Acceptability of home-based HPV self-sampling for cervical cancer screening among users and providers in the West region of Cameroon: a cross-sectional study | BMC Health Services Research

This study confirms the high acceptability of home-based HPV self-sampling in the West Region of Cameroon. While hospital-based screening is often limited by time, distance, and costs [9,10,11,12,13,14], home-based HPV self-sampling offers a promising alternative. Our findings suggest the need to address factors influencing screening practices as well as the role of men, community leaders and practical implementation aspects for its success.

Socio demographic characteristics

Our study included 300 women, 70 men, 33 community leaders, and 153 healthcare professionals. Many lived in urban areas, were married, and worked in the informal sector. Only one quarter of women’s partners participated, mainly due to daily occupations, family responsibilities, or single status. Similar challenges in involving men have been observed in other African settings, often linked to economic pressures and limited availability [24,25,26].

Although home-based HPV self-sampling was well accepted, socioeconomic constraints continued to influence screening behaviours in all settings.

Association between age, monthly income and practice of the screening

Most participants’ revenues are below 50,000 XAF (~ 80 euros), just slightly above the estimated minimum wage in Cameroon (41,875 XAF) [27]. Women with higher income were more likely to have been screened, because they face fewer barriers such as transport costs or children care. This aligns with the 2018 Cameroon Demographic and Health Survey, which showed an increase in CC screening rates (from 1 to 8%) with better economic conditions [28]. Higher income is linked with better health outcomes in LMIC [29,30,31]. These results highlight the impact of economic disparities and social determinants of health—such as income, transportation, and living conditions—on access to care, health behaviours, and outcomes [32,33,34]. They need to be well addressed by public health programs in order to enhance screening uptake. Home-based HPV self-sampling could alleviate some of the financial burden and hence improve access.

Association between level of knowledge and practice of cervical cancer screening

Our study found a significant association between the knowledge of CC screening and its practice, highlighting knowledge as a crucial determinant of health behaviour [14, 15]. Overall, 65% of participants had good knowledge of CC—higher than the 46% reported in the 2018 Cameroon Demographic and Health Survey. Whereas, only 28% knew about screening and 4% had ever been screened [28]. However, there were some differences between the questionnaire used in this study and that in the health survey. This rate is also higher than that in South Africa (28%) [35], where there is a clear need to improve awareness. Although instruction level is generally linked with better CC knowledge, as seen in Saudi Arabia [36], our study did not find a direct association between education and screening. This is due to the relatively high level of instruction of our sample (over 60% with at least secondary school level). However, specific knowledge of CC was positively associated with screening. Thus, highlighting the value of targeted education to boost participation, as shown in other African contexts [37,38,39]. Therefore, enhancing knowledge among women, families, and community leaders is a key issue to improving screening uptake, regardless of the screening setting. Home-based HPV self-sampling could offer a promising avenue to improve knowledge, as healthcare professionals can directly address information gaps during home visits.

Male partners and community leaders’ roles in cervical cancer screening

Men were included in this study because of their key role in family decision-making. Particularly in West African contexts where they act as heads of household [40]. While many supported home-based HPV self-sampling, one-third expressed negative attitudes toward CC screening. Similar findings in Uganda, Kenya, and Ethiopia link limited knowledge of CC risks, prevention and treatment to male reluctance. This is in line with previous research that highlighted men as both barriers to and supporters of CC screening initiatives [13, 41,42,43,44]. These findings suggest that enhancing male understanding could lead to greater support [42, 43, 45]. Yet, as the reasons for their negative attitudes were not fully explored in our study, further qualitative research would be required.

Community leaders also emerged as essential allies, with 90% expressing supportive views. Their influence on health behaviours is well documented in sub-Saharan Africa [46,47,48,49]. That underscores the importance of involving them at an early stage to CC screening initiatives.

