National Cervical Screening Program Research Articles

Validity of Vaginal Self-Collected Samples for Human Papillomavirus Deoxyribonucleic Acid Detection among Women in Rural Delta State, Nigeria

Background: With the emergence of human papillomavirus-based primary screening, the option of vaginal self-collected sample may overcome the barrier of speculum examination. Despite evidence of high acceptability of self-collection, there is need to evaluate the validity of such samples for HPV detection. This research aimed to determine the validity of self-collected vaginal samples for HPV detection among Nigerian women. Methods: A cross-sectional analytic study was conducted among 230 asymptomatic women, selected by multi-stage sampling method in Orhuwhorun community in Udu Local Government Area of Delta State between May to June 2021. Participants were instructed on self-collection (SC) of vaginal samples using Flobam female sample collection kit and a clinician-collected (CC) cervical sample was obtained using a similar swab. Paired specimens were tested for HPV genotyping using 21 HPV GenoArray Diagnostic kits. SPSS vs 25 was used for data analysis. Agreement between the two collection methods was calculated using concordance and discordance rates and Cohen's kappa statistic. A 2 by 2 contingency table was used to calculate sensitivity and specificity of both sampling methods. A p < 0.05 was considered statistically significant. Results: 230 women of mean age 41.08 years (SD ± 8.45) were enrolled and 228 paired SC and CC results were analyzed. Of the 228 samples, 44 (19.3%) and 48 (21.1%) had HPV on clinician-collected and self-collected samples respectively. The HPV detection concordance was 92.9% (95%CI: 89.7–96.3), Kappa value of 0.66 (p < 0. 001), showing substantial agreement. Sensitivity and specificity of SC compared to CC were 86.4% (95%CI: 76.2–96.5) and 94.6% (95%CI: 91.3–97.8) respectively. Odds ratio was 1.15 indicating SC is as good as CC for HPV detection. Conclusions: The excellent validity of SC support its use as an alternative form of HPV screening among Nigerian women hence the government should consider its introduction into the national cervical screening programme.

Acceptability of Human Papilloma Virus Self-Sampling for Cervical Cancer Screening in a Cohort of Patients from Romania (Stage 2).

(1) Background: Low patient’s adherence to conventional cervical cancer screening methods determined the need to take into consideration alternative approaches, and vaginal HPV self-sampling is one of them. We aimed to evaluate, using an online survey, the Romanian women’s acceptability of vaginal HPV self-sampling. (2) Methods: A 13-questions online survey was distributed on three Facebook groups, and the results were summarized. (3) Results: Despite of good educational background, 10.8% (n = 60) of the respondents did not know what a Pap smear is, and 33% (n = 183) were not informed about the free national cervical cancer screening program. Multivariate analysis revealed an increased likelihood of vaginal self-sampling acceptance among respondents who did not know about Pap test (OR: 7.80; 95%CI: 1.062–57.431; p = 0.021), national cervical cancer screening program (OR: 1.96; 95%CI: 1.010–3.806; p = 0.02), HPV infection (OR: 7.35; 95%CI: 3.099–17.449; p< 0.001) or HPV test (OR: 1.67; 95%CI: 0.950–2.948; p = 0.03). Moreover, women who did not previously undergo a cervical cancer screening program were more likely to accept the new screening method (OR: 1.62; 95%CI: 0.878–3.015; p = 0.04). (4) Conclusions: Our results showed high acceptability rates of vaginal HPV self-sampling among participants.

Smoking cessation strategy in the national cervical cancer screening program (SUCCESS): study protocol for a pragmatic cluster randomised trial and process evaluation in Dutch general practice

IntroductionCervical cancer screening in general practice could be a routine moment to provide female smokers with stop smoking advice and support. The aim of this study is to assess the...

