Perspectives on self-sampling for cancer screening among rural and urban women: Multilevel factors related to acceptability

Abstract

Purpose.

Self-sampling tests may be used to overcome barriers to screening that are more prevalent in rural populations compared to urban populations. This study aims to qualitatively examine the attitudes towards established and novel self-sampling tests for cervical and colorectal cancer among women, comparing themes from rural versus urban areas.

Methods.

We recruited women (ages 45-65) from 28 counties in Pennsylvania. Four focus groups were conducted with women from metropolitan counties, and 7 focus groups were conducted with women from non-metropolitan counties. A brief survey was conducted prior to the focus group regarding general health and willingness to complete self-sampling tests for cervical and colorectal cancer.

Findings.

We identified three themes about the potential for self-sampling for cancer screening: advantages and disadvantages of self-sampling compared to traditional testing, impact of self-sampling on patient interactions with their health care providers/clinics, and implications for improving/worsening access to quality health care services. We detected differences in responses from rural versus urban participants in the potential impact of self-sampling for cancer screening.

Conclusions.

There are several barriers and facilitators at the individual, interpersonal, and organizational levels that influence the feasibility of implementing self-sampling for cancer screening in routine clinical practice. Rural participants face unique barriers to cancer screening across all levels. These findings can be used to guide interventions aimed at increasing the use of self-sampling methods.

In 2020 in the United States, an estimated 4,290 women died from cervical cancer, and another 24,570 are estimated to have died from colorectal cancer.¹ A large percentage of these cancer deaths are preventable through routine screenings, which can detect both pre-cancerous cells and early-stage cancer, accompanied by appropriate follow-up care.^2,3 Individuals from rural areas are disproportionately affected by cancer, with higher incidence and mortality rates observed for both cervical and colorectal cancer in rural areas compared to urban areas.⁴ Cancer screening is also less prevalent in rural areas, further highlighting the need to address geographic disparities to improve cancer outcomes among all US women.^5,6

Leveraging different screening modalities and venues can increase uptake in all populations, providing patients with an option that best suits their lifestyle. This is especially true in rural areas that are unequally affected by the cancer burden. For colorectal cancer, these modalities include clinician-performed visualization tests (colonoscopy and sigmoidoscopy) and established self-sampling tests (stool tests).⁷ For cervical cancer, this includes clinician-sampled tests (Pap and human papillomavirus [HPV] test) and novel self-sampling tests for HPV.⁸

Self-sampling tests have high accuracy and are comparable to clinician-collected screening options.^9,10 In particular, the United States Preventive Services Task Force has determined that the risks and benefits of self-sampled stool testing are equivalent to colonoscopies for colorectal cancer screening.⁷ Additionally, the tests are more private and reduce the time burden for the patient. Self-sampling tests are highly acceptable among women in both rural and urban areas.¹¹ These tests may also be used to overcome barriers to screening that may be more prevalent in rural populations, such as lack of available specialists and greater required travel distance¹²; thus, self-sampling provides a promising strategy for increasing cancer screening in these rural populations with the largest cancer burden.

This study aimed to qualitatively examine the attitudes towards established and novel self-sampling tests among women in Pennsylvania, comparing themes from rural versus urban areas. Qualitative data collected through focus groups include participants’ reflections about the advantages and disadvantages of self-sampling tests, as well as their lived experience of the cancer screening process. We expected these reflections to differ based on rurality. These findings can be used to inform future efforts to increase uptake of cancer screening, particularly through the use of self-sampling tests.

Materials and Methods

Participant recruitment and procedures

Because of the disparities in cancer burden and screening by place of residence, we stratified recruitment by metropolitan status, according to the 2010 United States Department of Agriculture’s (USDA) rural-urban continuum codes (RUCC).¹³ We held separate focus groups for participants from Pennsylvania counties that were classified as metropolitan (or “urban,” i.e., with RUCC of 1-3) versus non-metropolitan (or “rural,” i.e., with RUCC of 4-9). We focused recruitment on 28 counties in central Pennsylvania that comprise the Penn State Cancer Institute catchment area; however, because of our interest in cancer screening in non-metropolitan areas, we also expanded recruitment for these focus groups to other non-metropolitan counties in the state.