Acceptability of home-based HPV self-sampling

Home-based HPV self-sampling was well accepted by women in our study (73.7%). Therefore, supporting its potential to improve screening uptake and advance WHO’s elimination goals. Additionally, our study found that one out of three women had participated in CC screening 5 years ago, what aligns with national statistics (4%) [28]. This positive outreach is eventually due to the availability of a free screening program, implemented as a pilot project prior to the 3T study since 2016. However, as previous research on 3T shows, financial access alone does not eliminate structural and individual barriers [10]. Research from Australia and Spain has suggested that home-based self-sampling can reduce common barriers such as embarrassment, time constraints, and fear of pain [50, 51]. HPV self-sampling is highly acceptable for CC screening. It offers the possibility to reach many unscreened women and increase CC screening coverage in sub-Saharan Africa [52, 53]. In our study, most women and their relatives expressed confidence in women’s ability to perform self-sampling correctly. Thus, reinforcing its suitability for task-shifting strategies [17, 18].

Notably, in eight of the nine health areas included in the study, the acceptance of home-based HPV self-sampling was very high (Fig. 3). However, in one health area (Fontsa Touala) with poor accessibility (Fig. 2), the acceptance rate was only moderate (additional file 2). Specifically, 9 out of the 11 women recruited in this health area expressed concerns that their home environment was not clean or hygienic enough to perform the HPV self-sampling. Additionally, some participants mentioned the distance to the health facility as a factor that could discourage them from seeking screening at hospital. These challenges are similar to findings from other studies on geographic and infrastructure-related barriers to CC screening [10, 13, 15, 54, 55]. Home-based self-sampling can help to reduce these obstacles, especially in rural regions like West Cameroon, where poor roads and reliance on motorbikes limit hospital access (Fig. 2).

Implementation perspectives of home-based HPV self-sampling

Effective communication between communities and HCPs is essential for successful CC screening programs, especially in low and middle income countries such as Cameroon. Community health workers play a key role in raising awareness, particularly in rural areas [56, 57]. Nevertheless, they should not be the sole communication channel, as they are not health experts. In Nigeria, Olubodun et al. recommend using diverse tools—SMS, phone calls, and town criers (individuals responsible for proclaiming official announcements in public, using tools such as bells, drums, or megaphones)—to enhance outreach [58]. Our findings corroborate this, showing a strong preference for megaphones as a means to reach large groups in public spaces (Fig. 4). This is consistent with Thoma’s observation that megaphones often outperform posters and media broadcasts [59].

In order to improve participation, screening activities should be in harmony with local routines. Participants favoured morning visits and HPV self-sampling on “sacred days”—culturally significant days when people remain at home. These community rest days provide strategic opportunities to reach more individuals while respecting local customs, similar to designated public holidays [60].

Although the HPV self-sampling was conducted at home, most participants preferred receiving their results at health facilities to avoid stigmatisation, especially in case of positive results [10]. This echoes findings from Gambia, where stigmatisation related to COVID-19 reduced acceptance of home-based follow-ups [61]. This underlines the importance of culturally sensitive communication, and the need for HCPs to be trained not only in clinical delivery but also in respectful, confidential result disclosure to maintain community harmony.

Strengths and limitations

To our knowledge, this is the pioneer quantitative study in sub-Saharan Africa to explore the acceptability and preferences for implementing home-based HPV self-sampling. However, the study presents several limitations. Firstly, it was carried out before the actual rollout of home-based HPV self-sampling, as part of a pre-implementation phase. This means we could not assess how people behave in real conditions, but the findings provide useful guidance for planning future programs. Secondly, the cross-sectional design does not allow the establishment of causal relationships. Finally, fewer men and close relatives were recruited than expected. Which reflects common difficulties in involving male partners in previous African studies [24, 25].

Despite these limitations, the study has several strengths. It includes an extensive and diverse set of participants across four different groups, all without prior experience of home-based self-sampling. The high number of women involved, as well as the inclusion of healthcare professionals and community leaders, helped capture a wide range of perspectives. We also reached participants from various health areas, with different levels of accessibility, including urban, semi-urban, and rural communities. These aspects increase the relevance and potential use of our findings in similar contexts.

The upcoming CASAHO A study which will compare home and hospital-based screening, will further explore key operational aspects such as kit delivery, results communication, and follow-up.