Aboriginal and Torres Strait Islander women's views of cervical screening by self‐collection: a qualitative study

ObjectiveThis study aimed to describe Aboriginal and Torres Strait Islander women's views of self‐collection introduced in the renewed National Cervical Screening Program. MethodsA total of 79 Aboriginal and/or Torres Strait Islander women (50 screened in previous five years, 29 under‐screened) from five clinics across three Australian states/territories participated. Topics discussed were perceptions of self‐collection, the instruction card and suggestions for implementing self‐collection. We employed yarning (a qualitative method), which established relationships and trust between participants and researchers to facilitate culturally safe conversations. Transcripts were analysed thematically. ResultsMost women were unaware of self‐collection before the yarn but found it to be an acceptable way to participate in cervical screening. Women perceived self‐collection would be convenient, provide a sense of control over the screening experience, and maintain privacy and comfort. The instructions were perceived to be simple and easy to follow. Women had concerns about collecting the sample correctly and the accuracy of the sample (compared to clinician‐collected samples). ConclusionsSelf‐collection is acceptable to Aboriginal and Torres Strait Islander women. Implications for public healthGiven the inequitable burden of cervical cancer experienced by Aboriginal and Torres Strait Islander women, self‐collection is likely to significantly improve participation and ultimately improve cervical cancer outcomes.

The impact of catch-up bivalent human papillomavirus vaccination on cervical screening outcomes: an observational study from the English HPV primary screening pilot

BackgroundIn England, bivalent vaccination (Cervarix) against high-risk human papillomavirus (HR-HPV) genotypes 16/18 was offered in a population-based catch-up campaign in 2008–2010 to girls aged 14–17 years. These women are now entering the national cervical screening programme. We determined the impact of catch-up bivalent vaccination on their screening outcomes.MethodsWe studied the overall and genotype-specific screening outcomes in 108,138 women aged 24–25 (offered vaccination) and 26–29 years (not offered vaccination) included in the English HPV screening pilot between 2013 and 2018.ResultsAt 24–25 years, the detection of high-grade cervical intraepithelial neoplasia (CIN2+) associated with HPV16/18 decreased from 3 to 1% (p < 0.001), with estimated vaccine effectiveness of 87% (95% CI: 82–91%). The detection of any CIN2+ halved from 6 to 3% (p < 0.001), with an estimated vaccine effectiveness of 72% (95% CI: 66–77%). The positive predictive value of a colposcopy for CIN2+ decreased for both low-grade (p < 0.001) and high-grade (p = 0.02) abnormalities on triage cytology. The decreases in screen-detected abnormalities at age 26-29 were of a substantially smaller magnitude.ConclusionsThese data confirm high effectiveness of bivalent HPV vaccination delivered through a population-based catch-up campaign in England. These findings add to the rationale for extending screening intervals for vaccinated cohorts.

Retrospective audit of amendments made at multidisciplinary team meetings following renewal of The National Cervical Screening Program

Background: The National Cervical Screening Program (NCSP) requirements for laboratories providing liquid based cytology (LBC) highlight the need to correlate histological, cytological, and colposcopic and clinical findings, often in the context of a multidisciplinary team meeting (MDT). This study aims to identify the rate of amendment to histological and cytological diagnoses at MDT review, and the impact on clinical management and outcome.

Towards the elimination of cervical cancer in low-income and lower-middle-income countries: modelled evaluation of the effectiveness and cost-effectiveness of point-of-care HPV self-collected screening and treatment in Papua New Guinea.

