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. 2026 Mar 29;58(1):2645175. doi: 10.1080/07853890.2026.2645175

Patient acceptance of HPV self-sampling approach for cervical cancer screening: evidence from a pilot study in Kazakhstan

Mereke Rakhmanova a, Yesbolat Sakko b, Assem Suleimenova c, Gulnara Sakhipova d, Aizada Marat e, Gulzhanat Aimagambetova f,g,✉
PMCID: PMC13037154  PMID: 41906369

Abstract

Background

Cervical cancer remains a major global health burden, particularly in low- and middle-income countries. In Kazakhstan, cervical cancer incidence is rising, despite an established cytology-based screening program. Self-sampling for human papillomavirus (HPV) genotyping is suggested as a promising strategy to improve screening participation, yet it has not been evaluated in Kazakhstan. Thus, this study aims to perform a preliminary assessment of self-sampling approach acceptance among Kazakhstani women.

Methods

A cross-sectional study was conducted among women attending outpatient clinics in large cities in Kazakhstan between August 2024 and June 2025. Participants used both the Evalyn Brush and BGI Sentis self-sampling kits and completed structured questionnaires assessing knowledge, perceptions, ease of use, discomfort, confidence and willingness to recommend. Descriptive and bivariate statistics were performed to evaluate associations with acceptance and usability.

Results

A total of 124 women were included in this pilot study, with a median age of 34.5 years (IQR: 27.5–44.0). Only 28.2% of respondents preferred self-sampling for their next screening, whereas 62.1% preferred gynaecologist-collected samples. The Evalyn Brush demonstrated higher ease of use (93.5%) compared to the BGI kit (45.2%). Confidence in correct self-collection was also higher for the Evalyn Brush (85.4% vs. 67.7%). Women who believed that home-based self-sampling is easier than Pap-smear were significantly more likely to prefer self-sampling for future screening (p < 0.001). Education level was associated with HPV knowledge but not with acceptance.

Conclusion

Self-sampling is acceptable for a proportion of Kazakhstani women, with the Evalyn Brush showing greater comfort, ease and confidence, indicating that device selection is critical for successful implementation. The findings support further large-scale evaluation that will guide improvements to Kazakhstan’s cervical cancer screening programme. A nationwide study is required for a more precise assessment of the self-sampling approach acceptance and the strategy’s feasibility.

Keywords: Cervical cancer, cervical cancer screening, HPV, self-sampling, acceptance, cervical sampling

KEY MESSAGES

  1. HPV self-sampling had low acceptance among Kazakhstani women (28.2%), with preference strongly driven by the perceived convenience, ease of use, comfort and confidence of using the device correctly.

  2. The Evalyn Brush had better acceptability than the BGI Sentis, with significantly better ease of use, perceived convenience compared with the Pap smear, confidence in using the device and willingness to recommend the device compared with the other device.

  3. Low acceptance of the self-sampling approach, despite positive experiences with ease of use, emphasizes the need to address concerns about the reliability of self-samples and the user’s confidence with devices before national roll-out.

1. Introduction

Cervical cancer remains one of the leading causes of cancer-related death among women worldwide, with more than 703,000 new cases and 373,000 deaths reported in 2022 [1–3]. Moreover, the estimated incidence will increase by the end of 2050, with 948,000 new cervical cancer cases resulting in 543,000 deaths [1]. Since the introduction of organized screening programmes in the 1950s, high-income countries have achieved more than a 50% reduction in cervical cancer incidence and mortality [4]. In contrast, more than 90% of cervical cancer deaths still occur in low- and middle-income countries (LMICs) where access to regular screening is limited [1,4–6].

In Kazakhstan, a middle-income country, cervical cancer is the second most common cancer among women, with a confirmed incidence rate of around 19–20 per 100,000 and with increasing trends over the past decade [2,7]. This makes the disease a major public health challenge that requires targeted interventions. Persistent infection with high-risk human papillomavirus (HPV) is responsible for over 75% of cervical cancer cases worldwide [1,8]. Research on the prevalence of HPV in Kazakhstan revealed 25% prevalence of high-risk HPV infection in the general female population [9] and 39–43% among women attending gynaecological clinics [10–13].

Cervical cancer prevention includes both primary (HPV vaccination) and secondary (screening and early treatment) approaches [2]. Regular screening is critical for early detection and prevention of the disease. The most common screening method, the Papanicolaou test (Pap-test), was widely introduced in 1950s and has proven effective but is limited by a relatively low sensitivity (47–60%), leading to false-negative results [14–18]. As suggested by the World Health Organization (WHO), combining Pap-test with HPV genotyping significantly improves the screening diagnostic accuracy [19]. Despite this, screening participation remains low in many countries, resulting in the growth of the underscreened population and subsequent increase in cervical cancer incidence.

In Kazakhstan, the cytology-based (Pap-test) cervical cancer screening programme is available. The programme is covered by the governmental budget and targets all women from 30 to 70 years old with free testing every 4 years [20,21]. However, the screening participation rates remain suboptimal, with only 45.9% of eligible women undergoing cervical cancer screening [20,21]. Participation also varied by place of residence, with 74% of urban women undergoing screening compared to only 38% of rural women [22]. Many factors affect cervical cancer screening attendance, including lack of awareness, time constraints, limited access to healthcare facilities, discomfort during the clinical examination and cultural and/or religious factors [23–27].

To overcome barriers and factors affecting cervical cancer screening attendance, self-sampling methods for HPV testing and screening have been introduced in many countries worldwide as an alternative to clinician-collected specimens [28,29]. These methods allow women to collect their own cervicovaginal samples, reducing discomfort, increasing privacy and improving accessibility, particularly for women in remote or resource-limited settings [3,30]. International research data shows that self-sampling has confirmed comparable accuracy to clinician-collected samples and shows promise in increasing screening uptake [3,28,30].

