Abstract
Background
Cervical cancer disparities exist among vulnerable populations, with over half of cases diagnosed in women who rarely or never screen. Emergency departments (EDs) may be an effective site to reach patients overdue for cancer screening, especially using human papillomavirus (HPV) self-sampling, where women use a swab to collect their own cervicovaginal sample. We surveyed women eligible for cervical cancer screening in three EDs to determine patient acceptability and preferences for HPV self-sampling in the ED to inform an ED-based prevention intervention.
Methods
This was a cross-sectional survey study of 30–65-year-old women presenting to three EDs in 2024 and 2025 with non-critical conditions, who spoke English or Spanish, and had no history of hysterectomy. Research assistants actively recruited in the ED using convenience sampling with interested patients. They provided brief education on how self-sampling is performed prior to conducting the survey.
Results
Of 359 women, 84% were somewhat or very willing to use a HPV self-sampling kit if offered in the ED, 91% were somewhat or very confident in their ability to collect their sample correctly, and 76% were somewhat or very comfortable using the self-sampling kit in an ED bathroom.
Over half (58%) would prefer to complete self-sampling rather than have collection completed by a physician or nurse. Participants in the oldest age group (60-65-year-olds) (OR = 3.11; 95% CI = 1.28,7.57) and participants with Medicaid (OR = 1.69; 95% CI = 0.95,3.03) were more willing to use self-sampling if it was offered compared to the youngest participants (30–39-year-olds) and those with private insurance, respectively. The most prevalent concerns of using the test were: that the test was not done right (47%) and not knowing how to perform the test (26%).
Conclusions
Our survey showed strong patient willingness, confidence, and comfort with HPV self-sampling in the ED, with over half of participants preferring self-sampling over traditional collection by a clinician. EDs interested in starting a HPV self-sampling program should consider ways to engage younger and non-Medicaid patients who were less willing to self-sample in the ED.
Concerns around not performing the test correctly highlight the need for clear instructions for self-sampling.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12889-026-28383-0.
Keywords: Cervical cancer screening, Emergency department, Human papillomavirus virus self-sampling, Patient acceptability
Background
Cervical cancer is one of the most common cancers among women globally [1]. Although screening for and treating pre-cancerous lesions has reduced incidence and mortality in the US [2], disparities persist for this preventable cancer. While several factors contribute to disparities, over half of cervical cancer cases are diagnosed among women who rarely or never screen [3, 4], with lower screening rates for racial/ethnic minority [5–8], low-income [9–11], and under-insured [9–12] women. Human papillomavirus (HPV) self-sampling, where women collect their own cervicovaginal sample, performs similarly to clinician-collected screening [13], effectively increases screening among under-screened women [14], and recently received US Food and Drug Administration (FDA) approval [15]. Compared to usual care, under-screened women report that self-sampling is more convenient, less embarrassing, and less stressful [16, 17]. Unfortunately, prior studies that have mailed HPV self-sampling kits to women with insurance coverage in large, integrated health systems have shown varied results, with 15% − 62% screened [18–20]. Alternative strategies for kit distribution are needed, especially for women who do not participate in routine primary care.
Emergency departments (EDs) often function in a safety net capacity for underserved patients [21] and thus can be a novel site to increase access to cancer screening. Prevention-based interventions in the ED have the potential to reach patients with disproportionate need [22] who may be open to education and enhanced connections with the health care system, particularly as they are a captive audience during the times in-between assessment, diagnostics, and treatment [23]. Prior ED-based prevention studies, such as universal diabetes screening [24, 25] and opt-out HIV testing [26], have proven feasible and successful to reach underserved populations who would not otherwise be screened. An optimal HPV self-sampling kit distribution strategy remains unknown [18, 19, 27], but ED-based, in-person distribution of self-sampling kits has the potential to alleviate issues identified in prior trials that mailed kits to women’s homes. Before developing and testing such a program, we surveyed women eligible for cervical cancer screening in three urban EDs to determine patient acceptability and preferences for HPV self-sampling in the ED to inform an ED-based prevention intervention.
Methods
This was a cross-sectional survey study of patients seen in three EDs in 2024 and 2025.
Sites included Robert Wood Johnson University Hospital (RWJUH) in New Brunswick, New Jersey (NJ), a Level I trauma center that sees 82,000 adult patients annually; University Hospital (UH) ED in Newark, NJ, a Level I trauma center and the only public medical center in NJ that treats 85,000 adults annually; and the University of Illinois Hospital and Health Sciences System (UI Health) ED in Chicago, Illinois (IL)- a level II trauma center with 34,000 adult patients annually.