IntroductionWHO has launched updated cervical screening guidelines, including provisions for primary HPV screen-and-treat. Papua New Guinea (PNG) has a high burden of cervical cancer, but no national cervical screening programme. We recently completed the first field trials of a screen-and-treat algorithm using point-of-care self-collected HPV and same-day treatment (hereafter self-collected HPV S&T) and showed this had superior clinical performance and acceptability to visual inspection of the cervix with acetic acid (VIA). We, therefore, evaluated the effectiveness, cost-effectiveness and resource implications of a national cervical screening programme using self-collected HPV S&T compared with VIA in PNG.MethodsAn extensively validated platform (‘Policy1-Cervix’) was calibrated to PNG. A total of 38 strategies were selected for investigation, and these incorporated variations in age ranges and screening frequencies and allowed for the identification of the optimal strategy across a wide range of possibilities. A selection of strategies that were identified as being the most effective and cost-effective were then selected for further investigation for longer-term outcomes and budget impact estimation. In the base case, we assumed primary HPV testing has a sensitivity to cervical intraepithelial neoplasia 2 (CIN2+) + of 91.8% and primary VIA of 51.5% based on our earlier field evaluation combined with evidence from the literature. We conservatively assumed HPV sampling and testing would cost US$18. Costs were estimated from a service provider perspective based on data from local field trials and local consultation.ResultsSelf-collected HPV S&T was more effective and more cost-effective than VIA. Either twice or thrice lifetime self-collected HPV S&T would be cost-effective at 0.5× gross domestic product (GDP) per capita (incremental cost-effectiveness ratio: US$460–US$656/life-years saved; 1GDPper-capita: US$2829 or PGK9446 (year 2019)) and could prevent 33 000–42 000 cases and 23 000–29 000 deaths in PNG over the next 50 years, if scale-up reached 70% coverage from 2023.ConclusionSelf-collected HPV S&T was effective and cost-effective in the high-burden, low-resource setting of PNG, and, if scaled-up rapidly, could prevent over 20 000 deaths over the next 50 years. VIA screening was not effective or cost-effective. These findings support, at a country level, WHO updated cervical screening guidelines and indicate that similar approaches could be appropriate for other low-resource settings.

214 HPV-Based cervical screening in Portugal

Introduction and aims of the study: Portugal’s National Cervical Screening Program has changed in 2017 from cytology-based screening to HPV testing-based screening, including women aged 25 to 60 years. Samples are collected in primary care and patients are referred to Cervical Pathology Units when screened positive for high-risk HPV. Our aim was to characterize patients with high-grade lesions referred to our unit with HPV based-testing and evaluate the outcomes. Methods: A retrospective observational study was conducted concerning the period from January to October 2020 in Instituto Português de Oncologia de Coimbra.

Understanding facilitators and barriers to follow-up after abnormal cervical cancer screening examination among women living in remote areas of Romania: a qualitative study protocol

IntroductionIn 2020 in Europe, Romania had the second highest incidence and mortality rates of cervical cancer, after Montenegro. To address cervical cancer in the country, the Romanian government established a...

The experience of under-screened and never-screened participants using clinician-supported self-collection cervical screening within the Australian National Cervical Screening Program.

Background:Australia has had significant successes in the prevention of cervical cancer. However, there is considerable scope for improving screening participation. In December 2017, Australia shifted from cytology to a human papillomavirus–based screening program as part of the renewed National Cervical Screening Program. This provided the opportunity to introduce a clinician-supported self-collection cervical screening pathway, which allows screening participants aged 30 years or more and who are under-screened or never-screened to screen via a self-collected human papillomavirus test.Objective:This study aimed to explore screening participant experiences of a clinician-supported self-collection cervical screening pathway.Methods:Interviews (n = 45) were conducted with participants who had used the clinician-supported self-collection cervical screening pathway in the Australian National Cervical Screening Program between December 2017 and April 2019. Interviews were analyzed using template analysis.Results:Under-screened and never-screened participants reported a variety of interrelated barriers to cervical screening due to the nature of the test. For these participants, self-collection was a preferable way to perform screening as it overcame various barriers, was easy to use and promoted a sense of empowerment. Participants reported that the role of their practitioner was influential in their decision to undertake cervical screening, and that the support and information provided was a key factor in their experiences of the self-collection pathway.Conclusion:Findings support the use of a clinician-supported model of care, as an alternative screening modality in Australia’s National Cervical Screening Program. As more countries consider the move from a cytology to human papillomavirus–based cervical screening program, this model may assist in greater engagement of under-screened participants.