Several self-sampling devices are available globally with demonstration of promising results in terms of diagnostic accuracy and usability [31,32]. A recent systematic review reported that self-sampling devices such as Evalyn Brush, Cervex Brush, FLOQSwab and Delphi Screener have comparable accuracy to clinician-collected samples, with concordance rates ranging from 89 to 97.5% and sensitivities up to 95–100% [30]. However, implementation of self-sampling as an additional modality for cervical cancer screening requires validation in local clinical setting and cultural adaptation. Understanding of women’s preferences, in particular type of self-sampling devices that patients find to be most acceptable, is essential for maximizing screening participation. Particularly in Kazakhstan self-sampling approach has never been practiced; however, due to low cervical cancer screening uptake, its implementation in clinical practice is justified. Thus, this study aimed to investigate the acceptance of self-sampling modality and specific self-sampling kits (BGI Sentis and Evalyn Brush) among Kazakhstani women. The study objective was to perform a preliminary assessment to identify which device is more acceptable for a potential large-scale implementation within the national cervical cancer screening programme.

2. Materials and methods

2.1. Study design and subjects

This study employed a cross-sectional design to assess and compare the acceptability, comfort, and overall user experience of two cervical self-sampling devices among women attending outpatient clinics in three major cities of Kazakhstan: Astana, Almaty and Aktobe. Data collection was carried out between August 2024 and June 2025.

Participants were eligible if they met the following inclusion criteria: (a) women aged 18 years or older; (b) had an intact cervix (no history of total hysterectomy or other surgery involving complete removal of the cervix) and (c) were able to understand and respond to study materials in Kazakh or Russian. Women were excluded if they were: (1) younger than 18 years of age; (2) had undergone a total hysterectomy (or other surgery resulting in removal of the cervix); (3) were pregnant at the time of recruitment or (4) unable to communicate in Kazakh or Russian.

Participants were recruited through opportunistic sampling. Women attending gynaecological consultations at the participating healthcare facilities were informed about the study by trained healthcare personnel and were invited to participate in the trial voluntarily. Those who expressed interest were screened for eligibility and provided with detailed study information. Written informed consent was obtained prior to participation. All participants were asked to use self-sampling devices in order to directly compare their experiences and perceptions.

A total of 325 women were approached with invitations to take part in this pilot study: in Astana − 45 women, in Almaty − 156 women and in Aktobe − 124 women. A total of 140 initially agreed to participate in the trial: in Astana − 30 women, in Almaty − 51 women and in Aktobe − 59 women. However, out of 140 women who agreed to take part, only 124 filled out and returned the questionnaires, thus were included in the study, making the response rate of 38% (124 of 325 initially approached).

2.2. Study procedures

After signing the informed consent, all participants were provided with paper-based instructions, self-sampling kits (Evalyn Brush and BGI Sentis), and questionnaires to report their experience with the kits. Before and after using the devices, participants completed the corresponding sections of the questionnaire. They were instructed to use both devices according to standardized written and visual instructions adapted from manufacturer guidelines. The order of device use was random for all participants. Each participant was asked to use both devices sequentially, following recommended insertion depth, rotation and handling procedures. After completion, the devices were disposed of in accordance with biosafety regulations and were not processed for laboratory analysis, as the study focused exclusively on acceptability and user experience, not diagnostic accuracy.

2.3. Study instruments

2.3.1. Self-sampling devices

Two commercially available self-sampling devices were evaluated in this study: the Evalyn Brush (Rovers Medical Devices B.V., Oss, The Netherlands) and the BGI Sentis (BGI Genomics Co., Ltd., Shenzhen, China). Both devices are designed for self-collection of cervicovaginal samples for HPV testing.

The Evalyn Brush is a plastic, single-use device consisting of a brush head with soft, flexible bristles attached to a handle designed for ergonomic grip and controlled insertion. The brush head is engineered to collect exfoliated cells from the cervix and upper vaginal canal through gentle rotation. The device includes a safety stopper to prevent over-insertion and ensure user comfort. It has been validated in multiple international studies as a reliable self-sampling tool for HPV DNA detection and cervical cytology. Manufacturer website: https://www.roversmedicaldevices.com/products/evalyn-brush/

The BGI Sentis self-sampling kit is a sterile, single-use device intended for the collection of cervicovaginal specimens for HPV DNA testing. The kit typically consists of a sampling brush or swab, a sample preservation card containing transport medium and illustrated instructions for self-collection. The brush component is designed to be soft, flexible and user-friendly to minimize discomfort and optimize sample adequacy.

Manufacturer website: https://www.bgi.com/global/product/sentis/

2.3.2. Study questionnaires

Two questionnaires were used to collect patients’ data: (1) patients’ socio-demographic and clinical data and (2) a survey to assess the trial of HPV self-sampling and different self-sampling kits.

The first 16-item questionnaire containing clinical data will be filled out by clinicians for medical data accuracy (Supplementary file 1). The second questionnaire used in this study was adapted from De Pauw et al. (2021), which explored women’s attitudes and preferences regarding self-sampling for cervical cancer screening in the VALHUDES study [26]. The original questionnaire included items evaluating comfort, ease of use, confidence in performing self-sampling and willingness to use similar devices in the future. Minor contextual and linguistic adaptations were made to ensure cultural and language appropriateness for the Kazakhstani population. The adapted version was translated into Kazakh and Russian using forward-backward translation by bilingual experts to ensure linguistic and cultural appropriateness (Supplementary file 2). The final version was pilot-tested among 30 participants to confirm clarity and comprehensibility, after which minor linguistic and formatting adjustments were made. The questionnaire was administered in Kazakh and Russian according to each participant’s language preference. Trained study personnel distributed the questionnaires, provided instructions for device use and were available to clarify the participant queries when necessary. The adapted questionnaire was designed to evaluate participants’ knowledge, perceptions and experiences regarding self-sampling, as well as their preferences for future cervical cancer screening methods.