Primarily, we recruited participants by advertising on local social media pages for general interest topics. In addition, we advertised the study with flyers posted in community venues, including federally qualified health centers, libraries, and senior centers. Women who were interested in participating contacted our study office by phone or email. Our study staff reviewed eligibility criteria and obtained verbal consent to participate. To be eligible, participants had to be comfortable communicating in English, able to access the Internet, and be between ages 45 and 65 years (i.e., typically eligible for routine screening for cervical² and colorectal³ cancers according to the American Cancer Society guidelines). We did not exclude participants based on history of cancer screening. A total of 55 women (representing 26 counties) participated in 11 focus groups (metropolitan: k=4, n=21; non-metropolitan: k=7, n=34); thus, focus groups had an average of 5 participants.

Study procedures coincided with the beginning of the coronavirus disease 2019 (COVID-19) pandemic. To accommodate social distancing guidelines, focus groups were held using HIPAA-compliant Zoom, a video conferencing platform. As a result, participants had to have access to either a computer/smartphone with Internet access or a phone. We encouraged participants to enable their cameras for the duration of the focus group, but we did not exclude participants who did not have camera access. During enrollment, we provided participants with instructions for accessing the focus group through the video conferencing platform. We mailed participants a packet of information, including the video conferencing instructions, a summary of the research study (i.e., in lieu of a written consent form), brief educational information on cancer screening, and full-page images of self-sampling tools and instructions for their use (for colorectal cancer: InSure® FIT (Enterix Inc.); for cervical cancer: Evalyn® Brush (Rovers Medical Devices)). One to 3 days before each focus group, we called or emailed participants a reminder of the date and time for their focus group. At the conclusion of each focus group, we sent participants (either by mail or email) a thank you letter and a $40 gift card.

Data collection and analysis

After obtaining verbal consent and prior to the focus group, we administered a brief survey over the phone. The survey included 18 questions, collecting information related to participant demographics, general health, history of cervical and colorectal cancer screenings, and willingness to complete self-sampling tests for both cancer types. We descriptively summarized responses to each question using means and frequencies.

One facilitator and 2 note-takers conducted each focus group. The facilitator reviewed study procedures and goals, and then reminded the participants that the focus group would be audio-recorded. The study team used a semi-structured focus group discussion guide to gather participants’ perspectives on self-sampling for cancer screening. During the focus group, participants viewed images of self-sampling tools and instructions for their use. Participants then responded to prompts from the facilitator. At the end of the focus group, the facilitator stopped the audio-recording and thanked all the participants for their comments. Focus groups took an average of 66 minutes (range: 51-79 minutes) to complete.

Data collection continued until thematic saturation was achieved.^14,15 Focus group audio-recordings were transcribed using Rev.com (San Francisco, CA). We used content analysis^14,16,17 to identify themes from the focus groups based on a “start list”^15,16 of codes drawn from the discussion guide. We developed an integrative code structure¹⁶ by iteratively revising the code list as we conducted a preliminary review of the transcripts. Then, at least 2 study team members independently coded each transcript. Overall, we achieved high average intercoder agreement, ranging from 91%-97% across codes. Discrepancies in coding were resolved through discussion with the whole study team. We generated code reports, and at least 2 study team members reviewed each code report, identifying illustrative quotes and themes. Finally, the whole study team met to finalize emergent themes and their relationships.

We used nVivo (QSR International, Burlington, MA) to code transcripts and conduct qualitative analysis. Data collection and analysis for this study were approved by the Penn State College of Medicine Institutional Review Board/Human Subjects Protection Office.

Results

The average age of participants was 57 years (range: 47-65). Of the 55 participants, 54 identified as White, and all participants identified as non-Hispanic/Latina (Table 1). Fifteen participants (27%) reported a personal history of cancer; one reported having been diagnosed with cervical cancer, and none reported colorectal cancer. Willingness to complete a self-sampling screening test was high, with 80% (n=44) indicating that they would be very or somewhat willing to use such a test for cervical cancer, and 84% (n=46) for colorectal cancer.

Table 1.

Characteristics and attitudes regarding self-sampling tests among women ages 45-65 in Pennsylvania (n=55), 2020.

