sectional

Relevant Context

•
•

Findings

Significance to RQ

N=58

Sample Size
OB-GYN
PA
Other:

Practice Setting(s)

Specific Patient Population
Implementation Stage
Primary Outcome
Overall Appraisal

1

Aboriginal health organization
Academic health center
Community health center
Gender-diverse clinic

General practice
Hospital
Private practice
Other:

Unspecified
Pre

Post

knowledge and acceptability of and opinions about HPV self-screening
High quality

At the time of publication, Canadian screening programs used cytology-based Pap testing.
The authors note that some provincial jurisdictions were working towards incorporating HPV screening as a primary approach to CCS, a shift that would open the door to selfcollection.

Overall: Most providers would offer HPV self-collection for CCS.
Benefits of self-collection
•
Increased rates of CCS completion.
•
Decreased <pain and embarrassment= (p. 35) for patients.
•
Increased efficiency and <time savings= (p. 35) for providers and patients.
Risks of self-collection
•
Missed opportunity to examine patient, <to visualize pathology= (p. 38).
•
Missed opportunity to review other health concerns or recommended screening.
Barriers to implementation
•
Lack of familiarity with <HPV self-swabs as alternative to Pap testing= (p. 35): only 48.3% of respondents had <fair, good, or very good= current knowledge of self-collection
despite 94.8% performing CCS at least weekly.
Provider characteristics
•
The potential for <missed diagnosis of pathology= (p. 35) was more concerning in younger physicians and those newer to practice than in older and more experienced providers.
•
There was consensus amongst providers regarding the most important advantage of self-collection over Pap test: self-collection would mean more patients would complete
CCS.
•
OB-GYNs reported that <time-saving for patients= was the most important attribute of self-collection, whereas primary care providers identified <decreased pain and discomfort
for patients= as most important (p. 35).
•

As the only Canadian study included in this IR, this article provides more relevant insights than those in other jurisdictions. However, the timing of the article relative to current
practice limits its applicability, especially in British Columbia, where self-collection is in use across the province.

80

Abbreviations: CCS = cervical cancer screening; FP = family physician; HPV = human papillomavirus; NP = Nurse Practitioner; OB-GYN = Obstetrician-Gynecologist; PA = Physician Assistant; US = United States
1

Please see critical appraisal summaries in Appendix E for explanation of quality rating.