Renewal of the National Cervical Screening Program: health professionals' knowledge about screening of specific populations in NSW, Australia.

The National Cervical Screening Program was renewed in Australia from 1 December 2017, with the introduction of 5-yearly human papilloma virus (HPV) screening from age 25, and the release of updated national screening guidelines. This study aimed to determine health professional knowledge of the renewed screening program following implementation. We invited health professionals providing cervical screening in New South Wales (NSW), Australia, to complete an online survey in late 2018, to better understand their knowledge of the renewed screening guidelines, in particular regarding screening of specific populations, and to ascertain whether they had undertaken any educational activities relevant to the renewal. A total of 241 responses were included in the data analysis. Health professionals demonstrated good knowledge of some aspects of the renewed program, including 64-85% correctly identifying limited indications for testing people younger than 25 years, 87% correctly identifying the need for completion of the Test of Cure protocol following treatment of high-grade lesions, and 71-80% correctly identifying management of symptomatic women. However several key knowledge gaps were identified including management of immune-deficient women (only 37% of respondents were aware of the need for 3-yearly screening), screening after total hysterectomy (56% were aware of guidance) and approximately 66% of health professionals correctly identifying indications for self-collected screening. One in ten health professionals had not undertaken any education specific to the renewal of the program. We found significant associations between knowledge levels and practitioner characteristics, including practitioners' frequency of access to the guidelines, specific educational activities undertaken and geographic location. Health professionals demonstrated strong knowledge of key aspects of the renewed National Cervical Screening program. However, our findings highlight some important gaps that may impact successful delivery of the program in Australia, and some significant associations between practitioner characteristics and knowledge levels, which will be important for education providers to note. Targeted educational interventions informed by these findings could support health professionals to better translate guidelines into practice and ensure successful delivery of this important public health program, particularly in regard to management of immune-deficient women, screening after hysterectomy and indications for self-collected screening.

HPV test kao primarni test skrininga u prevenciji cervikalnog karcinoma u Republici Hrvatskoj

The knowledge that persistent infection with the human papillomavirus (HPV) is a necessary cause of cervical cancer has led to changes in strategies for the prevention and early detection of this cancer, with aim to eradicate it. Primary prevention through the use of vaccines that prevent HPV infection has been implemented since 2006, while secondary prevention of cervical cancer has been significantly improved by the introduction of the HPV test, either as the only method of primary screening or in combination with the Pap test. Screening based on the Pap smear has been unquestionably successful in reducing incidence and mortality in the last century. More recently, there have been gradual changes in the use of the HPV test, from its use as a reflex test after the detection of mild cytological abnormalities, through co-testing, to the use of the HPV test as the only test in primary screening thanks to the evidence gathered from the use of large, randomized research and meta-analysis. The advantages of using the HPV test over the Pap test include a higher sensitivity in detecting premalignant lesions, a higher negative predictive value of the test, and a safe extension of the time interval between screenings. However, the introduction of the HPV test as a primary screening test is not so simple and requires strict testing quality control and elaborate guidelines to ensure an optimal strategy and prevent additional burden on the healthcare system. This review presents the national cervical cancer screening program in the Republic of Croatia, the problems that prevented the start of a pilot project in one Croatian county selected for the introduction of the HPV test as a primary screening test in the prevention of cervical carcinoma, and the tasks ahead in the next period which would ensure the smooth implementation of the pilot project and implement the HPV test as the primary screening test in Croatia. Based on the results of the pilot project, it is necessary to precisely define: the age at which primary HPV testing should start and stop in the cervical cancer screening program, the examination interval after a negative primary HPV test, further procedures with women with a positive primary HPV test, the procedures for conducting reflex cytological testing and further treatment of the patient in accordance with the findings, the possibilities and justification of introducing self-sampling as part of the cervical cancer screening program based on the HPV test as the primary screening test, and finally the type of HPV test that is most suitable for the primary screening in Croatia.

