Acceptability, feasibility and appropriateness of integrating HPV self-sampling for cervical cancer screening into voluntary family planning services in Malawi

Abstract

Introduction: Despite being preventable, the cervical cancer burden remains high in Malawi and other low-income countries. The World Health Organization recommends cervical cancer screening (CCS) using human papillomavirus (HPV) testing. The coverage of HPV-based CCS is low but may increase with self-sampling of vaginal fluid. We assessed the acceptability, feasibility and appropriateness of two models for integrating HPV self-sampling for CCS into family planning (FP) services in Malawi.

Methods: We conducted a mixed-methods study nested within a 1:1 cluster randomized trial comparing two service delivery models in 16 health facilities in Lilongwe and Zomba Districts: Model 1 involved clinic-based vaginal self-sampling and HPV testing, whereas Model 2 included both clinic-based and community-based self-sampling and HPV testing facilitated by community health workers called Health Surveillance Assistants (HSAs). The study population were healthcare providers purposively selected from the facilities. We administered a survey using a 5-point Likert-scale tool at the Pre-, Mid-, and Final implementation phases of the study, supplemented by in-depth interviews and focus group discussions ( > = 1 per facility) to clarify survey findings. We audio-recorded qualitative interviews and then transcribed and analysed data using Nvivo 12 software and thematic content analysis. The quantitative survey data were analyzed using the Fisher exact test to test for association in Stata Version 16.

Findings: A total of 273 providers (nurses, clinicians, lab staff and HSAs) were recruited in the Pre- (n = 90), Mid- (n = 91), and Final-implementation (n = 92) phases. The majority of survey participants (> 90%) in both models agreed that integrating CCS into FP via HPV self-sampling was acceptable, appropriate, and feasible. Providers reported the following positive attributes of service integration and self-sampling: efficiency, reduction in workload (for clinicians and nurses), simplicity of self-sampling, cost-savings (for clients), promotion of women’s privacy and empowerment and reduction of negative myths and misconceptions associated with speculum vaginal examination. A minority of participants raised the following feasibility-related concerns: intermittent shortage of resources, increased workload for CHWs facilitating community-based sample collection, and lab personnel conducting HPV testing. Nevertheless, the availability of equipment and supplies, well-trained personnel, continuous mentorship, staff commitment, and teamwork facilitated the implementation of both models.

Conclusions: Both models of integrating CCS into FP were acceptable, feasible, and appropriate. They provide a platform to rapidly increase CCS uptake in Malawi. Nevertheless, strategies to optimize supply chain management and minimize the workload of CHWs and laboratory staff are needed to improve the scale-up of the models.

Keywords: Cervical cancer screening; HPV; Implementation; Integration; Self-sampling.