Survey design
Survey questions included demographics, primary care access, cervical cancer screening history, willingness, confidence, and comfort of HPV self-sampling in the ED and preferences for HPV self-sampling modality (adapted from Montealegre et al. [28]). Prior to answering HPV self-sampling questions, the research assistant showed the participant a self-sampling swab (Copan FLOQSwab) and its instructional brochure, and offered a brief video on how to conduct self-sampling. Participants were told that all questions and preferences were hypothetical and that they would not be conducting actual self-sampling. The survey was available in English and Spanish (see English version in supplementary file).
Survey administration
The US Preventive Services Task Force [29], American Cancer Society [30], and professional associations like the American College of Obstetricians and Gynecologists (ACOG) and Society of Gynecologic Oncology (SGO) recommend primary HPV testing for women aged 30–65 years, partly due to the strong negative predictive value and fewer colposcopies [31]. As such, we surveyed 30–65-year-old women presenting to the ED with non-critical conditions, who spoke English or Spanish, and who had not had a hysterectomy. Research assistants (RAs) recruited in the ED using convenience sampling; they approached eligible patients during their recruitment shift, informed them about the study, and assessed eligibility. Informed consent to participate was obtained from all participants in the study. The RAs then conducted the survey with interested patients. The survey was housed in REDCap (Research Electronic Data Capture), a secure, web-based software platform designed to support data capture for research studies.
Most recruitment shifts were conducted during regular business hours. Several RAs were fluent in Spanish, aiding in communication with Spanish-speaking patients. Survey participants received a $15 physical gift card, which was distributed after survey completion. This study was reviewed and approved by the Institutional Review Boards of Rutgers University (Protocol #: Pro2024000440) and University of Illinois Chicago (Protocol #: STUDY2025-0299).
Statistical analysis
We characterized the overall sample and outcome variables of willingness, confidence, comfort, and preference for using HPV self-sampling in the ED with counts and frequencies.
Differences in demographic and medical characteristics for participants across sites were examined with chi-square tests. The outcome variables had three response choices- very, somewhat, and not. For willingness, participants were asked: If you were offered this test [HPV self-sampling] right now, how willing would you be to use it? For confidence, participants were asked: If the test were available right now, how confident would you be about doing the test correctly? For comfort, participants were asked: How comfortable would you feel using the self-collection kit in one of the restrooms of the ED? We conducted multivariable analysis using proportional odds models for outcomes of willingness, confidence, and comfort with HPV self-sampling in the ED while controlling for demographics, site, and overdue status. For the preference outcome, we conducted multivariable analysis using a binary logistic model (ED-based HPV self-sampling vs. traditional screening). For multivariable models, we used type 3 p-values for overall effect of covariates. Statistical analyses were conducted using SAS Version 9.4.
Results
Demographics
Across all sites, 359 women surveyed had at least one outcome question completed and were used in analysis (Table 1). Participants were 45.1 years on average (SD = 9.7); 40% identified as Black, 15% as Hispanic, and 57% had high school diploma or less education. 40% (40%) had private insurance, 34% had Medicaid, and 19% were uninsured. 30% (30%) did not have a primary care provider (PCP) and 21% were overdue for cervical cancer screening (i.e., last Pap > 3 years or Pap/HPV co-test > 5 years).
Table 1.
