Nicola Creagh

‘I Don't Think There Is a One‐Size‐Fits‐All’: A Qualitative Study Exploring Healthcare Professional and Service Provider Perspectives of Using Innovative Models of Cervical Screening to Improve Equitable Access to Self‐Collection

ABSTRACTIntroductionIn the Australian National Cervical Screening Program (NCSP), self‐collection can be performed in any setting deemed appropriate by the healthcare professional who orders the test, creating opportunities to develop innovative cervical screening models that can address known barriers to access for under‐ and never‐screened women and people with a cervix. This study explored the acceptability and appropriateness of innovative models and key considerations for their design and implementation from the perspectives of clinical and non‐clinical providers.MethodsWe conducted online, semi‐structured interviews with healthcare professionals, pathology providers and community service providers (June–October 2023). Data were analyzed using template analysis, a form of thematic analysis.ResultsThere were 132 participants from across Australia (82 clinical providers [e.g., doctors, nurses, midwives]; 34 non‐clinical providers [e.g., health/community service staff, disability support workers, bicultural workers]; and 16 pathology sector professionals). Four overarching themes were identified: acceptability, appropriateness, screening quality and safety, and implementation considerations. Most found innovative models acceptable when appropriately tailored to the needs of different population groups, particularly through community outreach, home in‐reach and peer‐supported services. Embedding clinical governance and oversight in the cervical screening pathway was a high priority to ensure that screening participants received adequate information about cervical screening and appropriate follow‐up care. Participants identified the need for clearly defined roles in the cervical screening pathway, sustainable funding and professional development opportunities to expand the role of nurses and optimize the roles of non‐clinical providers.ConclusionsInnovative models of cervical screening using self‐collection can offer more accessible, inclusive, and convenient care, especially for under‐ and never‐screened populations. Clinical governance and oversight must be embedded in the cervical screening pathway to maintain high‐quality screening services and to support the implementation of tailored and targeted innovative screening models.

Beyond words: operationalizing inclusive language in Australian cervical screening health promotion policy

Abstract Health equity is a fundamental concern within the broader health promotion aim of creating equal opportunities for health and bringing health differentials down to the lowest level possible. Cervical screening is just one example of a preventative health program where a health promotion lens is required to address entrenched health inequities. We draw on theorizations of policy ecologies to provide a framework for better understanding the processes involved in operationalizing policy with greater inclusivity in language in health promotion. Twenty-eight semi-structured interviews were conducted with 29 key informants between April and October 2022 to explore the operationalization of inclusive language in health promotion in the context of a national program to promote cervical screening to currently underscreening communities in Australia. Four thematic categories emphasize the balance required between demands and domains: (i) the need for clinical guidelines and flexibility in their translation and interpretation; (ii) organizational mandates, clinical practice, and patient-centred care; (iii) socio-cultural norms, behaviours, and attitudes amid politicized/ing milieus; and (iv) community preferences and the need for medical accuracy. As such, we identified how the operationalization of inclusive language in policy is influenced by and influences other domains where cervical screening is promoted. These findings hold wider implications for how the historical legacies of and contemporary need for ‘women’s health’ can be maintained and respected amid demands for greater gender inclusion. At the same time, the failure to trace diverse and diffuse modes and contexts of operationalization may (re)produce health inequities in practice if left unexamined.

The acceptability of, and informational needs related to, self‐collection cervical screening among women of Indian descent living in Victoria, Australia: A qualitative study

AbstractBackgroundIn July 2022, self‐collection became universally available as part of Australia's National Cervical Screening Program. This change aims to address screening inequities experienced among underscreened populations, including women of Indian descent. This study explored experiences of cervical screening, alongside the acceptability of self‐collection, among women of Indian descent living in Victoria, Australia. We also aimed to articulate the informational needs to promote self‐collection among this population.MethodsFive focus group discussions with 39 women living in Victoria were conducted in English (n = 3) and Punjabi (n = 2). Transcripts were thematically analysed, as informed by the Theoretical Framework of Acceptability.ResultsWomen were motivated by the choice to self‐collect, perceiving the ability to maintain modesty and greater autonomy as key enablers. Healthcare practitioners were seen as central in supporting patient‐centred models of care. Perceived barriers to self‐collection included concerns around its accuracy and women's confidence in collecting their own sample. Widespread dissemination of culturally tailored promotion strategies communicating concepts such as 'privacy' and 'accuracy' were suggested by women to promote self‐collection.ConclusionSelf‐collection was highly acceptable among women of Indian descent, particularly when assured of its accuracy, and sociocultural norms and previous screening experiences are considered. This study highlights the huge potential that self‐collection can play in increasing equity in Australia's cervical screening programme.Patient or Public ContributionMembers of the public were involved in focus group discussions. Findings were summarised and disseminated via a poster. A bicultural worker was involved in all stages of the research.

Inclusive language in health policy – a timely case (study) of cervical screening in Australia

Language is important in health policy development. Policy changes in Australia to increase cervical screening offers a timely case example to explore the function of inclusive language in health policy. Gender and sexuality diverse people with a cervix have been largely invisible within health promotion programs, which has led to reduced awareness of, and access to, cervical screening. Twenty-eight semi-structured interviews were conducted with 29 key informants between April and October 2022 about the role of inclusive language in cervical screening policy, promotion, and delivery in the context of a national program to promote cervical screening. Three themes were identified from what key informants believed to be the role of inclusive language: (1) the common goal of inclusive language as policy advocacy for broader inclusivity; (2) the inevitable partiality of inclusive language in policy as an opportunity to start conversation; and (3) policy as a bridge between essential but diffuse components of the health sector with multidirectional influences. Inclusive language was seen to operationalise equity in health policy within the broader aim of eliminating cervical cancer among under-screened populations.

