Examining Attitudes Toward HPV Self-Collection Among Clinicians Practicing in Federally Qualified Health Centers Using the Cabana Guideline Based Practice Improvement Framework

In recent years, cervical cancer incidence rates in the United States have increased by 1.7% annually from 2012 to 2019 among women ages 30–44, and the rate of distant-stage cervical cancer has increased for all women by 1.3% annually from 2001 to 2018.^1,2 Specific subpopulations experienced a higher increase in distant-stage cervical cancer.^2,3 While the United States has experienced these increases, other countries (e.g., Australia, Scotland, and Norway) are reporting declines in cervical cancer and planning for the elimination as a public health problem in the near future.^4–6 Likely contributing to these increases in the United States, cervical cancer screening rates are declining; from 2005 to 2019, the percentage of women 21–65 years old overdue for screening increased from 14.4% to 23.0%.⁷ Those without insurance have significantly higher rates of being overdue for screening than those with insurance.^7,8 In 2020, only 51% of patients in federally qualified health centers (FQHCs) were up to date on cervical cancer screening, compared to 82.9% of the general U.S. population.⁹ In a study at a safety-net setting, the majority of women diagnosed with cervical cancer had no prior health care system contact (69%) and were not previously screened (63%).¹⁰ Additionally, 21% of those screened did not follow up after a positive screening test.¹⁰

Cervical cancer screening recommendations are shifting from cytology-based (i.e., Pap smears) to HPV-based testing (i.e., cotesting or primary HPV testing) as reflected in current screening guidelines from the American Cancer Society (ACS)¹¹ and the United States Preventive Services Task Force.^12,13 In May 2024, the Food and Drug Administration (FDA) approved the use of in-clinic HPV self-collection, and a home-based test was approved in 2025.^14,15 HPV self-collection can expand access to cervical cancer screening by increasing screening options and addressing patient preferences, reducing the need for a speculum exam, and potentially decreasing provider burden.¹⁶ Several countries have introduced self-collection in their national screening programs and observed an increase in women opting for self-collection over clinician-collected samples.^17,18

As new techniques such as self-collection for cervical cancer screening are introduced, clinicians’ attitudes toward these techniques should be evaluated to understand potential factors that impact adoption. The Cabana Guideline Based Practice Improvement Framework provides an excellent guide to examine clinicians’ adoption of practice guidelines.¹⁹ The factors described in the Framework include knowledge (i.e., lack of familiarity and awareness), attitudes (i.e., lack of agreement with specific and general guidelines, outcome expectancy, self-efficacy, and motivation), and external barriers (e.g., time, resources, patient perceptions of new guidelines), and the impact on clinician’s subsequent behavior.¹⁹

While HPV self-collection is a promising method for increasing screening opportunities for underserved communities, it is unclear how clinicians perceive self-collection and its utility in their patient population. This article describes attitudes toward HPV self-collection among clinicians practicing in FQHCs, guided by the Cabana Guideline Based Practice Improvement Framework.

This article describes clinicians’ perceptions of HPV self-collection guided by the Cabana Guideline Based Practice Improvement Framework. Attitudes toward HPV self-collection varied, with clinicians reporting positive and negative attitudes. The main benefits of HPV self-collection included being more convenient for patients and increasing access to care. The main concerns included patients incorrectly completing the test or obtaining an inadequate sample, a reduction in patients coming to appointments with providers, and patients not returning the test or attending follow-up appointments. This is consistent with other literature exploring the barriers and facilitators to self-collection.²³

As reported in Fuzzell et al. (2023), compared to previous research with clinicians in the general population,²⁴ clinicians in the current study practicing in safety-net settings were more willing to offer self-collection in either the office or at home. However, they were less likely to recommend self-collection for all patients (6%) compared to general clinicians (43%).²⁴ Approximately 5% of clinicians in the current study said they would not offer self-collection to any patient, compared to 21% of the general population clinicians.²⁴ The concerns related to HPV self-collection were similar between the groups, with the largest concerns being patients not collecting adequate samples, not returning the sample, and not presenting for routine care or follow up. In the current study, the largest benefit of self-collection was screening patients who prefer not to have a speculum exam. In the general population clinicians, the main benefits were screening patients who have limited access or ability to travel to clinic and those with other logistical barriers.²⁴