Participant characteristics by site (N = 359)
| Characteristic | Group | All | New Brunswick, NJ (n = 167) |
Chicago, IL (n = 96) |
Newark, NJ (n = 90) |
p-value |
|---|---|---|---|---|---|---|
| Age | 30 to 39 years | 123 (34.3%) | 60 (35.5%) | 30 (30.9%) | 33 (35.5%) | 0.15 |
| 40 to 49 years | 110 (30.6%) | 51 (30.2%) | 30 (30.9%) | 29 (31.2%) | ||
| 50 to 59 years | 85 (23.7%) | 44 (26.0%) | 20 (20.6%) | 21 (22.6%) | ||
| 60 to 65 years | 35 (9.7%) | 12 (7.1%) | 16 (16.5%) | 7 (7.5%) | ||
| Education Level | Some high school | 46 (12.8%) | 16 (9.5%) | 12 (12.4%) | 18 (19.4%) | 0.42 |
| High school degree/ trade school | 160 (44.6%) | 62 (36.7%) | 53 (54.6%) | 45 (48.4%) | ||
| College degree | 112 (31.2%) | 61 (36.1%) | 25 (25.8%) | 26 (28.0%) | ||
| Masters degree or higher | 38 (10.6%) | 27 (16.0%) | 7 (7.2%) | 4 (4.3%) | ||
| Insurance | Medicaid | 122 (34.0%) | 35 (20.7%) | 49 (50.5%) | 38 (40.9%) | 0.36 |
| Medicare | 26 (7.2%) | 7 (4.1%) | 13 (13.4%) | 6 (6.5%) | ||
| No Insurance | 68 (18.9%) | 31 (18.3%) | 6 (6.2%) | 31 (33.3%) | ||
| Private Insurance | 143 (39.8%) | 96 (56.8%) | 29 (29.9%) | 18 (19.4%) | ||
| Language | English | 294 (81.9%) | 136 (80.5%) | 95 (97.9%) | 63 (67.7%) | < 0.0001 |
| Spanish | 65 (18.1%) | 33 (19.5%) | 2 (2.1%) | 30 (32.3%) | ||
| Race/Ethnicity | Black or African American | 144 (40.1%) | 36 (21.3%) | 63 (64.9%) | 45 (48.4%) | < 0.0001 |
| Hispanic or Latino | 54 (15.0%) | 24 (14.2%) | 0 (0.0%) | 30 (32.3%) | ||
| White | 95 (26.5%) | 61 (36.1%) | 30 (30.9%) | 4 (4.3%) | ||
| More Than One Race | 25 (7.0%) | 22 (13.0%) | 1 (1.0%) | 2 (2.2%) | ||
| Other | 31 (8.6%) | 22 (13.0%) | 3 (3.1%) | 6 (6.5%) | ||
| Primary Care Provider | No | 106 (29.5%) | 47 (27.8%) | 18 (18.6%) | 41 (44.1%) | 0.0001 |
| Yes | 251 (69.9%) | 122 (72.2%) | 79 (81.4%) | 50 (53.8%) | ||
| Cervical Cancer Screening Status | Overdue | 74 (20.6%) | 31 (18.3%) | 16 (16.5%) | 27 (29.0%) | 0.034 |
| Up to Date | 285 (79.4%) | 138 (81.7%) | 81 (83.5%) | 66 (71.0%) |
Education level, insurance type, language, race/ethnicity, and having a primary care physician differed by study site. The NJ sites had more participants who spoke Spanish than Chicago (p < 0.0001) and higher proportions of Hispanic participants whereas Chicago had more Black participants (p < 0.0001). More Newark participants had no primary care provider (p = 0.0001) and were overdue for cervical cancer screening (p = 0.034) than the other sites.
Acceptability of HPV self-sampling in the ED
Overall, most participants (84%) were somewhat or very willing to use a HPV self-sampling kit if it was offered while in the ED, and 91% were somewhat or very confident in their ability to collect their sample correctly (Fig. 1). Most participants (76%) said they were somewhat or very comfortable using the self-sampling kit in an ED bathroom. Of the rest who were not comfortable, open-ended responses found that 38% cited lack of bathroom cleanliness, 12% worried about doing the doing the test correctly, and 9% preferred testing at home (more clean, comfortable, and private). When given the choice, 58% of women would prefer to complete HPV self-sampling and 42% preferred traditional screening by a physician or nurse.
Fig. 1.
HPV self-sampling perceptions of survey participants
When given a list of five common concerns of using the test kit, 43% of participants had no concerns, 31% had one concern, and 26% had two or more concerns. Among those who endorsed a concern, the most prevalent concerns were that the test was not done right (47%) and not knowing how to perform the test (26%). Open-ended responses found the most common additional concerns to be physical or vision limitations (n = 6) and concern about the test accuracy or validity (n = 6).
Multivariable analysis of HPV self-sampling acceptability by patient characteristics (Table 2) used proportional odds ratio models for comfort, confidence, and willingness outcomes and logistic model for preference. Willingness significantly differed by insurance status.
Table 2.