2.4. Study model

Figure 1 illustrates the hypothesized acceptance mechanism. Background characteristics are assumed to shape women’s pre-intervention perceptions and attitudes. These attitudes influence how each device is experienced, with separate pathways for Evalyn Brush and BGI Sentis kits. Kit-specific experiences then determine whether a device is accepted and recommended to others. The ultimate outcome is overall acceptance of self-sampling, defined as a preference for using it in future screening instead of clinician-collected samples. This model is conceptual and was used to guide analysis, not to present statistical results.

Figure 1.

The figure presents a conceptual model describing the hypothesized pathway from background characteristics to screening preference. Background factors, including medical and reproductive history, lifestyle and general health, knowledge and health behavior, and socio-demographic characteristics, are proposed to shape pre-intervention attitudes and beliefs. These attitudes, alongside background factors, feed into two concurrent device-specific pathways (BGI Sentis and Evalyn Brush) that each participant experienced, progressing through experience of use and specific kit acceptance before converging on an overall screening preference (self-sampling vs. clinician-collected samples). This model is conceptual and was used to guide the analysis rather than to present statistical results.

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Conceptual framework of factors influencing HPV self-sampling preference.

2.5. Ethical approval

The study protocol was approved by the Nazarbayev University Research Ethics Committee (NU-IREC); Protocol of approval #621/03102022 (21.10.2022). Informed consent was obtained from each subject; all the documents, samples collected and results are kept confidential.

2.6. Statistical analysis

Descriptive and bivariate statistics were performed to investigate the acceptance of HPV self-sampling kit use. Wilcoxon rank-sum, Kruskal-Wallis and Pearson’s chi-square were used to find associations between various factors (demographics, education, knowledge, baseline perceptions and user experience) and outcomes of acceptance. Two-sided hypothesis testing with 95% confidence intervals was provided, where p < 0.05 is considered statistically significant.

To assess overall kit acceptance, two composite convenience scores were derived: Evalyn convenience and BGI convenience. Each was calculated as the sum of six specific items related to the respective kit. For the Evalyn Brush, items included: instruction clarity (q5), ease of collection (q7a), lack of unpleasantness (q7b), lack of pain (q7c), perceived collection correctness (q7d) and preference for home-sampling over a clinic visit (q7f). The BGI card score was similarly derived from corresponding items q6 and q8a-q8f. These sum scores, along with individual items, were evaluated using Cramer’s V for categorical pairs, Eta-squared (η2) for numeric-categorical pairs and Pearson’s r for numeric pairs to determine association magnitudes in the network layout.

Mermaid live editor online platform was used to create hypothesized acceptance mechanism chart (Figure 1) (https://mermaid.live/), Stata 19.5 was used to do all statistical analysis (StataCorp, 2025, StataCorp, College Station, TX), MS Excel was used to create all the tables. Pandas, NetworkX, Matplotlib, NumPy, Pingouin and Python’s built‑in math library were used to create the Conceptual Hierarchical Network Layout (Figure 2). For this network, the magnitude of associations was determined by Cramer’s V for categorical pairs, Eta-squared η2 for numeric-categorical pairs and Pearson’s r for numeric pairs.

Figure 2.

The network visualizes statistically significant associations (magnitude ≥ 0.30) among variables related to HPV self-sampling preference. Nodes represent variables; edges represent pairwise associations, with color and thickness reflecting association strength and significance. Dark green edges indicate strong, statistically significant associations (Mag ≥ 0.50, p < 0.05); light green edges indicate moderate associations (0.30 ≤ Mag < 0.50, p < 0.05 or marginal); orange edges flag associations at collinearity risk (Mag ≥ 0.70). Labeled magnitude values are shown only for strong and very strong edges. Central nodes represent the primary outcome (q9outcome: preferred screening method for the next visit) and two composite convenience scores derived from device-specific user experience items (evalynconvenience; bgiconvenience). Peripheral nodes represent device-specific experience items (q7 and q8 series), background variables (sociodemographic, clinical, and reproductive), and behavioral factors. Key survey items shown in the network: q7a/q8a – ease of sample collection (Evalyn/BGI); q7b/q8b – perceived unpleasantness of the procedure (Evalyn/BGI); q7d/q8d – perceived accuracy of sample collection (Evalyn/BGI); q7e/q8e – willingness to recommend the procedure to others (Evalyn/BGI); q7f/q8f – perceived home-based convenience compared to Pap smear (Evalyn/BGI). Full variable definitions are provided in Supplementary File 2.

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Conceptual hierarchical network layout of factors associated with HPV self-sampling preference.

Associations with magnitude ≥ 0.30 were included, with edge colours and widths defined by magnitude and p‑value cut-offs (≥ 0.70, ≥ 0.50, 0.30–0.50; p < 0.05 or 0.05–0.10). Nodes were arranged in concentric layers by variable type (outcome, key convenience, question groups, remaining questions, demographics and clinical/pregnancy), with radii adjusted to improve readability. Outcome and key convenience nodes were highlighted, and only strong and very strong edges were labelled with magnitude values.

3. Results

3.1. Socio-demographic and clinical characteristics of study subjects

Table 1 presents the sociodemographic and clinical characteristics of the study participants according to their preference for self-sampling. A total of 124 women were included in this pilot study, with a median age of 34.5 years (IQR: 27.5–44.0). Most participants were of Kazakh ethnicity (82.3%), married (62.1%) and had higher or specialized secondary education (79.0%) (Table 1).

Table 1.

Socio-demographic and clinical characteristics of study subjects.