	N (%)
Average age (range)	57 (47-65)
Race
White	54 (98%)
More than one race	1 (2%)
Ethnicity
Non-Hispanic/Latina	55 (100%)
Personal history of cancer
Yes	15 (27%)
No	40 (73%)
Type of personal cancer history (n=15)
Cervical	1 (7%)
Colorectal	0 (0%)
Other	14 (93%)
Willingness to use cervical cancer self-sampling test
Very or somewhat willing	44 (80%)
Very or somewhat unwilling	11 (20%)
Willingness to use colorectal cancer self-sampling test
Very or somewhat willing	46 (84%)
Very or somewhat unwilling	9 (16%)

Based on the focus groups conducted with these participants, we identified 3 themes about the potential for self-sampling for cancer screening, described below. These themes spanned individual, interpersonal, and organizational levels of the socioecological framework.¹⁸ First, participants identified both advantages and disadvantages of self-sampling, (eg, greater independence, more convenience, less accuracy, and greater fear) in comparison to traditional testing. Second, participants described the potential impact of self-sampling on their interactions with their health care providers/clinics. Third, participants anticipated benefits of self-sampling in increasing access to quality health care services, but this enthusiasm was dampened by concerns about insurance coverage for self-sampling and follow-up tests. In addition, we detected some differences in responses from rural versus urban participants in the potential impact of self-sampling for cancer screening.

Theme 1: Self-sampling for cancer screening offers patients both advantages and disadvantages in comparison to traditional testing (individual-level)

Focus group discussions highlighted the individual-level advantages and disadvantages of self-sampling for cancer screening (Table 2). There were 3 distinct advantages of self-sampling compared to in-person screening that emerged from the discussions: (1) greater independence, (2) more convenience, and (3) overcoming aversive attitudes to in-person screening. Additionally, there were 4 commonly discussed disadvantages of self-sampling: (1) less knowledge, (2) less accuracy, (3) less efficiency, and (4) greater fear.

Table 2.

Illustrative quotes for themes describing the advantages and disadvantages of self-sampling for cancer screening at the individual level.

Advantages of self-sampling	Disadvantages of self-sampling
Greater independence: self-sampling requires less travel and can be completed without coordinating with others It’s kind of dreadful to spend 2-3 hours a day just commuting to a doctor’s appointment. I mean, that’s your whole day.”	Less knowledge: lack of awareness or understanding of self-sampling and screening tests “That’s almost a knowledge barrier where people might just not know what’s covered, what they need, what’s beneficial.” “To be honest with you, I don’t ever remember ever having a discussion about HPV.”
More convenience: self-sampling takes less time and is more feasible to complete than in-person screening “…the fact that you can do it at your convenience, you don’t have to worry about making an appointment to see your physician, or a nurse practitioner…. [It’s] kind of the luxury of not having to drive into town.” “I’m retired, and it was still hard to schedule. I had to call them up, and then they didn’t have that calendar there yet, so I had to call again later on. That part wasn’t as convenient as it should have been.”	Less accuracy: self-sampling seems harder to execute accurately than in-person screening “I think the only barrier with the home test, again, may be older people who would not be comfortable with testing themselves or could not actually physically, maybe, do the test. They would need help with it, rather than a younger person…. I think there are a lot of people that would be hesitant on being able to perform it.
Overcoming aversive attitudes to in-person screening: in-person screening is embarrassing, tense, unpleasant, and invasive “I would have rather gone that route and then avoid all of that foolishness with the prep, then procedure, the time off of work, just the yuckiness of it all.” “I think it’s a comfort level, too. If you’re home, in the comfort of your home, you’re a lot less stressed, you might have an easier time getting things into orifices that shouldn’t be accepting things. For me, it would be that I’m a lot less stressed than being in a doctor’s office, having these types of tests being taken.”	Less efficiency: self-sampling cannot treat other health issues, and it has to be completed more frequently than in-person tests “So it’s beneficial to get more of that internal exam and get the results of the cell tests that they’re doing to test for cancer cells or the HPV. But going to the provider, they kind of do a little bit more that you’d be afraid that you’d miss out on that.” “You don’t know if there’s any precancerous polyps there or polyps they could just remove while they’re taking a look.” “I’d rather go have the colonoscopy and have it done for ten years [than complete a stool test annually].”
	Greater fear: fearful, mistrustful perceptions of self-sampling “I know that the colorectal cancer screening that I’ve known about before would not have picked up what my particular issue was. That’s always in the back of my mind, that it [wouldn’t] pick up everything and give someone a false sense of security.”