Multivariable models for acceptability of HPV self-sampling in the ED by participant characteristics
| Characteristic | Group | Willingness | Confidence | Comfort | Preference | ||||
|---|---|---|---|---|---|---|---|---|---|
| Adjusted OR (95% CI) | p-valuea | Adjusted OR (95% CI) | p-valuea | Adjusted OR (95% CI) | p-valuea | Adjusted OR (95% CI) | p-valuea | ||
|
Age (Reference = 30 to 39 years) |
40 to 49 years | 1.30 (0.75,2.23) | 0.090 | 1.04 (0.60,1.81) | 0.24 | 0.71 (0.41,1.22) | 0.45 | 1.23 (0.70,2.18) | 0.77 |
| 50 to 59 years | 1.40 (0.78,2.51) | 1.50 (0.81,2.79) | 1.12 (0.62,2.01) | 1.37 (0.74,2.53) | |||||
| 60 to 65 years | 3.11 (1.28,7.57) | 2.18 (0.89,5.33) | 0.88 (0.39,1.95) | 1.25 (0.55,2.83) | |||||
|
Education Level (Reference = Some high school) |
High school degree/ trade school | 0.60 (0.28,1.27) | 0.29 | 0.83 (0.39,1.76) | 0.41 | 1.26 (0.62,2.57) | 0.91 | 1.69 (0.81,3.57) | 0.50 |
| College degree | 0.86 (0.38,1.93) | 1.32 (0.59,3.00) | 1.08 (0.51,2.33) | 1.47 (0.66,3.29) | |||||
| Masters degree or higher | 0.52 (0.20,1.39) | 0.87 (0.32,2.35) | 1.17 (0.45,3.00) | 1.96 (0.71,5.45) | |||||
|
Insurance (Reference = Private) |
Medicaid | 1.69 (0.95,3.03) | 0.036 | 1.12 (0.62,2.02) | 0.52 | 1.07 (0.61,1.90) | 0.22 | 0.73 (0.41,1.32) | 0.78 |
| Medicare | 0.58 (0.24,1.40) | 0.73 (0.29,1.85) | 0.55 (0.22,1.37) |
0.82 (0.32,2.08) |
|||||
| No Insurance | 0.76 (0.36,1.62) | 1.60 (0.72,3.56) | 1.68 (0.79,3.58) | 0.87 (0.39,1.92) | |||||
|
Language (Reference = English) |
Spanish | 1.17 (0.51,2.71) | 0.71 | 0.73 (0.31,1.72) | 0.47 | 0.87 (0.39,1.97) | 0.75 | 0.45 (0.19,1.11) | 0.084 |
|
Race/ Ethnicity (Reference = White) |
Black or African American | 1.34 (0.73,2.48) | 0.13 | 1.36 (0.73,2.56) | 0.85 | 0.88 (0.48,1.61) | 0.28 | 0.61 (0.33,1.14) | 0.41 |
| Hispanic or Latino | 0.81 (0.34,1.92) | 1.17 (0.48,2.87) | 0.49 (0.21,1.15) | 1.32 (0.50,3.48) | |||||
| More Than One Race | 1.35 (0.51,3.62) | 1.00 (0.38,2.63) | 0.57 (0.23,1.42) | 0.88 (0.32,2.47) | |||||
| Other | 0.46 (0.20,1.07) | 1.51 (0.59,3.89) | 1.43 (0.58,3.48) | 1.07 (0.41,2.79) | |||||
|
Primary Care Provider (Reference = No) |
Yes | 1.19 (0.70,2.00) | 0.52 | 1.15 (0.67,1.97) | 0.62 | 1.17 (0.70,1.96) | 0.56 | 1.17 (0.68,2.00) | 0.58 |
|
Cervical Cancer Screening Status (Reference = Not Overdue) |
Overdue | 1.02 (0.57,1.81) | 0.95 | 1.09 (0.60,1.98) | 0.78 | 0.64 (0.37,1.12) | 0.12 | 1.07 (0.59,1.94) | 0.83 |
|
Site (Reference = New Brunswick, NJ) |
Chicago, IL | 0.59 (0.32,1.07) | 0.19 | 1.18 (0.63,2.19) | 0.51 | 3.17 (1.69,5.94) | 0.0001 | 0.51 (0.28,0.94) | 0.096 |
| Newark, NJ | 0.68 (0.36,1.29) | 0.78 (0.41,1.50) | 0.79 (0.44,1.44) | 0.74 (0.39,1.43) | |||||
aType 3 P-Values For Overall Effect Of Covariates
Compared to those with private insurance, those with Medicaid had higher odds of being more willing to use the kit (OR = 1.69; 95% CI = 0.95,3.03). Age trended towards significance with the oldest age group (60-65-year-olds) having higher odds of being more willing to use the kit (OR = 3.11; 95% CI = 1.28,7.57). There were no significant predictors of confidence to correctly use the test kit. Hospital site was highly significant for comfort, with those from Chicago having increased odds of being more comfortable doing an HPV self-sampling test (OR = 3.17; 95%.