Factor Total (%) Does not prefer self-sampling (row %) (col%) Prefer self-sampling (row %) (col%) p value T-test
N 124 (100%) 88 (71.0%) 35 (29.0%)    
Age, median (IQR) 34.5 (27.5, 44.0) 35.5 (28.0, 47.5) 32.0 (26.0, 39.0) 0.095 Wilcoxon rank-sum
Age Group       0.29 Pearson’s chi-squared
 10–19 1 (0.8%)†        
 20–24 8 (6.5%) 5 (62.5%) (6.0%) 3 (37.5%) (9.0%)    
 25–34 53 (42.7%) 35 (66.0%) (40.0%) 18 (34.0%) (51.0%)    
 35–44 31 (25.0%) 25 (80.6%) (28.0%) 6 (19.4%) (17.0%)    
 45–54 18 (14.5%) 11 (61.1%) (12.0%) 7 (38.9%) (20.0%)    
 55–64 12 (9.7%) 11 (91.7%) (12.0%) 1 (8.3%) (3.0%)    
 65+ 1 (0.8%) 1 (100.0%) (1.0%) 0 (0.0%) (0.0%)    
Ethnicity       0.59 Pearson’s chi-squared
 Kazakh 102 (82.3%) 72 (70.6%) (82.0%) 30 (29.4%) (86.0%)    
 Russian 8 (6.5%) 7 (87.5%) (8.0%) 1 (12.5%) (3.0%)    
 Others 12 (9.7%)† 8 (72.7%) (9.0%) 3 (27.3%) (9.0%)    
  2 (1.6%) 1 (50.0%) (1.0%) 1 (50.0%) (3.0%)    
BMI, median (IQR) 24.4 (21.3, 27.4) 25.0 (21.6, 28.0) 23.0 (20.2, 25.5) 0.01 Wilcoxon rank-sum
Education level       0.025 Pearson’s chi-squared
 Secondary 21 (16.9%)† 13 (65.0%) (15.0%) 7 (35.0%) (20.0%)    
Specialized secondary 47 (37.9%) 41 (87.2%) (47.0%) 6 (12.8%) (17.0%)    
 Higher 51 (41.1%) 33 (64.7%) (38.0%) 18 (35.3%) (51.0%)    
  5 (4.0%) 1 (20.0%) (1.0%) 4 (80.0%) (11.0%)    
Sexual activity (start), median (IQR) 21.0 (19.0, 23.0) 21.0 (19.0, 23.0) 21.0 (19.0, 24.0) 0.64 Wilcoxon rank-sum
 Marital status       0.94 Pearson’s chi-squared
 Not married 22 (17.7%)† 14 (66.7%) (16.0%) 7 (33.3%) (20.0%)    
 Married 77 (62.1%) 52 (67.5%) (59.0%) 25 (32.5%) (71.0%)    
  25 (20.2%) 22 (88.0%) (25.0%) 3 (12.0%) (9.0%)    
Smoking       0.73 Pearson’s chi-squared
 No 115 (92.7%)† 82 (71.9%) (93.0%) 32 (28.1%) (91.0%)    
 Yes 5 (4.0%) 4 (80.0%) (5.0%) 1 (20.0%) (3.0%)    
 Past smoker 2 (1.6%) 1 (50.0%) (1.0%) 1 (50.0%) (3.0%)    
  2 (1.6%) 1 (50.0%) (1.0%) 1 (50.0%) (3.0%)    
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†One person did not answer about their preference for self-sampling.

Abbreviations: IQR – Interquartile range; BMI – body mass index.

A statistically significant difference was observed in education level between those who preferred self-sampling and those who did not (p = 0.025). Women who chose self-sampling tended to be more highly educated (51%) compared to those who did not chose self-sampling (38%). Apart from education level, no substantial socio-demographic or clinical differences were observed between the two groups.

3.2. Patient knowledge and baseline perceptions regarding self-sampling

3.2.1. HPV knowledge

No significant differences were observed in HPV-related knowledge between women who preferred self-sampling and those who did not (p = 0.51). Overall, 52.4% of respondents were aware that cervical cancer is caused by HPV (Table 2).

Table 2.

Participants’ knowledge and baseline perceptions regarding self-sampling.

Domain Total (%) Does not prefer self-sampling (%) Prefer self-sampling (%) p value*
1. Did you know before participating in this study that cervical cancer is caused by the human papillomavirus (HPV), a sexually transmitted virus?       0.51
No 58 (46.8%) 39 (44%) 18 (51%)  
Yes 65 (52.4%) 48 (55%) 17 (49%)  
Missing data 1 (0.8%) 1 (1%) 0 (0%)  
2. Do you consider self-sampling a good solution for reaching more women who do not visit a doctor for cervical cancer screening?       0.42
No 18 (14.5%) 13 (15%) 5 (14%)  
Yes 63 (50.8%) 39 (44%) 24 (69%)  
I don’t know 43 (34.7%) 36 (41%) 6 (17%)  
3a. I believe that a sample collected by a doctor is better than a self-collected one.       0.016
No 8 (6.5%) 3 (3%) 5 (14%)  
Yes 94 (75.8%) 72 (82%) 22 (63%)  
I don’t know 22 (17.7%) 13 (15%) 8 (23%)  
3b. I think most women would choose self-sampling instead of visiting a doctor.       0.041
No 36 (29.0%) 28 (32%) 8 (23%)  
Yes 38 (30.6%) 21 (24%) 17 (49%)  
I don’t know 50 (40.3%) 39 (44%) 10 (29%)  
3c. Self-sampling is suitable for women who have not undergone cervical cancer screening.       0.045
No 20 (16.1%) 17 (19%) 3 (9%)  
Yes 61 (49.2%) 37 (42%) 24 (69%)  
I don’t know 43 (34.7%) 34 (39%) 8 (23%)  
4. I think most women would prefer the following self-sampling method (assuming self-sampling and doctor-collected samples have the same accuracy).       0.72
Self-collected vaginal swab 56 (45.2%) 35 (40%) 21 (60%)  
Self-collected urine sample 13 (10.5%) 8 (9%) 5 (14%)  
No preference 15 (12.1%) 11 (12%) 4 (11%)  
I don’t know 40 (32.3%) 34 (39%) 5 (14%)  
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*Pearson’s Chi-square test.