The first advantage to self-sampling described by the participants was greater independence afforded by self-sampling methods for cancer screening. Participants indicated that self-sampling could increase independence by eliminating the need for travel. One participant presented a travel limitation for rural residents, saying “Out in the country, there’s no such thing as public transportation.” Another advantage described by participants was the convenience of self-sampling. One participant preferred the flexibility of self-sampling, saying “[You could do it], like, any time of the day. You’re busy, can’t get off work, you got kids. Do it 9:00 at night. You could do it 6:00 a.m.” Participants also discussed their aversive attitudes to in-person screening, which self-sampling could address. Participants indicated that in-person screening was stressful and lacking in privacy. One participant described her previous experience with getting a Pap test, saying “It seemed like you knew it was coming, and right away you just tensed every muscle in your body.”

A commonly discussed disadvantage to self-sampling was the lack of knowledge and awareness about self-sampling options and about cancer screening tests in general. As one participant said, “I honestly didn’t realize that you could do something like this at home.” Another participant commented on the uncertainty of completing the test correctly, saying “Even if you do get it right and it’s negative, you’re worried, ‘Did I do it wrong? And that’s why it’s a negative?’” Participants also expressed concerns that self-sampling seemed less efficient than in-person screening; that is, a provider may be able to detect and evaluate other health concerns when conducting an in-person screening, which would not be possible in the context of self-sampling. A major disadvantage described was greater fear and negative perceptions surrounding self-sampling, which were closely related to concerns about accuracy. One participant stated her preference for in-person tests, saying “I think that I’ll lean to my provider, and that’s simply out of fear. I just have more faith in them doing a better job than me.”

Theme 2: Self-sampling for cancer screening could change patients’ interactions with their health care providers or clinics (interpersonal-level)

Focus group participants described providers’ preferences for in-person tests as a potential challenge to using a self-sampling option. One participant shared her experience when discussing a self-sampling option with her provider, saying “I talked to my doctor about it and wanted to do the home one, and she said, ‘Well, there’s so many false positives that you end up with a colonoscopy anyhow.’” Participants also discussed the importance of having opportunities to talk to their providers about different screening options. As one participant said, “I’d like to see this [information about screening options] at the doctor’s office for them to encourage us to talk, rather than say, ‘You’re 50. This is what you’re doing. Go.’ And then they just send you for the colonoscopy.”

Another topic discussed was the patient-provider relationship. Specifically, participants questioned whether the quality of the relationship with their provider would change by doing a self-sampling test and thus not seeing their provider in-person. Participants described the desire to maintain a positive, collaborative relationship with their provider throughout the decision-making process, for example, saying “I think [you need to] create or maintain an environment where it is a collaboration, where you’re communicating, you’re getting your questions answered, you’re not being rushed. It’s a big decision.”

Participants also discussed how they saw self-sampling as a good option if it was a patient’s first time getting screened. One participant suggested that self-sampling may serve as an entry point into in-person screening, saying “If it’s something that they could do in the privacy of their home and very easily, at least that first-step screening might convince more people to embrace it.” However, a lack of provider recommendation for self-sampling tests may prevent patients from even having this option.

Theme 3: Self-sampling for cancer screening has implications for improving, and for worsening, access to quality health care services (organizational-level)

Participants described challenges they experienced in accessing health care, which could be obviated to some extent by self-sampling for cancer screening. Their challenges in accessing health care centered on (1) raw numbers of primary care and specialty providers practicing in their communities, and (2) difficulty in visiting a clinic due to logistical concerns, such as scheduling. In general, participants reflected that self-sampling could reduce these barriers. For example, one participant said, “…the fact that you can do it at your convenience, you don’t have to worry about making an appointment to see your physician, or a nurse practitioner… [It’s] kind of the luxury of not having to drive into town.”

In addition to concerns about availability of care, participants also had concerns about quality of care, and they anticipated both benefits and drawbacks from introducing self-sampling into this clinical milieu. Several participants shared vivid anecdotes about medical errors that they attributed (correctly or incorrectly) to the poor quality of care available, particularly in rural areas. Many participants described the “self-advocacy” they adopted to overcome these challenges (examples: “Self-advocacy is a big issue” and “We have to be our own self advocates”). Self-sampling resonates with their general framework of being in charge of their own care, but if questions emerged while using the self-sampling tools, participants were not confident that they would be able to get answers from their providers. For example, one participant said, “I would like accessibility somehow to my provider, whether it’s a nurse or someone for some support through [completing the self-sampling test]. I think that it could be a great thing, but… if I have questions, then how long would I have to wait to get that responded? Would my provider answer that or would the company that makes these screening tools have to be responsible?” Thus, self-sampling could overcome or exacerbate concerns participants had about the adequacy of their local health care systems.