CI = 1.69,5.94). Site was also significant for preference with those from Chicago having lower odds of preferring HPV self-sampling versus traditional screening compared to participants at New Brunswick (OR = 0.51; 95% CI = 0.28,0.94). Language was marginally significant for preference with Spanish-speaking participants having lower odds of preferring HPV self-sampling compared to English-speaking (OR = 0.45; 95% CI = 0.19,1.11). Across all outcomes, there were no significant differences for education level, race/ethnicity, having a primary care provider, or screening status. Because the proportional odds assumption was violated in some cases, we conducted sensitivity analyses using binary logistic models for comfort, confidence, and willingness. Specifically, we collapsed somewhat and not into one category and compared it to very. Findings mirrored those found in the proportional odds model (results not shown).
Discussion
Our survey showed strong patient acceptability of HPV self-sampling in the ED. Most participants were willing to use a HPV self-sampling kit if it was offered while in the ED, were confident in their ability to collect their sample correctly and were comfortable using the kit in an ED bathroom. Over half of women would prefer to complete HPV self-sampling rather than traditional screening by a physician or nurse.
We found 84% of our sample from three EDs was willing to use the kit. This finding is mirrored by other studies that have investigated patient acceptability of HPV self-sampling in the ED. For example, one study prior to FDA approval of HPV self-sampling found high willingness (87%) among ED patients, but lower comfort using self-sampling in the ED (58%) [28]. This pattern of slightly lower comfort was similar to our findings, where 76% of our participants were comfortable using the self-sampling kit in an ED bathroom. A smaller (N = 38), more recent study in one ED also found high willingness to self-sample in an ED bathroom (76%), with Hispanic participants more willing than non-Hispanic using bivariate analysis [32]. We did not observe differences by race/ethnicity, though Spanish-speaking participants were marginally less likely to prefer HPV self-sampling than English-speaking. This may be due to perceptions of changes in care quality or provider encounters [33]. Additional cultural tailoring for intervention materials may be warranted. We also found differences in participant comfort and preference for doing an HPV self-sampling test by hospital site, which suggests the collection setting is important [34]. In the ED specifically, facility-level differences in bathroom location, cleanliness, or privacy may influence uptake and take-home options may encourage participation by allowing women a more comfortable and private setting.
Importantly, we did find differences in willingness by insurance type and age. Results indicated participants with Medicaid and older participants were more willing to use the test. In contrast to self-sampling studies [16, 35] among insured populations or part of integrated health systems, our sample included women without health care connections: approximately 19% uninsured women and 30% without a PCP. More comprehensive interventions may be needed for uninsured women as they were less willing to self-sample in the ED. Others have found low traditional screening trends among younger [36] and older [37] women, which may influence willingness to self-sample. Still, these findings suggest targeted messaging to increase awareness and make self-sampling more appealing to those in their thirties are warranted.
We also found 90% of the sample was confident in using the kit correctly, and no significant demographic differences in multivariable analysis. This may be due to our participants viewing a video and written instructions before completing the survey. Although over 40% reported no concerns about using the kit, some worried about the test being done right, which is consistent with US and global trends [38]. This underscores the need for clear instructions and opportunities to provide tailored support to women before or during kit use [39, 40].
Our study had several limitations. First, our survey asked about hypothetical HPV self-sampling use, so self-sampling behaviors can only be speculated. Second, in January 2026, the Health Resources and Services Administration (HRSA) announced guidelines that most insurance plans must cover costs for primary HPV self-sampling starting in January 2027 [41].
Surveys were collected prior to this announcement, and providing cost information may affect differences in patient willingness going forward. Third, there was varying staffing capacity across sites for recruiting Spanish-speaking patients, which resulted in differences across sites.
Moreover, the use of convenience sampling may affect the representativeness of the sample.
Nevertheless, the distribution of the sample was generally consistent with the demographic distribution of the ED sites.
While our findings of high patient acceptability and willingness are encouraging, it is important to note that follow-up management is vital to successful screening programs for underserved populations, especially those in the ED for which patients may not have a primary care physician. Patient navigation may be particularly helpful as it reduces time from abnormal screening to diagnosis and improves patient satisfaction with care [42–44], though contextually appropriate strategies are needed [45, 46]. As such, HPV self-sampling in the ED requires workflows with strong linkage to follow-up care as a core component. Additional research is needed to ensure that women who screen HPV-positive after self-sampling outside of traditional settings are able to obtain timely follow-up care.
Our study is the first to examine willingness among the ED population using multivariable analysis. Acceptability can be complex, so by controlling for potential confounders, our results provide robust findings on which factors may affect patient acceptability. EDs across the country vary in a variety of factors, including patient population, resources, and size, highlighting the importance of future multi-site studies for HPV self-sampling to improve generalizability of findings.