3.2.2. Baseline perceptions of self-sampling

Participants’ knowledge and baseline perceptions regarding self-sampling are reported in Table 2. The majority (50.8%) agreed that self-sampling is a good solution for reaching women who do not visit a doctor; however, there was no significant difference between preference groups (p = 0.42) (Table 2). Several factors were significantly associated with preference for self-sampling. Overall, 75.8% of participants believed that a sample collected by a doctor is better than a self-collected one. Women who believed that a doctor-collected sample is better were less likely to prefer self-sampling (63% vs. 82%, p = 0.016). Nearly one-third (30.6%) of participants thought that most women would choose self-sampling instead of visiting a doctor. Women who believed this were significantly more likely to prefer self-sampling themselves; 49% compared with 24% (p = 0.041). Additionally, 49.2% considered self-sampling suitable for women who have not previously undergone cervical cancer screening. This belief was held by 69% of women who preferred self-sampling versus 42% of those who did not (p = 0.045).

3.3. Self-sampling acceptance

Figure 2 illustrates a cross-association between examined variables. The acceptance of self-sampling is strongly associated with both Evalyn and BGI’s conveniences. Moreover, convenience scores of the two devices are also associated with each other (0.51).

BGI Sentis kit convenience scores were strongly associated with its ease of sample collection (0.65), ease compared to Pap-smear (0.56) and recommendation to friends/family (0.51). Evalyn’s convenience was strongly associated with unpleasantness of the procedure (0.53), its ease compared to Pap-smear (0.52) and ease of sample collection (0.50).

Table 3 shows participants’ experiences and acceptance of self-sampling. Overall, 28.2% of participants preferred self-sampling for their next cervical cancer screening, while 62.1% preferred gynaecologist-collected and 8.9% general practitioner-collected samples.

Table 3.

Participants’ acceptance and experience with self-sampling, stratified by preference for self-sampling.

Domain Value (%) Does not prefer self-sampling (%) Prefer self-sampling (%) p value*
Total 124 (100%) 88(71%) 35(28.2%)
5. Do you find the instructions for self-collecting a vaginal sample using the Rover’s Evalyn Brush clear?       0.19
No 8 (6.5%) 4 (5%) 4 (11%)  
Yes 111 (89.5%) 80 (91%) 31 (89%)  
I don’t know 5 (4.0%) 4 (5%) 0 (0%)  
6. Do you find the instructions for self-collecting a vaginal sample using the plastic brush for the BGI card clear?       0.69
No 6 (4.8%) 4 (5%) 2 (6%)  
Yes 104 (83.9%) 77 (88%) 27 (77%)  
I don’t know 14 (11.3%) 7 (8%) 6 (17%)  
7a. The sample collection was easy       0.012
Disagree 5 (4.0%) 5 (6%) 0 (0%)  
Somewhat agree 32 (25.8%) 28 (32%) 4 (11%)  
Agree 84 (67.7%) 53 (60%) 31 (89%)  
I don’t know 3 (2.4%) 2 (2%) 0 (0%)  
7b. I find this procedure unpleasant       0.062
Agree 12 (9.7%) 12 (14%) 0 (0%)  
Somewhat agree 32 (25.8%) 21 (24%) 11 (31%)  
Disagree 73 (58.9%) 50 (57%) 23 (66%)  
I have no opinion 7 (5.6%) 5 (6%) 1 (3%)  
7c. The sample collection was painful       0.97
Agree 6 (4.8%) 4 (5%) 2 (6%)  
Somewhat agree 14 (11.3%) 10 (11%) 4 (11%)  
Disagree 97 (78.2%) 69 (78%) 28 (80%)  
I have no opinion 7 (5.6%) 5 (6%) 1 (3%)  
7d. I think I collected the sample correctly       0.3
Disagree 6 (4.8%) 5 (6%) 1 (3%)  
Somewhat agree 52 (41.9%) 39 (44%) 13 (37%)  
Agree 54 (43.5%) 34 (39%) 20 (57%)  
I have no opinion 12 (9.7%) 10 (11%) 1 (3%)  
7e. I would recommend this procedure to my friends/family       0.04
Disagree 9 (7.3%) 9 (10%) 0 (0%)  
Somewhat agree 34 (27.4%) 25 (28%) 9 (26%)  
Agree 63 (50.8%) 38 (43%) 25 (71%)  
  18 (14.5%) 16 (18%) 1 (3%)  
7f. I find self-sampling with the Rover’s Evalyn Brush at home easier than the Pap smear because I don’t need to go to the doctor.       <0.001
Disagree 15 (12.1%) 13 (15%) 2 (6%)  
Somewhat agree 39 (31.5%) 37 (42%) 2 (6%)  
Agree 61 (49.2%) 31 (35%) 30 (86%)  
I have no opinion 9 (7.3%) 7 (8%) 1 (3%)  
8a. The sample collection was easy       0.077
Disagree 21 (16.9%) 19 (22%) 2 (6%)  
Somewhat agree 42 (33.9%) 30 (34%) 12 (34%)  
Agree 56 (45.2%) 36 (41%) 20 (57%)  
I have no opinion 5 (4.0%) 3 (3%) 1 (3%)  
8b. I find this procedure unpleasant       0.94
Agree 17 (13.7%) 12 (14%) 5 (14%)  
Somewhat agree 43 (34.7%) 32 (36%) 11 (31%)  
Disagree 53 (42.7%) 38 (43%) 15 (43%)  
I have no opinion 11 (8.9%) 6 (7%) 4 (11%)  
8c. The sample collection was painful       0.41
Agree 14 (11.3%) 8 (9%) 6 (17%)  
Somewhat agree 32 (25.8%) 23 (26%) 9 (26%)  
Disagree 71 (57.3%) 53 (60%) 18 (51%)  
I have no opinion 7 (5.6%) 4 (5%) 2 (6%)  
8d. I think I collected the sample correctly       0.036
Disagree 24 (19.4%) 18 (20%) 6 (17%)  
Somewhat agree 46 (37.1%) 37 (42%) 9 (26%)  
Agree 38 (30.6%) 21 (24%) 17 (49%)  
I have no opinion 16 (12.9%) 12 (14%) 3 (9%)  
8e. I would recommend this procedure to my friends/family       0.32
Disagree 23 (18.5%) 18 (20%) 5 (14%)  
Somewhat agree 40 (32.3%) 28 (32%) 12 (34%)  
Agree 43 (34.7%) 26 (30%) 17 (49%)  
I have no opinion 18 (14.5%) 16 (18%) 1 (3%)  
8f. I find self-sampling with the plastic brush for the BGI card at home easier than the Pap smear because I don’t need to go to the doctor.       0.011
Disagree 26 (21.0%) 21 (24%) 5 (14%)  
Somewhat agree 41 (33.1%) 33 (38%) 8 (23%)  
Agree 46 (37.1%) 25 (28%) 21 (60%)  
I have no opinion 11 (8.9%) 9 (10%) 1 (3%)  
10. Are you vaccinated against HPV?       0.85
No 97 (78.2%) 69 (78%) 27 (77%)  
Yes 8 (6.5%) 6 (7%) 2 (6%)  
I don’t know 19 (15.3%) 13 (15%) 6 (17%)  
11. Do you regularly undergo cervical cancer screening (i.e. once every 4 years)?       0.52
No 24 (19.4%) 16 (18%) 8 (23%)  
Yes 90 (72.6%) 66 (75%) 24 (69%)  
I don’t know 10 (8.1%) 6 (7%) 3 (9%)  
12. When was the last time you underwent cervical cancer screening (cytology tes)?       0.98
4 years ago 4 (3.2%) 3 (3%) 1 (3%)  
3 years ago 8 (6.5%) 6 (7%) 2 (6%)  
2 years ago 32 (25.8%) 22 (25%) 10 (29%)  
1 year ago 48 (38.7%) 33 (38%) 15 (43%)  
I do not remember 32 (25.8%) 24 (27%) 7 (20%)  
13. Do you know the result of your previous cervical cancer screening (cytology test)?       0.52
No 36 (29.0%) 27 (31%) 8 (23%)  
Yes 84 (67.7%) 60 (68%) 24 (69%)  
Missing data 4 (3.2%) 1 (1%)