Trust and cancer screening: Effects of a screening controversy on women’s perceptions of cervical cancer screening

There is a paucity of data on trust of service users in cervical screening. A significant controversy in Ireland’s national cervical cancer screening programme emerged in 2018. The Health Service Executive (HSE) confirmed that a clinical audit had revealed that more than 200 women who developed cancer had not been told of earlier misdiagnosed smear tests. During this high profile controversy we conducted qualitative interviews exploring factors that influence cervical screening participation. Women who had been invited for routine screening tests were recruited from the national screening register. Telephone interviews were conducted with 48 women aged 25–65 years; with a range of screening histories – 34 were adequately screened (attended all routine screening tests) and 14 were inadequately screened (attended some/no screening tests). Thematic analysis was conducted and all interviewees spontaneously raised the screening controversy revealing that the crisis had resulted in serious loss of trust, faith and confidence in the screening programme. Publicity surrounding the controversy had some beneficial effects, including increased awareness of the value of screening and beliefs that intense focus on the programme will improve the service long-term. Strategies which incorporate these findings could help rebuild trust in screening.

Cervical Cancer Mortality in Romania: Trends, Regional and Rural-Urban Inequalities, and Policy Implications.

Background and Objectives: Despite being largely preventable, cervical cancer mortality still remains an important public health problem globally, in Europe, and in Romania. The European Union member states are urged to implement systematic, population-based screenings for cervical cancer, but the programs developed by the countries remain very heterogeneous. This study aimed to investigate the differences in cervix cancer mortality between Romania and EU and within Romania over the last two decades and to reveal the major sources of inequalities and the policy implications. Materials and Methods: We analyzed the number of deaths and the mortality rates by cervical cancer, standardized using the direct method, over two decades (2001–2016 for the EU, and 2001–2019 for the national and sub-national analyses). Trends, mortality reduction over the years, and mortality differences at the beginning and end of the time interval have been calculated for the EU and Romania, at national and sub-national levels (rural–urban and regions). Results: Our results revealed differences in cervical cancer mortality between Romania and EU and within Romania (among regions and rural–urban areas). These differences used to be very high in the past and are still persisting. Conclusions: The country should revisit its national cervical cancer screening program, which has been implemented for many years, but with a very limited participation rate. Due to the similar problems existing in Central-Eastern Europe, targeted support from the EU for the members from this geographical area could contribute to the minimization of differences in cervical cancer mortality among the EU members.

Interval cancer audit and disclosure in cervical screening programmes: An international survey.

Legal cases involving the National Cervical Screening Programme in Ireland following non-disclosure of an interval cervical cancer audit prompted this first international comparative survey of interval cervical cancer audit. A survey of 22 international population-based cervical screening programmes was conducted, to determine if they undertook audit of invasive cervical cancers. Those countries/regions that perform reviews were asked (i) how the audit was undertaken, including how the reviews were performed and how they controlled for retrospective bias, (ii) how women are informed of the audit process and how their consent is obtained, and (iii) how audit results were disclosed to patients. Seventeen countries/regions invited completed the survey (77%); 65% (11/17) have an audit process for interval cervical cancers. Five perform individual patient reviews; three perform programme-wide review, with calculation of interval cancer detection rates; one routinely performs programme-wide review with calculation of interval cancer detection rates and offers individual reviews, and one routinely performs local hospital-level reviews. In the remaining country/region, hospital laboratories audit cancers, with a national audit process for all cervical cancers. Varying methodologies for retrospective cytology review were employed; four include control samples, with a ratio varying from 1:1 to 1:2. Three conduct a blinded review. Most countries/regions do not discuss interval cancer audit with participants and 3/11 (27.3%) inform women when a cervical cancer audit takes place. Disclosure is limited and variable. The responses suggest that there is no consistent approach to audit of interval cervical cancers or to disclosure of audit results.