Some clinicians in the current study expressed concerns about HPV self-collection based on incorrect information, as shown in the open-ended item responses. First, cytology was assumed to be either a more effective screening test or a necessary part of cervical cancer screening. Guidelines since 2018 have recommended HPV testing alone (primary HPV) as an option.^11,12 However, uptake in the United States has been very low (<1% of clinics offer HPV alone).²⁵ Second, confusion relates to the management of a positive result on a primary HPV test. Because HPV testing is very sensitive but not very specific, a second test (usually a Pap test) is needed to determine the follow-up steps after a positive result on primary HPV screening.²⁶ Third, while clinicians correctly noted that patients could not reach the cervix on a self-collection, they did not understand that self-collected HPV testing is intended to be a vaginal sample.²⁷ Because of PCR amplification techniques, reaching the cervix is not required for accurate results on these tests. Consistent with other literature,²⁴ these concerns reflect the need to educate clinicians about HPV testing and self-collection, including the benefits of HPV testing, updates to screening and management guidelines, and the logistics of HPV self-collection. An example of educational materials for clinicians is the Clinician Communication Guide from the National Roundtable on Cervical Cancer, which explores the approved devices, patient eligibility, and discussion points.²⁸

This study has both limitations and strengths. The first limitation is a small sample size (n = 147). Approximately 85% of participants were female, and 70% were White, which may not be representative of clinicians throughout the United States and limits the generalizability of study results. As the qualitative data are based on write-in responses, the study team did not have the opportunity to explore and expand on the participants’ responses. A strength of this study is that the sample is composed of FQHC/safety-net clinicians. While this may limit the generalizability of the results and potentially influence their attitudes and perceptions of self-collection, these settings also offer a promising opportunity to have patients complete self-collection, given that cervical cancer screening rates tend to be lower in these practices. Additionally, the use of the Cabana Guideline Based Practice Improvement Framework to guide the survey development and data analysis is a strength of the study design and analysis. While this study includes previously published quantitative data,²⁰ it builds upon this work by analyzing responses to an additional open-ended survey item and mapping the responses to the Framework, which provides more context for the quantitative responses reported in Fuzzell et al. (2023). This study was conducted prior to the FDA approval of HPV self-collection, which provides important baseline information for clinicians’ perceptions of self-collection. Since HPV self-collection has been approved, clinician attitudes and perception of barriers might change with formal recognition of the value of self-collection that would not be represented in the current study. This study can help guide the adoption of self-collection by informing future interventions to: (1) provide clinician-focused educational about HPV self-collection and (2) address clinicians’ concerns and barriers to offering self-collection to their patients.

HPV self-collection has the potential to increase cervical cancer screening access, especially among underserved populations. Clinicians practicing in safety-net settings support HPV self-collection for patients who otherwise would not complete screening due to other barriers (e.g., transportation, difficulty with speculum exams); however, many clinicians still have reservations about the reliability of self-collection, their patients’ ability to collect an adequate sample, and the reduction in pelvic exams potentially leading to delays in identifying health concerns. With the potential for reaching under-screened populations and the recent approval of HPV self-collection in a clinical setting, further research with providers addressing these concerns is needed.

H.N.O.: Formal analysis, writing—original draft, writing—review and editing, visualization; P.L.: Formal analysis, investigation, writing—review and editing; L.F.: Investigation, writing—review and editing; N.C.B.: Formal analysis, investigation, writing—review and editing; M.C.: Writing—review and editing; H.B.F.: Conceptualization, methodology, investigation, writing—review and editing; R.B.P.: Conceptualization, methodology, investigation, resources, writing—review and editing, funding acquisition; S.T.V.: Conceptualization, methodology, investigation, resources, writing—review and editing, supervision, funding acquisition.