A third systems-level concern raised by participants in reference to self-sampling for cancer screening revolved around costs and insurance coverage. Many participants raised questions about whether insurance plans would cover the costs of self-sampling and, further, what costs would be incurred for any necessary follow-up testing. Some participants assumed that self-sampling would be less expensive than traditional cancer screening, for example, saying “[Self-sampling] might be less expensive. I don’t know cost-wise what this is… but it might help that group of people [who are uninsured or underinsured], too, since insurance costs and copays are so significant now.” However, most participants were less sure that self-sampling would offer a cost benefit, for example, saying: “What is insurance going to cover? I’d do this [self-sampling test], but then is it covered? And if this one comes back and I need a second follow-up, then what does insurance cover?” Participants recognized that costs and insurance coverage would likely influence patient motivation to use one screening modality over another.

Cross-cutting differences in themes from rural versus urban communities

Of the themes identified relating to the individual, interpersonal, and organizational levels of the socioecological model, we detected some differences in responses from rural versus urban participants. These differences have potential impacts on self-sampling for cancer screening in these different communities. For example, at the individual level, participants from rural communities shared that they face unique travel barriers due to lack of public transportation. Discussions surrounding travel barriers led to additional concerns of having to depend on others in order to get to their cancer screening appointments. One participant described her travel barriers by saying, “My closest relative is 45 minutes away. She would either have to drag the kids with her or find somebody to watch her kids if I needed a ride.” A corollary of the distances rural participants reported travelling to health care clinics for in-person screening was the time required for travel and appointments. For example, one participant said, “It’s kind of dreadful to spend 2-3 hours a day just commuting to a doctor’s appointment. I mean, that’s your whole day.”

At the organizational level, participants from rural communities shared they often experience difficulties in getting an appointment due to clinic availability in scheduling and the limited number of providers. This lack of access to health care resources was closely linked to other barriers, e.g., travel burden. For example, one rural participant said, “The specialist that was closest to me, when I called to make an appointment, [there] was a six-month wait to get an appointment there. I’m like, ‘Okay, well, if it’s cancer, what’s going to happen in that six months?’ Then I had to drive an hour to the appointment that was sooner, but then I’m taking half a day off of work to drive an hour away versus an hour and a half off work.”

Discussion

Self-sampling as a cancer screening method presents both potential advantages and disadvantages spanning levels of the socioecological framework.¹⁸ Our focus groups revealed that women’s perceptions of self-sampling are affected by factors and experiences at the individual, interpersonal, and organizational levels. At the individual level, participants reflected on their own knowledge, attitudes, and preferences surrounding cervical and colorectal cancer screening. At the interpersonal level, participants described relationships and interactions with health care providers and their impact on cancer screening decisions. Finally, at the organizational level, participants discussed how the health care system affects their experience with cancer screening and indicated how self-sampling could improve or worsen the quality of care. Rural participants faced some unique barriers to screening across all levels. Overall, the focus groups have implications for optimal implementation of self-sampling screening methods for cervical and colorectal cancer, specifically in populations with low screening rates.

Focus groups highlighted key individual-level benefits of self-sampling, including increased independence and convenience, as well as the ability to avoid common discomforts associated with in-person screening. A recent literature review focused on attitudes about HPV self-sampling found that convenience and independence were among the most commonly reported motivators for self-sampling.¹⁹ Consistent with previous research reporting high acceptability of self-sampling screening methods,^11,19,20 participants in the current study indicated high levels of willingness to use these tools, and they reported several perceived advantages of self-sampling. Together, these findings indicate that self-sampling holds considerable promise for increasing cancer screening among the general population. However, participants also discussed disadvantages to self-sampling, including lack of knowledge, potential challenges collecting a sample, inefficiencies, and fear. These disadvantages could hinder the implementation of self-sampling programs; however, they could potentially be addressed through educational interventions. An effective intervention may be able to address barriers by highlighting research that shows most patients are able to collect an adequate sample and that the accuracy of self-sampling is similar to that of clinician-administered tests.^10,21–23