Practitioners support and intention to adopt universal access to self‐collection in Australia's National Cervical Screening Program

AbstractObjectivePrimary care practitioners are crucial to engaging people in Australia's national cervical screening program. From July 2022, practitioners have been able to offer all screen‐eligible people the choice to collect their own self‐collected sample; an option introduced to increase equity. This study explored how practitioners are intending to incorporate universal access to self‐collection into their clinical care.MethodsSemi‐structed interviews with 27 general practitioners, nurses, and practice managers from 10 practices in Victoria, Australia conducted between May and August 2022. Interviews were deductively coded, informed by the Consolidated Framework for Implementation Research. The Diffusion of Innovations theory was used to categorise intention to provide self‐collection.ResultsParticipants were supportive of universal access to self‐collection, citing benefits for screen‐eligible people and that it overcame the limited adaptability of the previous policy. Most participants' practices (n = 7, 70%) had implemented or had plans to offer the option for self‐collection to all. Participants deliberating whether to provide universal access to self‐collection held concerns about the correct performance of the self‐test and the perceived loss of opportunity to perform a pelvic examination. Limited time to change practice‐level processes and competing demands within consultations were anticipated as implementation barriers.ConclusionsThe extent to which self‐collection can promote equity within the program will be limited without wide‐spread adoption by practitioners. Communication and education that addresses concerns of practitioners, along with targeted implementation support, will be critical to ensuring that self‐collection can increase participation and Australia's progression towards elimination of cervical cancer.

“So, if she wasn’t aware of it, then how would everybody else out there be aware of it?”—Key Stakeholder Perspectives on the Initial Implementation of Self-Collection in Australia’s Cervical Screening Program: A Qualitative Study

Background: In December 2017, the Australian National Cervical Screening Program transitioned from 2-yearly cytology-based to 5-yearly human papillomavirus (HPV)-based cervical screening, including a vaginal self-collection option. Until July 2022, this option was restricted to under- or never-screened people aged 30 years and older who refused a speculum exam. We investigated the perspectives and experiences of stakeholders involved in, or affected by, the initial implementation of the restricted self-collection pathway. Methods: Semi-structured interviews were conducted with 49 stakeholders as part of the STakeholder Opinions of Renewal Implementation and Experiences Study. All interviews were audio recorded and transcribed. Data were thematically analysed and coded to the Conceptual Framework for Implementation Outcomes. Results: Stakeholders viewed the introduction of self-collection as an exciting opportunity to provide under-screened people with an alternative to a speculum examination. Adoption in clinical practice, however, was impacted by a lack of clear communication and promotion to providers, and the limited number of laboratories accredited to process self-collected samples. Primary care providers tasked with communicating and offering self-collection described confusion about the availability, participant eligibility, pathology processes, and clinical management processes for self-collection. Regulatory delay in developing an agreed protocol to approve laboratory processing of self-collected swabs, and consequently initially having one laboratory nationally accredited to process samples, led to missed opportunities and misinformation regarding the pathway’s availability. Conclusions: Whilst the introduction of self-collection was welcomed, clear communication from Government regarding setbacks in implementation and how to overcome these in practice were needed. As Australia moves to a policy of providing everyone eligible for screening the choice of self-collection, wider promotion to providers and eligible people, clarity around pathology processes and the scaling up of test availability, as well as timely education and communication of clinical management practice guidelines, are needed to ensure smoother program delivery in the future. Other countries implementing self-collection policies can learn from the implementation challenges faced by Australia.

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.

‘I’m a bit of a champion for it actually’: qualitative insights into practitioner-supported self-collection cervical screening among early adopting Victorian practitioners in Australia

Abstract Background: Self-collection for cervical screening has been available in the Australian National Cervical Screening Program since 2017 and is now available to all people as an option for cervical screening through a practitioner-supported model. Documenting early adopting practitioner experiences with self-collection as a mechanism to engage people in cervical screening is crucial to informing its continuing roll-out and implementation in other health systems. Aim: This study aimed to describe the experiences of practitioners in Victoria, Australia, who used human papillomavirus (HPV)-based self-collection cervical screening during the first 17 months of its availability. Methods: Interviews (n = 18) with practitioners from Victoria, who offered self-collection to their patients between December 2017 and April 2019, analysed using template analysis. Findings: Practitioners were overwhelmingly supportive of self-collection cervical screening because it was acceptable to their patients and addressed patients’ barriers to screening. Practitioners perceived that knowledge and awareness of self-collection were variable among the primary care workforce, with some viewing self-collection to be inferior to clinician-collected screening. Practitioners championed self-collection at an individual level, with the extent of practice-level implementation depending on resourcing. Concerns regarding supporting the follow-up of self-collected HPV positive patients were noted. Other practical barriers included gaining timely, accurate screening histories from the National Cancer Screening Register to assess eligibility. Practitioners’ role surrounded facilitating the choice between screening tests through a patient-centred approach.