The impact of primary human papillomavirus screening on negative loop excision histology following biopsy-proven high-grade cervical intra-epithelial lesions: A review from a large tertiary colposcopy unit.

The renewed National Cervical Screening Program incorporating primary human papillomavirus (HPV) screening was implemented in Australia in December 2017. In a previous study conducted in the UK, primary HPV screening was found to be associated with a 25% reduction in the incidence of negative histology following loop electrosurgery excision procedure (LEEP). To examine the change in incidence and associated risk factors for a negative LEEP with introduction of primary HPV screening. A retrospective review of the records of all patients undergoing a LEEP excision for biopsy-proven high-grade cervical intra-epithelial lesions between 1 January 2014 and 30 June 2019 in a specialised centre. There were 1123 patients who underwent a LEEP included in the analysis. The incidence of a negative LEEP specimen was 7.5% (59/784) and 5.3% (18/339) in the pre- and post-HPV screening cohort. More patients in the post-HPV screening group had low-grade cytology on referral (P<0.001), smaller cervical lesions on colposcopy (P=0.012) and longer biopsy to treatment interval (P=0.020). Primary HPV screening was associated with a significant reduction in the incidence of a negative LEEP specimen in a propensity matched cohort (11.2% to 5.1%, P=0.006) and a 41% (P=0.045) decreased relative risk of a negative LEEP on multivariate analysis. Primary HPV screening results in a lower incidence of negative LEEP histology, despite a longer biopsy to treatment wait time and higher proportion of low-grade cytology at triage.

European trends in cervical cancer mortality in relation to national screening programs, 1985–2014

BackgroundCervical cancer is the fourth leading oncological cause of death in women. Variable trends in cervical cancer mortality have been observed across Europe, despite the widespread adoption of screening programs. This variability has previously been attributed to heterogeneity in the quality of screening programs. MethodsAge-standardized cervical cancer death rates for European countries between 1985 and 2014 were analyzed using Joinpoint regression. Countries were dichotomized based on year of implementation and population invitational coverage of national population-based cervical cancer screening programs. National cervical cancer mortality trends during the study period were compared based on this classification. ResultsDecreasing trends in mortality were observed in all European countries with the specific exceptions of Bulgaria, Greece and Latvia. The highest rates of cervical cancer mortality throughout the study period were in Romania (16.0-14.9/100,000) and the lowest rates in Italy (1.4-1.2/100,000). The greatest percentage decline in mortality was observed in the United Kingdom and the greatest absolute reduction in mortality was seen in Hungary. European countries which implemented a national population-based cervical cancer screening program prior to 2009 demonstrated greater improvements in cervical cancer mortality outcomes compared to those that did not (p = 0.016). ConclusionCervical cancer mortality is improving in most European countries; however, substantial variation remains. Trends in mortality were associated with the time of implementation of national population-based cervical screening programs.

Evaluating the Performance of Hybrid Capture 2 Test as a Primary Screening Test from Studies Conducted in Low and Middle-Income Country Settings- Special Focus India.

Among the screening tests for cervical cancer, advantages of screening with second generation molecular Hybrid Capture 2 (HC2) test is the high sensitivity and negative predictive value that makes it easy to implement as a cervical cancer screening policy necessitating less screening rounds. High income countries are now implementing HC2 test in their national cervical cancer screening program. Since the acceptance of any screening test depends on the sensitivity of the test, the current study was carried out to evaluate the sensitivity of HC2 test reported from Low- and Middle-income countries (LMIC) which share major burden of cervical cancer globally and to establish if HC2 test could be used as a primary screening test in India. Materials and methods:The population based cross sectional studies from LMICs which evaluated HC2 test as a primary screening modality to diagnose Cervical intraepithelial neoplasm grade 2 and above (CIN2+) lesions were included. Results:A total of 18 studies from LMIC involving 1,13,086 women were reviewed for sensitivity of HC2 as a primary screening test. The overall average sensitivity and specificity to diagnose CIN2+ lesions were 79.84% (95% CI-71.01,86.73) and 85.63% (95% CI- 84.37,86.92) respectively. India demonstrated an average sensitivity and specificity of 65% (95% CI 57,77) and 93% (95% CI- 92,94) respectively. Conclusion:Results from LMIC demonstrate a comparably low sensitivity of HC2 test to diagnose CIN2+ lesions as compared to that reported from High income countries. Sensitivity of HC2 was substantially low for India. The current study discusses issues of HC2 assay and the role of untreated Reproductive tract infections as probable causes for low sensitivity of the test. This needs further research in an attempt to improve the sensitivity of the test in an era of self-sampling and low-cost HPV test on horizon to improve the coverage for cervical cancer.