An interpersonal-level barrier to self-sampling that we identified was provider knowledge and preferences. Some participants shared that when they asked their providers about self-sampling screening tests, they were encouraged to use a clinician-sampled test instead. For self-sampling options to become routine in clinical practice, provider knowledge and acceptance of the available screening options, test accuracy, and test benefits need to be improved. While this gap in knowledge discussed by focus group participants was surrounding both cervical and colorectal screening, previous research showed that staff and clinicians from federally qualified health centers in Pennsylvania were most unfamiliar with the cervical cancer self-sampling option.²⁴ Beyond unfamiliarity, these staff and clinicians feared the tests (both colorectal and cervical) would be inaccurate despite existing evidence indicating that self-sampling tools are accurate and efficient.^10,23 By increasing provider knowledge and acceptance of self-sampling testing options, we would expect to see more clinicians offering the test to their patients, particularly in populations where traditional screening options are not as feasible; this can be achieved using a brief educational program aimed at increasing knowledge and affecting beliefs among providers.²⁵ Since knowledge was also identified as an individual-level barrier, future interventions should aim to increase both patient and provider knowledge about self-sampling options.

At the organizational level, based on our findings, clinic availability and scheduling issues may disproportionately affect rural residents. This may be due to lack of providers in the area, lack of available appointment times, or inability to schedule appointments within a reasonable timeframe. Self-sampling allows these residents to access cancer screening more quickly than if they have to receive screening in-person (unless follow-up procedures are necessary). While patients should still be encouraged to participate in routine preventive clinical visits, self-sampling provides an opportunity to get screened when the patient is due for testing rather than waiting until an in-person appointment is available. Thus, self-sampling can be used to overcome these organizational-level barriers that disproportionately affect rural residents.

The differences between responses from focus group participants living in rural versus urban areas have implications for integrating self-sampling methods into clinical practice in different types of communities. One factor that may differ between rural and urban populations is the type of patient-provider relationship. Previous research has shown that the nature and quality of the patient-provider relationship can influence health behaviors such as HPV vaccination and colorectal cancer screening.^26,27 In rural settings, the patient-provider relationship is more socioemotional (i.e., care-oriented) than in urban settings, which are characterized by a more instrumental communication style (i.e., cure-oriented).²⁸ This socioemotional communication style builds trust between the physician and the patient, which presumably would support discussions about self-sampling tests. However, our findings suggest that participants still have to overcome the barrier of low provider knowledge and acceptance of self-sampling tests. Additionally, rural participants were concerned that self-sampling tests would compromise their relationship with their provider. To address this concern, interventions are needed to (1) increase provider knowledge and acceptance of self-sampling tests and (2) promote these tests as flexible options that can support the existing, collaborative relationship between providers and their rural patients.

Conclusion

Our findings suggest that future research interventions aimed at increasing screening for colorectal cancer and cervical cancer may be most successful if developed using the socioecological framework or other behavioral models as a guide. Models, such as the socioecological framework, that are based on Bandura’s social learning theory,²⁹ help to explain individual behaviors in relation to others and their environment. If possible, future interventions should target the individual-, interpersonal-, and organizational-level factors highlighted by study participants in order to increase screening rates to the greatest extent. These findings can also be useful for interventions targeting only one level of the socioecological framework by focusing on specific barriers that populations may face in getting screened, such as individual-level logistical barriers, like travel, or interpersonal factors, such as maintaining the patient-provider relationship. Ultimately, these interventions can lead to increased use of self-sampling options for cancer screening, which could lead to reduced cancer morbidity and mortality.

In terms of study strengths, the study population included participants from both rural and urban counties in Pennsylvania, allowing us to make comparisons and draw conclusions about rural/urban differences. Additionally, we examined attitudes surrounding both established self-sampling options for colorectal cancer and novel self-sampling options for cervical cancer. Research about self-sampling in rural communities specifically for cervical cancer is limited, and this research helps to fill the gap in the literature. One limitation of the present study is that the findings may not generalize to other populations. The study population was not racially or ethnically diverse, further limiting generalizability of the findings. We chose to use RUCC codes to define counties as rural or urban. Using this county-level classification may not capture the rural/urban differences that exist on a smaller level within each county.

In conclusion, this study found that there are several multilevel barriers and facilitators that influence the feasibility of implementing self-sampling for cancer screening in routine clinical practice. These findings can be used to guide interventions aimed at increasing the use of self-sampling methods. Interventions should target each level of the socioecological model to maximize intervention effectiveness, paying particular attention to unique population characteristics, such as rurality.