  1. (9%)

  
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*Pearson’s Chi-square test.

The majority of women found the instructions for self-collecting a vaginal sample using either the Rover’s Evalyn Brush (89.5%) or the plastic brush for the BGI card (83.9%) clear, with no significant differences between women who preferred self-sampling and those who did not (p = 0.19 and p = 0.69, respectively).

Regarding the ease of use and discomfort, for the Evalyn Brush, 93.5% of participants agreed that sample collection was easy. Women who preferred self-sampling were significantly more likely to report ease of use compared with those who did not (89% vs. 60%, p = 0.012).

In contrast, only 45.2% found the BGI card easy to use, with no significant difference between preference groups (p = 0.077).

Most women did not find self-sampling unpleasant or painful. For the Evalyn Brush, 58.9% disagreed that the procedure was unpleasant, and 78.2% disagreed that it was painful; these perceptions did not differ significantly between preference groups (p = 0.062 and p = 0.97). Notably, none of the women who found the procedure unpleasant chose the self-sampling option. Similar patterns were observed for the BGI card, with 42.7% of participants disagreeing that the procedure was unpleasant and 57.3% disagreeing that it was painful, with no statistically significant differences between groups (p = 0.94 and p = 0.41, respectively).

Most participants expressed willingness to recommend self-sampling, especially the Evalyn Brush. For the Evalyn Brush, 78.2% (50.8% – ‘Agree’ and 27.4% – ‘Somewhat Agreed’) reported that they would recommend the method to friends or family. Women who preferred self-sampling were significantly more willing to recommend it (71% vs. 43%, p = 0.04). No significant difference was observed for the BGI card (p = 0.32), though 67% (34.7% – ‘Agree’ and 32.3% – ‘Somewhat Agreed’) of women were willing to recommend the kit.

Perceived convenience of home-based sampling showed strong associations with preference. For the Evalyn Brush, 80.7% (49.2% – ‘Agree’ and 31.5% – ‘Somewhat Agreed’) agreed that home-based self-sampling is easier than a Pap smear, with substantially higher agreement among women who preferred self-sampling (86% vs. 35%, p < 0.001). For the BGI Sentis card, 70.2% (37.1% – ‘Agree’ and 33.1% – ‘Somewhat Agreed’) shared this view, again with higher agreement among those preferring self-sampling (60% vs. 28%, p = 0.011).

3.4. Potential barriers to self-sampling

Potential barriers to self-sampling were evaluated by assessing participants’ perceptions of the instructions, ease, unpleasantness, pain, confidence in collecting the sample correctly and ease of performing the procedure at home. The differences were noted between the Rover’s Evalyn Brush and the BGI Sentis kit.

Most participants found the instructions for both self-sampling kits clear. For the Evalyn Brush, 6.5% reported unclear instructions, and 4.0% did not respond, while for the BGI plastic brush, 4.8% found the instructions unclear and 11.3% did not respond. No statistically significant differences in preference for self-sampling were observed based on instruction clarity.