Conclusions
These findings of high patient willingness, confidence, and comfort are promising, but suggest some sub-groups may benefit from additional screening messaging and instructions for self-sampling are important components to increase uptake. Facility-level differences by hospital are also key contextual factors to consider for successful implementation. Our next step is to conduct a multi-site pilot trial implementing HPV self-sampling kit distribution in EDs to improve cervical cancer screening access.
Supplementary Information
Acknowledgements
The authors thank the research assistants who contributed to data collection, especially Mohamed Aly, Zach Brahmbhatt, Emma Bridgeman, Camille Grullon, Bernadine Guimary, Yugledys Hoyos, Eileen Hsieh, Sophia Kics, Neha Maddali, Zain Mughal, Giana Oelkers, Yash Pathak, Josefina Sofia, Rufine Kendra Soh, and Chris Stark.
Authors' contributions
SH, RK: Study concept and oversight. SH: Led manuscript writing. SH, RK, JL, AM and CM: Funding acquisition. PO: Data analysis. SH, RS, RI, CM, AM and SK: Oversight of data acquisition. All authors: Study design, interpretation of the data, drafting of the manuscript, critical revision of the manuscript for important intellectual content.
Funding
Funding for this project came from LHS STAR NJ (P30HS029759)- an affiliate program of NJ ACTS (UM1TR004789)- and a University of Illinois Chicago College of Medicine Thematic Grant Award. RK was supported by National Cancer Institute/National Institutes of Health (K22 CA258675).
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was reviewed and approved by the Institutional Review Boards of Rutgers University (Protocol #: Pro2024000440) and University of Illinois Chicago (Protocol #: STUDY2025-0299). Informed consent to participate was obtained from all participants in the study. Signed documentation of consent was waived, and participants reviewed an electronic information letter about the study prior to starting the survey. The study was conducted in accordance with the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. Cancer J Clin. 2024;74(3):229–63. [DOI] [PubMed] [Google Scholar]
- 2.Islami F, Fedewa SA, Jemal A. Trends in cervical cancer incidence rates by age, race/ethnicity, histological subtype, and stage at diagnosis in the United States. Prev Med. 2019;123:316–23. [DOI] [PubMed] [Google Scholar]
- 3.Pruitt SL, Werner CL, Borton EK, Sanders JM, Balasubramanian BA, Barnes A et al. Cervical Cancer Burden and Opportunities for Prevention in a Safety-Net Healthcare system. Cancer Epidemiol Biomarkers Prev. 2018;27(12):1398–406. [DOI] [PMC free article] [PubMed]
- 4.Benard VB, Jackson JE, Greek A, Senkomago V, Huh WK, Thomas CC, et al. A population study of screening history and diagnostic outcomes of women with invasive cervical cancer. Cancer Med. 2021;10(12):4127–37. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.McDaniel CC, Hallam HH, Cadwallader T, Lee HY, Chou C. Persistent racial disparities in cervical cancer screening with Pap test. Prev Med Rep. 2021;24:101652. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Spencer JC, Kim JJ, Tiro JA, Feldman SJ, Kobrin SC, Skinner CS, et al. Racial and ethnic disparities in cervical cancer screening from three U.S. Healthcare settings. Am J Prev Med. 2023;65(4):667–77. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Sokale IO, Montealegre JR, Oluyomi AO, Thrift AP. Trends and racial/ethnic differences in predictors of cervical cancer screening among US women ages 30–64 years. Cancer epidemiology, biomarkers & prevention: a publication of the American Association for Cancer Research. cosponsored Am Soc Prev Oncol. 2023;32(1):82–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Datta GD, Pana MP, Mayrand MH, Glenn B. Racial/ethnic inequalities in cervical cancer screening in the United States: an outcome reclassification to better inform interventions and benchmarks. Prev Med. 2022;159:107055. [DOI] [PubMed] [Google Scholar]
- 9.Benavidez GA, Zgodic A, Zahnd WE, Eberth JM. Disparities in meeting USPSTF breast, cervical, and colorectal cancer screening guidelines among women in the United States. Prev Chronic Dis. 2021;18:E37. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Hall IJ, Tangka FKL, Sabatino SA, Thompson TD, Graubard BI, Breen N. Patterns and trends in cancer screening in the United States. Prev Chronic Dis. 2018;15:E97. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Moss JL, Geyer NR, Lengerich EJ. Patterns of cancer-related healthcare access across pennsylvania: analysis of novel census tract-level indicators of persistent poverty. Cancer Epidemiol biomarkers prevention: publication Am Association Cancer Res cosponsored Am Soc Prev Oncol. 2024;33(4):616–23. [DOI] [PubMed] [Google Scholar]
- 12.Kaiser Family Foundation. Many women use preventive services, but gaps in awareness of insurance coverage requirements persist: findings from the 2022 KFF Women’s Health Survey San Francisco. 2023. Available from: https://www.kff.org/permissions-citations-reprints/.
