Elsevier

Gynecologic Oncology

Volume 138, Issue 2, August 2015, Pages 317-322
Gynecologic Oncology

Acceptability of self-sample human papillomavirus testing among medically underserved women visiting the emergency department

https://doi.org/10.1016/j.ygyno.2015.05.028Get rights and content

Highlights

  • Non-attendance for cervical cancer screening was highly prevalent among women presenting to a high-volume, urban emergency care center.

  • Over 85% of participants were willing to use self-sample HPV testing for cervical cancer screening.

  • Opportunistic self-sample HPV testing is highly acceptable to women seeking care in a emergency department setting.

Abstract

Objective

Self-sample human papillomavirus (HPV) testing in public emergency departments (EDs) may be a viable strategy to opportunistically screen women who otherwise do not attend for regular Papanicolaou test-based cervical cancer screening. We describe the acceptability of self-sample HPV testing among women presenting to two high-volume, urban EDs that primarily care for the medically underserved.

Methods

In 2014, a total of 210 women 21 years of age and older were recruited from two public ED waiting areas following a two-stage cluster sampling design. Questionnaire items inquired about demographics, healthcare access and utilization, history of cervical cancer screening, and acceptability of self-sample HPV testing. Descriptive analyses were performed.

Results

Overall, 34.8% of participants were considered screening non-attendees based on their adherence to the current guidelines for Pap testing every three years. Acceptability of self-sample HPV testing was high, with over 85% of participants reporting that they would be willing to use the test if available. A smaller proportion (58%) was deemed likely to accept self-sample HPV testing in a public ED restroom setting. Primary concerns expressed by women were that the sampling may not be done correctly (64%) and that they may not know how to perform the sampling (39%).

Conclusions

Opportunistic self-sample HPV testing is acceptable to women seeking care at a high-volume, urban emergency care center. The use of this intervention potentially offers a unique strategy to improve cervical cancer screening among high-risk women who otherwise do not attend for regular screening.

Introduction

Since its introduction in the 1940s, Papanicolaou test-based screening has dramatically impacted cervical cancer morbidity and mortality in the U.S. and other countries with population-based screening programs. However, sociocultural and structural barriers that limit screening coverage continue to pose significant challenges to the effectiveness of these programs, with most invasive cancers occurring in never- and under-screened women [1], [2], [3]. In the U.S., lack of health insurance is one of the most significant structural barriers to regular cervical cancer screening [4], [5], [6]. Women without health insurance are less likely to attend for screening, with only 63.8% of uninsured women reporting a Pap test in the past three years compared to 88.7% among privately insured women [7]. Uninsured women are also more likely to be diagnosed at more advanced stages of disease that require more intensive treatments with a decreased chance of cure [8], [9]. In one study, 35% of uninsured women and 34% of those with Medicaid had advanced cancer at diagnosis, compared to 25% among privately insured patients [8].

For many adults without health insurance, local emergency departments (EDs) often serve as a primary point of care, providing otherwise inaccessible healthcare services [10]. Given that the ED visit may represent an uninsured patient's only encounter with the healthcare system, many emergency providers advocate that the ED go beyond providing urgent care for a patient's chief complaint and become a platform for the delivery of public health interventions [11]. Interventions in this model include those that aim to identify and intervene with high-risk patients. Women who do not attend for cervical cancer screening undoubtedly represent a high-risk, hard-to-reach population that may benefit from opportunistic screening encounters.

The causal relationship between persistent infection with oncogenic (i.e., high-risk) human papillomavirus (HPV) and cervical cancer [12] has stimulated the application of high-risk HPV testing as a cervical cancer screening strategy. The U.S. Food and Drug Administration (FDA) recently approved the HPV test as an alternative to Pap testing for primary cervical cancer screening among women 25 years and older [13] based on substantial evidence that the detection of HPV DNA alone is superior to cytology for detecting high-grade cervical intraepithelial neoplasia [14], [15], [16], [17], [18]. The test's high sensitivity makes it a viable option for opportunistic screening in resource-constrained settings and among hard-to-reach populations. Evidence from resource-constrained settings indicates that a single HR-HPV test among women aged 30–59 years may be associated with up to a 50% reduction in the detection of advanced cervical cancer and cervical cancer mortality [17].

The feasibility of opportunistic HR-HPV screening is augmented by the test's ability to be conducted with similar specificity and sensitivity on both clinician- and self-collected cervical samples [19], [20], [21]. Self-collection, which can be done in an unsupervised manner and involves a fairly simple procedure, offers the advantage of privacy and the adaptability to informal settings, such as restrooms. Furthermore, a preponderance of data indicates that self-sample HPV testing effectively increases screening participation in otherwise never- and under-screened women [22], [23].

Self-sample HPV testing in public EDs may be a viable strategy to opportunistically screen women who otherwise do not attend for regular cervical cancer screening (screening non-attendees). Public EDs in large urban centers, such as that of Harris County, Texas, see a large volume of patients, with over 170,000 encounters per year logged in Harris County's two public EDs [24]. With an average wait time of 6 h (Harris Health System, unpublished data), women waiting in the ED represent a captive population in which to implement a public health intervention. The purpose of the present study was to describe patterns of cervical cancer screening utilization and the acceptability of self-sample HPV testing among patients seeking healthcare at two high-volume, urban public EDs.

Section snippets

Participant recruitment

Women 21 years of age and older were recruited from the ED waiting areas of two public hospitals in Houston (Lyndon B. Johnson and Ben Taub Hospitals). A two-stage cluster sampling design modeled after the World Health Organization's Expanded Programme on Immunizations (EPI) method [25] was used to systematically sample individuals. EPI cluster sampling affords the benefit of a probability-based sample when a simple random sample is not feasible due to time and cost constraints and/or the lack

Results

Of the 306 women approached, 224 (73.2%) agreed to participate. Of these, 216 (70.5%) were eligible and 210 (68.6%) completed the interview. Demographic and healthcare characteristics of the sample are summarized in Table 1. The mean age of study participants was 38.1 years. Hispanic women represented the largest racial/ethnic group (56.7%), followed by African Americans (24.8%) and Non-Hispanic Whites (17.1%). Most participants were born in the U.S. (59.3%), had a high school education or less

Discussion

Despite steady reductions in its incidence over the past 50 years, cervical cancer remains an important public health problem in the U.S. and elsewhere. In nations where population-based screening strategies have been implemented, the majority of women diagnosed with cervical cancer are never- and under-screened women [1], [2], [3]. The purpose of this study was to determine whether self-sample HPV testing is acceptable to women seeking care at two large EDs serving a medically underserved,

Conflict of interest statement

None of the authors have any conflicts of interest to declare.

Acknowledgements

We thank the leadership for the Departments of Emergency Medicine at Ben Taub and Lyndon B. Johnson hospitals for their support. The development of the instructional materials used in this project was made possible through a pilot grant from the Dan L. Duncan Cancer Center at Baylor College of Medicine. JRM is supported by a grant from the National Institutes of Health (P01CA082710, PI: M Follen).

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    Drs. Scheurer and Ramondetta contributed equally to this work.

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