A minority of participants reported difficulty performing the procedure. For the Evalyn Brush, 4% disagreed, and 25.8% somewhat agreed that the procedure was easy. Women who found the procedure difficult were less likely to prefer self-sampling: none (0/5) of those who disagreed and only 4/32 of those who somewhat agreed chose self-sampling (p = 0.012). For the BGI kit, 16.9% disagreed and 33.9% somewhat agreed, suggesting slightly higher perceived difficulty with the BGI kit. Only 2/21 (9.5%) of those who disagreed and 12/42 of those who somewhat agreed chose self-sampling (p = 0.077). Overall, the BGI kit was perceived as more difficult to use.

3.4.1. Unpleasantness and pain

Perceived discomfort varied by device (Table 4). With the Evalyn Brush, 9.7% found the procedure unpleasant and 25.8% somewhat unpleasant, while for the BGI card, 13.7% reported it as unpleasant and 34.7% somewhat unpleasant. Nearly half of participants expressed some degree of unpleasantness with the BGI kit. Preference for self-sampling was very low among those reporting unpleasantness: 0/12 (Evalyn) and 5/17 (BGI) who found the procedure unpleasant chose self-sampling. Differences were not statistically significant.

Table 4.

Comparative acceptability and user experience of Evalyn Brush and BGI Sentis.

Indicator Evalyn Brush (%) BGI Sentis (%)
Ease of use 67.7 45.2
Unpleasantness 9.7 13.7
Pain 4.8 11.3
Confidence in correct sampling 43.5 30.6
Ease at home vs. Pap smear 49.2 37.1
Willingness to recommend 50.8 34.7
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Pain during sample collection was uncommon for both kits. For the Evalyn Brush, 4.8% agreed it was painful and 11.3% somewhat agreed. For the BGI card, 11.3% agreed and 25.8% somewhat agreed, indicating slightly more participants experienced discomfort with the BGI card. Only 2/6 (Evalyn) and 6/14 (BGI) who perceived the procedure as painful later chose self-sampling. However, no significant differences were observed.

3.5. Patient preference

The Evalyn Brush was consistently rated more favourably than the BGI kit across nearly all measures of usability, comfort and acceptability. A higher proportion of participants agreed that sample collection was easy with the Evalyn Brush compared to the BGI kit (67.7% vs. 45.2%), and fewer women found the procedure unpleasant (9.7% vs. 13.7%) or painful (4.8% vs. 11.3%). Confidence in correct sample collection was also higher for the Evalyn Brush (43.5% vs. 30.6%), and participants were more willing to recommend it to family or friends (50.8% vs. 34.7%). Additionally, more women felt that performing the test at home using the Evalyn Brush was easier than visiting a doctor (49.2% vs. 37.1%). Taken together, these findings indicate that the Evalyn Brush demonstrated higher overall acceptability and patient preference compared to the BGI self-sampling kit.

Overall, participants expressed high satisfaction with both self-sampling devices; however, preference patterns and willingness to recommend differed between the Evalyn Brush and the BGI Sentis kits. Both devices were generally well-received, with recommendations influenced primarily by ease of use, confidence in collecting the sample correctly and positive perceptions of self-sampling. The Evalyn Brush tended to be favoured among younger and more highly educated participants, whereas the BGI Sentis kit was more often recommended by women with secondary or specialized secondary education. Positive attitudes toward self-sampling consistently predicted greater willingness to recommend both devices.

4. Discussion

Cervical cancer remains a significant public health problem worldwide and in Kazakhstan, largely due to insufficient screening coverage and limited participation in conventional cervical cancer screening programmes [2,20]. Barriers such as discomfort related to pelvic examination, lack of time to attend a clinic, cultural sensitivities and limited access to gynaecological services contribute to low screening uptake [3,23]. Self-sampling for HPV testing has emerged as a promising strategy to overcome these barriers by offering women a convenient, private and acceptable alternative to clinician-collected samples [3,30]. Therefore, the present study aimed to assess women’s acceptability and preferences regarding the self-sampling approach using two different devices, Evalyn Brush and BGI Sentis, to determine their potential for improving cervical cancer screening participation in Kazakhstan.

In this study, overall acceptance of the self-sampling approach, defined as women’s preference for self-collection over clinician collection for their next cervical cancer screening, was 28.2%, while device-specific acceptance, defined as willingness to recommend the kit to friends or family, was 50.8% for the Evalyn Brush and 34.7% for the BGI Sentis kit. When compared with the international research evidence, our overall acceptability level is substantially lower than the values typically reported [30,33]. Multiple studies have demonstrated that end users generally find HPV self-sampling highly acceptable, frequently prefer self-sampling over clinician-sampling for future screening, and express strong willingness to undergo self-sampling again. Across diverse populations, acceptability has commonly ranged between 50% and 98% [26,26,7,34–44]. Most studies also describe extremely positive user experiences, consistently noting high satisfaction, minimal discomfort and low embarrassment, which is in line with our findings. Overall, these findings contrast with the lower preference observed in our cohort, where, although attitudes toward usability and comfort were positive, relatively few women intended to adopt self-sampling for future screening. The findings suggest that contextual, cultural and population-specific factors may influence acceptance and require further investigation in a large-scale study.

The level of education (in particular the higher education) was significantly associated with preference for self-sampling in this study, reflecting previous evidence that awareness and health literacy influence uptake [41]. However, some other researchers reported no correlation between the level of education [39,42]. In our future nation-based study, further evaluation of the educational level on self-sampling modality acceptance will be assessed.