- 13.Arbyn M, Verdoodt F, Snijders PJ, Verhoef VM, Suonio E, Dillner L, et al. Accuracy of human papillomavirus testing on self-collected versus clinician-collected samples: a meta-analysis. Lancet Oncol. 2014;15(2):172–83. [DOI] [PubMed] [Google Scholar]
- 14.Arbyn M, Smith SB, Temin S, Sultana F, Castle P. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. BMJ (Clinical Res ed). 2018;363:k4823. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Approves FDA. HPV Tests That Allow for Self-Collection in a Health Care Setting [press release]. Atlanta, Georgia: National Cancer Institute; 2024. [Google Scholar]
- 16.Parker SL, Amboree TL, Bulsara S, Daheri M, Anderson ML, Hilsenbeck SG, et al. Self-sampling for human papillomavirus testing: acceptability in a U.S. safety net health system. Am J Prev Med. 2024;66(3):540–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Smith JS, Des Marais AC, Deal AM, Richman AR, Perez-Heydrich C, Yen-Lieberman B, et al. Mailed human papillomavirus self-collection with papanicolaou test referral for infrequently screened women in the United States. Sex Transm Dis. 2018;45(1):42–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Winer RL, Lin J, Anderson ML, Tiro JA, Green BB, Gao H, et al. Strategies to increase cervical cancer screening with mailed human papillomavirus self-sampling kits: a randomized clinical trial. JAMA. 2023;330(20):1971–81. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Winer RL, Lin J, Tiro JA, Miglioretti DL, Beatty T, Gao H, et al. Effect of mailed human papillomavirus test kits vs usual care reminders on cervical cancer screening uptake, precancer detection, and treatment: a randomized clinical trial. JAMA Netw Open. 2019;2(11):e1914729–e. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Reiter PL, Shoben AB, Cooper S, Ashcraft AM, McKim Mitchell EM, Dignan, et al. A mail-based HPV self-collection program to increase cervical cancer screening in appalachia: results of a group randomized trial. Cancer Epidemiol biomarkers prevention: publication Am Association Cancer Res cosponsored Am Soc Prev Oncol. 2025;34(1):159–65. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Ohaiba MM, Anamazobi EG, Okobi OE, Aguda K, Chukwu VU. Trends and patterns in emergency department visits: a comprehensive analysis of adult data from the National Center for Health Statistics (NCHS) Database. Cureus. 2024;16(8):e66059. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Vogel JA, Rising KL, Jones J, Bowden ML, Ginde AA, Havranek EP. Reasons patients choose the emergency department over primary care: a qualitative metasynthesis. J Gen Intern Med. 2019;34(11):2610–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Bouda Abdulai AS, Mukhtar F, Ehrlich M. United States’ performance on emergency department throughput, 2006 to 2016. Ann Emerg Med. 2021;78(1):174–90. [DOI] [PubMed] [Google Scholar]
- 24.Lee DC, Reddy H, Koziatek CA, Klein N, Chitnis A, Creary K, et al. Expanding diabetes screening to identify undiagnosed cases among emergency department patients. West J Emerg Med. 2023;24(5):962–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Danielson KK, Rydzon B, Nicosia M, Maheswaren A, Eisenberg Y, Lin J, et al. Prevalence of undiagnosed diabetes identified by a novel electronic medical record diabetes screening program in an urban emergency department in the US. JAMA Netw Open. 2023;6(1):e2253275. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Lin J, Mauntel-Medici C, Heinert S, Baghikar S. Harnessing the power of the electronic medical record to facilitate an Opt-Out HIV screening program in an urban academic emergency department. J Public Health Manag Pract. 2017;23(3):264–8. [DOI] [PubMed] [Google Scholar]
- 27.Pretsch PK, Spees LP, Brewer NT, Hudgens MG, Sanusi B, Rohner E, et al. Effect of HPV self-collection kits on cervical cancer screening uptake among under-screened women from low-income US backgrounds (MBMT-3): a phase 3, open-label, randomised controlled trial. Lancet Public health. 2023;8(6):e411–21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Montealegre JR, Landgren RM, Anderson ML, Hoxhaj S, Williams S, Robinson DJ, et al. Acceptability of self-sample human papillomavirus testing among medically underserved women visiting the emergency department. Gynecol Oncol. 2015;138(2):317–22. [DOI] [PubMed] [Google Scholar]