Disparities in the change of cervical cancer mortality rate between urban and rural Chiang Mai in the era of universal health care and the Thai national screening program

BackgroundThe Ministry of Public Health of Thailand established universal health coverage (UHC) in 2002, which also included national-level screening for cervical cancer in 2005. This study examined the changes in mortality of cervical cancer in rural and urban areas in Chiang Mai Province of northern Thailand during the era of UHC and the immediately preceding period.MethodsData of cervical cancer patients in Chiang Mai in northern Thailand, who died from 1998 through 2012, were used to calculate the change in age-standardized rates of mortality (ASMR) using a joinpoint regression model and to calculate estimated annual percent changes (APC). The change in mortality rate by age groups along with changes by geographic area of residence were determined.ResultsAmong the 1177 patients who died from cervical cancer, 13(1%), 713 (61%) and 451 (38%) were in the young age group (aged < 30), the screening target group (aged 30–59) and the elderly group (aged ≥60), respectively. The mortality rate among women aged 30–59 significantly declined by 3% per year from 2003 through 2012 (p < 0.001). By area of residence, the mortality rate in women targeted by the screening program significantly decreased in urban areas but remained stable in more rural areas, APC of − 7.6 (95% CI: − 12.1 to − 2.8) and APC of 3.7 (95% CI: − 2.1 to 9.9), respectively.ConclusionThe UHC and national cervical cancer screening program in Thai women may have contributed to the reduction of the mortality rate of cervical cancer in the screening target age group. However, this reduction was primarily in urban areas of Chiang Mai, and there was no significant impact on mortality in more rural areas. These results suggest that the reasons for this disparity need to be further explored to equitably increase access to cervical cancer services of the UHC.

Knowledge, attitudes, beliefs, intentions and behaviours of Australian Indigenous women from NSW in response to the National Cervical Screening Program changes: a qualitative study

Background: Indigenous women in New South Wales Australia are nearly four times more likely to die from cervical cancer than non-Indigenous women due to lower screening rates. We aimed to understand Indigenous women's cervical screening awareness, behaviours, knowledge, perceptions, motivators and barriers since the December 2017 National Cervical Screening Program changed to HPV testing, new screening age and screening interval, and introduced the new self-collection test.Methods: A qualitative study was conducted with 94 Indigenous women 25 to 74 years of age across metropolitan, regional and remote New South Wales. A team of six specialist researchers conducted the fieldwork, analysis and reporting. All data were coded thematically.Findings: Participants showed limited awareness of the renewed cervical screening program and the role of cervical screening in cervical cancer prevention, with most having a strong negative attitude towards cervical screening. Several motivators and behavioural barriers to screening were identified into four audience segments based on key characteristics. Most participants eligible to self-collect were unwilling to, due to concerns they would administer it incorrectly, injure themselves or have to return for a more invasive test.Interpretation: This study demonstrates the complex and heterogenous nature of attitudes and behaviours, among Indigenous women and highlights the intrinsic negative attitudes and social norms that are currently shaping community discourse and ultimately limiting screening. Our findings support the need for enhancing positive sentiment and community advocacy.Funding: Cancer Institute NSW Cervical Screening Program