Device-specific comparisons further highlight these differences. In previous studies, willingness to use the Evalyn Brush for future screening ranged from approximately 86% to over 89%, and up to 87% of participants favoured home-based self-sampling using this device [27,38,45]. In contrast, in our study the Evalyn Brush reached a recommendation rate of 50.8%, although this reflects a different definition of acceptability than those used in prior work. Limited evidence exists for BGI Sentis, but one study reported that 65% of participants would use the kit again [31], which is higher than the 34.7% recommendation rate observed in our sample.

Although no direct comparison studies exist between the Evalyn Brush and the BGI Sentis kit, previous research consistently reports higher acceptability rates for the Evalyn Brush, whereas the BGI Sentis kit has demonstrated only moderate acceptability (65%). The higher acceptability observed for the Evalyn Brush relative to the BGI Sentis device aligns with previous findings indicating that the Evalyn Brush is generally well-received and associated with high user satisfaction and confidence.

In line with international research, our study found that limited confidence in performing the test correctly, perceived difficulty, discomfort and reduced convenience were key barriers to HPV self-sampling preference. Prior studies have highlighted concerns over the accuracy and quality of self-collected samples, doubts that results would be as reliable as clinician-collected specimens and fear of improper sampling [30,31,37,46–49]. Low confidence and technique uncertainty consistently reduce willingness for future self-sampling [33], and even widely accepted devices like the Evalyn Brush can leave some users unsure about proper use [50].

Additionally, convenience, particularly the perceived feasibility of collecting a sample at home, has been identified as a key determinant of future uptake [33,43], consistent with our observation that perceived home convenience had the strongest association with preference. Overall, our findings support existing literature showing confidence, device usability and misconceptions about sample reliability remain the major barriers to future adoption, reinforcing the need for enhanced user education and optimized device selection to improve acceptability and screening participation.

4.1. Study strengths and limitations

This study represents the first investigation in Kazakhstan to evaluate women’s acceptance of the self-sampling approach for cervical cancer screening and preferences toward a specific self-sampling device. The cross-sectional study design enabled systematic assessment of experiences and perceptions within a defined population, and the direct comparison of two available self-sampling kits (Evalyn Brush and BGI Sentis) provided valuable comparative insights relevant for national screening strategies. A major strength is the detailed assessment of device-specific experiences, including ease of use, discomfort, confidence in correct sampling and willingness to recommend, allowing a nuanced understanding of patient preferences. The study also integrates socio-demographic and perception-related variables, enabling identification of factors associated with preference for self-sampling. Overall, this study provides important baseline evidence for further nationwide large-scale study that aims to collect evidence for shaping future improvements to cervical cancer screening programme in Kazakhstan. However, the study was limited by its modest sample size, which may limit statistical power for subgroup analyses and reduce the precision of some estimates. Recruitment from selected clinical settings may affect generalizability to the wider population. Also, the study was conducted in a healthcare setting among women already presenting for screening or follow-up; therefore, findings may underestimate acceptability among underscreened women. To build upon these findings, a nationwide, large-scale study involving thousands of participants is planned to further evaluate self-sampling acceptance and feasibility and inform integration into Kazakhstan’s cervical cancer prevention programmes.

4.2. Clinical implications

Although only 28.2% of participants supported self-sampling in this study, the findings still highlight its potential value in expanding cervical cancer screening options in Kazakhstan. Among women who did opt for self-sampling, both devices, particularly the Evalyn Brush, were well-accepted and rated positively in terms of comfort and usability. This indicates that self-sampling can become an alternative for underscreened women once they are informed, motivated, and confident in performing the procedure. Integrating self-sampling into the national screening program, enrolling the screening non-attenders, could support Kazakhstan’s efforts to improve early detection of cervical cancer. This approach aligns with the WHO recommendations endorsing HPV self-sampling as a safe, effective strategy to expand screening participation.

5. Conclusion

Cervical cancer screening coverage remains suboptimal, and self-sampling has been proposed as a strategy to increase participation. In this study, overall acceptance of self-sampling approach for the screening was low, with only 28.2% of women choosing it for future screening. Despite this, two utilized self-sampling devices were generally well-accepted among Kazakhstani women, with usability, comfort and confidence in correct sample collection identified as the main determinants of preference. The Evalyn Brush demonstrated higher overall acceptability than the BGI Sentis kit, with participants reporting greater ease of use, lower discomfort, higher confidence in sampling and stronger willingness to recommend the procedure. These findings highlight that device design and perceived convenience are critical for successful adoption of self-sampling strategies, suggesting that the Evalyn Brush may be better suited to increase screening uptake in this population. Future large-scale studies covering different regions of Kazakhstan should be implemented for a more precise evaluation of the self-sampling devices acceptance. This will enable improving the current cervical cancer screening strategy and developing a novel more effective approach for cervical cancer prevention.

Supplementary Material

Supplementary file 2.docx
IANN_A_2645175_SM4700.docx (60.5KB, docx)
Supplementary file 1.docx
IANN_A_2645175_SM4699.docx (17.6KB, docx)

Funding Statement

This research has been funded by the Science Committee of the Ministry of Science and Higher Education of the Republic of Kazakhstan (Grant No. AP26194759, ‘Cervical Cancer Screening Using Self-sampling Approach: Validation of Human Papillomavirus Self-sampling Kits Among Kazakhstani Women’). Gulzhanat Aimagambetova is the PI of the project.

Disclosure statement

The authors have no conflict of interest to declare.

Data availability statement

The data related to this study are available on the Zenodo repository https://zenodo.org/records/18267740

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary file 2.docx
IANN_A_2645175_SM4700.docx (60.5KB, docx)
Supplementary file 1.docx
IANN_A_2645175_SM4699.docx (17.6KB, docx)

Data Availability Statement

The data related to this study are available on the Zenodo repository https://zenodo.org/records/18267740

Articles from Annals of Medicine are provided here courtesy of Taylor & Francis

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