- 29.Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, et al. Screening for cervical cancer: US preventive services task force recommendation statement. JAMA. 2018;320(7):674–86. [DOI] [PubMed] [Google Scholar]
- 30.Fontham ETH, Wolf AMD, Church TR, Etzioni R, Flowers CR, Herzig A, et al. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. Cancer J Clin. 2020;70(5):321–46. [DOI] [PubMed] [Google Scholar]
- 31.Einstein MH, Zhou N, Gabor L, Sahasrabuddhe VV. Primary human papillomavirus testing and other new technologies for cervical cancer screening. Obstet Gynecol. 2023;142(5):1036-43. [DOI] [PubMed]
- 32.Ashji G, Sagastume E, Wood N, Adler D, Abar B. Acceptability of hrHPV self-sampling intervention through the emergency department. Am J Emerg Med. 2025;93:218–9. [DOI] [PubMed] [Google Scholar]
- 33.Stoltzfus KC, Popalis ML, Reiter PL, Moss JL. Perspectives on self-sampling for cancer screening among rural and urban women: multilevel factors related to acceptability. J Rural Health. 2022;38(2):391–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Fullerton MM, Ford C, D’Silva C, Chiang B, Onobrakpor SI, Dievert H, et al. HPV self-sampling implementation strategies to engage under screened communities in cervical cancer screening: a scoping review to inform screening programs. Front public health. 2024;12:1430968. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Purdy NL, Katz ML, Reiter PL. Women’s acceptability of HPV self-collection in a healthcare setting following FDA approval in the United States. Women Health. 2025;65(7):606–17. [DOI] [PubMed] [Google Scholar]
- 36.Suk R, Hong YR, Rajan SS, Xie Z, Zhu Y, Spencer JC. Assessment of US preventive services task force guideline-concordant cervical cancer screening rates and reasons for underscreening by age, race and ethnicity, sexual orientation, rurality, and insurance, 2005 to 2019. JAMA Netw Open. 2022;5(1):e2143582. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Sokale IO, Montealegre JR, Oluyomi AO, Thrift AP. Trends and racial/ethnic differences in predictors of cervical cancer screening among us women ages 30–64 years. Cancer Epidemiol Biomarkers Prev. 2023;32(1):82–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Nishimura H, Yeh PT, Oguntade H, Kennedy CE, Narasimhan M. HPV self-sampling for cervical cancer screening: a systematic review of values and preferences. BMJ Glob Health. 2021;6(5):e003743. [DOI] [PMC free article] [PubMed]
- 39.Kobetz E, Seay J, Koru-Sengul T, Bispo JB, Trevil D, Gonzalez M, et al. A randomized trial of mailed HPV self-sampling for cervical cancer screening among ethnic minority women in South Florida. Cancer Causes Control. 2018;29(9):793–801. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Marshall S, Vahabi M, Lofters A. Acceptability, feasibility and uptake of HPV self-sampling among immigrant minority women: a focused literature review. J Immigr Minor Health. 2019;21(6):1380–93. [DOI] [PubMed] [Google Scholar]
- 41.Health Resources and Services Administration. Women’s Preventive Services Guidelines [May 6, 2026]. Available from: https://www.hrsa.gov/womens-guidelines
- 42.Chan RJ, Milch VE, Crawford-Williams F, Agbejule OA, Joseph R, Johal J, et al. Patient navigation across the cancer care continuum: an overview of systematic reviews and emerging literature. Cancer J Clin. 2023;73(6):565–89. [DOI] [PubMed] [Google Scholar]
- 43.Bernardo BM, Zhang X, Beverly Hery CM, Meadows RJ, Paskett ED. The efficacy and cost-effectiveness of patient navigation programs across the cancer continuum: a systematic review. Cancer. 2019;125(16):2747–61. [DOI] [PubMed] [Google Scholar]
- 44.Nelson HD, Cantor A, Wagner J, Jungbauer R, Fu R, Kondo K, et al. Effectiveness of patient navigation to increase cancer screening in populations adversely affected by health disparities: a meta-analysis. J Gen Intern Med. 2020;35(10):3026–35. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Ma GX, Zhu L, Zhai S, Lin TR, Tan Y, Johnson C, et al. Empowering low-income asian american women to conduct human papillomavirus self-sampling test: a community-engaged and culturally tailored intervention. Cancer Control. 2022;29:10732748221076813. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Elmore CE, Laughon K, Mitchell EM. Self-collection of samples for HPV testing to increase participation in cervical cancer screening by immigrant women: an integrative review. Public Health Nurs. 2020;37(5):677–95. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.