What young women (aged 24–29 years) in Australia think about self-collection for cervical screening: a brief report

Introduction

Australia’s National Cervical Screening Program (NCSP) offers human papillomavirus (HPV)-based primary screening to all women and people with a cervix aged between 25 and 74 years every 5 years.¹ Since 2018, when HPV screening replaced Papanicolaou smears, the NCSP has offered an option for some people to collect their own vaginal sample (self-collection), rather than undergoing a speculum examination to collect a cervical sample.² Self-collection was initially restricted to under- and never-screened people, who were aged ≥30 years, and declined a clinician-collected specimen.² Under these conditions, self-collection was challenging to implement.³ In mid-2022, updated evidence confirming the equivalence of self-collection to clinician collection cervical samples for detecting high-grade cervical dysplasia⁴ informed a revision of guidelines to allow all participants due for screening a choice between self-collection and clinician-collected screening.⁵ This meant that women and people with a cervix,^A aged between 25 and 29 years (hereafter referred to as young women) could, for the first time, opt to participate in the NCSP via self-collection.

Most people in this age group will have had access to Australia’s National HPV Vaccination program. Screening is still recommended among HPV-vaccinated women, as vaccination does not prevent all HPV types that can cause cervical cancer.⁶ In 2023, Australia switched its HPV vaccine schedule to a single dose of nonavalent HPV vaccine, which is now available free in an ongoing extended catch-up program up to the age of <26 years. All women in Australia are invited to undergo their first cervical screening test (CST) when they turn 25 years, through receiving a letter from the National Cancer Screening Register, which prompts them to see their primary care provider. There are well described barriers to screening participation that may impact initial and ongoing participation in the NCSP, including a lack of awareness and time, negative experiences during previous screening, experiences of physical pain, emotional distress or previous sexual trauma.^7,8

Although there is a large body of evidence demonstrating that self-collection is highly acceptable, and leads to greater participation,^4,9,10 there has been limited research into the screening preferences of young women in Australia. The most recent data indicates that only 53% of 25–29 year olds are up-to-date with screening, suggesting that timely initiation of screening at 25 years is not occurring.¹¹ As many of the well-described barriers emerge because of negative screening experiences, understanding the role of self-collection in initial screening engagement and in regular participation is important. We therefore aimed to explore the perceptions of young women about the availability of self-collection, at the time when this option was first introduced.

Methods and approach

We recruited young women aged 24–29 years currently living in Australia (n = 21, from 73 expressions of interest; 53 of whom did not respond to a follow-up invitation) through a paid social media advertisement to participate in a semi-structured interview, either on Zoom or in-person. The interview guide (Supplementary material file S1) explored awareness and acceptability of cervical screening and self-collection, previous screening experiences, preferences for screening, and suggestions for health promotion. Interviews went for 11–29 min (average 20 min) and were conducted in July/August 2022, as self-collection was first made accessible to young people in Australia. All interviews were audio recorded and transcribed verbatim using an AI transcription service, Otter AI. Transcripts were cleaned and cross-checked for accuracy and data familiarisation before being de-identified and uploaded to NVIVO 12. Directed content analysis utilising an a priori coding framework informed by the Theoretical Framework of Acceptability¹² was applied.¹³ The Theoretical Framework of Acceptability was operationalised to explore young women’s prospective acceptability or experience of self-collection (Table S2). An inductive approach was employed to further explore subthemes within the high-level domains of the Theoretical Framework of Acceptability. Primary coding was completed by author AB, who iteratively consulted CZ and CN to develop the framework until no new themes were identified.

Results

Discussion

We found that young women perceived self-collection to be a valuable addition to the NCSP, although they still valued the choice to opt for a clinician-collected CST. In this group of women, many reported negative previous experiences of cervical screening, a factor known to be a barrier to future screening participation.^7,8 The introduction of self-collection is likely to play a role in mitigating this as an ongoing barrier for people with this experience.⁸

Although most participants had heard of self-collection, promotional efforts should inform young people that the test is as accurate as a clinician-collected CST, that it is easy and simple to do yourself, that you still need to attend the doctor to access the test, and there is still an option to have a clinician-collected CST. These findings are consistent with other studies that have explored information needs related to self-collection for young women⁷ in Australia and other priority populations, including women of culturally and linguistically diverse communities, Aboriginal and Torres Strait Islander women and Indigenous women globally, women living rurally, aged >60 years or people identifying as LGBTQ, particularly at the intra- and inter-personal level.^7,9,14–19 This study highlights the critical role of primary care providers (but not limited to GPs)^17,20,21 in providing accurate information to participants, and in facilitating and supporting an informed choice between screening options.²² Mobile health technologies or social media could be leveraged by primary care to facilitate this communication through providing reminders to screen, automated or manual phone-calls, education or awareness, or peer-support.^23,24

Australian data already indicate that the proportion of CSTs that are self-collected is increasing each month, across age groups, jurisdictions, rurality and socio-economic status.²⁵ There are early indications that self-collection is working to engage under- and never-screened people into the program.²⁵ However, international trials of self-collection have reported that although it can increase participation, variation in follow-up rates for women with a positive test result is evident, ranging from 41% to 100% in trials included in a recent meta-analysis,²⁶ again, highlighting the role of a supportive practitioner and accessible health system. It should be noted that many of these trials offer self-collection through mail-out models (unlike in Australia), predominantly targeted only at under-screened groups.

This study was limited by its small sample, which did not include any participants who identified as gender diverse. The qualitative nature of the study may also have enabled a social desirability bias. Despite these limitations, this study does provide useful insights into the cervical screening preferences of young adults.

Conclusion

Young women are now able to access state of the art prevention strategies against cervical cancer in line with Australia’s National Strategy for the Elimination of Cervical Cancer.²² Further efforts are required to inform young people about the relative simplicity and effectiveness of self-collection for cervical screening, and about single-dose HPV vaccination, and how to access them.

Supplementary material

Supplementary material is available online.