Table 1.

Summary of studies reviewed

Study/Country	Methods	Participants	Phenomenon(s) of interest	Findings & Themes
Polek, Hardie, 2017. United States.	Survey.	5,695 women – 113 lesbian, 135 bisexual, 5,446 heterosexual women ages 18–26.	To characterize rates of HPV vaccination in women based on their sexual orientation to further characterize at-risk groups to support nurse practitioner vaccination efforts.	Significant differences were found in vaccine uptake based on sexual orientation. Bisexual women were most likely to be vaccinated, and differed significantly from heterosexual and lesbians, which did not differ significantly from each other. The results suggest improvements in sexual minority rates but ongoing low rates of vaccination in adult women.
Perks, Algoso, Peters, 2018. Australia.	Mixed-methods. Semi-structured interviews, qualitative descriptive. Thematic analysis.	147 women, aged 18 and older.	To determine characteristics of women accessing health from Liverpool Women’s health centre and explore their experiences of the service.	Providing accessible and comforting healthcare services can increase participation of vulnerable women in routine cervical cancer screening. Providing accessible screening can reduce morbidity and mortality from cervical cancer. Two main themes and one sub-theme of the study: 1. Reasons for choosing a woman’s health clinic, with a sub-theme of gender preference, and 2. Attending to physical and emotional needs. Women described cervical cancer screening as an invasive procedure and felt more comfortable with a female provider who developed a trusting relationship and conveyed a sense of genuine interest about the woman’s overall health and wellbeing. The participants also stated that the nurse practitioners at the clinic paid special attention to developing trusting relationships with women and attended to the physical and emotional needs of the patient to increase level of comfort.
Maar, Burchell, Little, Ogilvie, Severini, Yang, Zehbe, 2013. Canada.	Participatory action research approach. Semi-structured interviews, in-depth interviews. Thematic analysis.	18 nurses, nurses practitioners, community health representatives, social workers, physicians – all who provide care to women in 11 First Nations partner communities in rural Northwest Ontario. 17 female, 1 male.	To examine structural barriers that prevent First Nations women’s participation in cervical cancer screening.	Major themes that emerged included shortage of appropriate healthcare providers, lack of a recall system, transportation barriers, education and socioeconomic inequalities, low health literacy, and generational effects on First Nations women The theme regarding shortage of appropriate healthcare providers was further developed into lack of female-trained, consistent providers who provide reassurance and trusting relationships with women undergoing cervical cancer screening. Structural barriers to cervical cancer screening were identified for underserved, rural women, such as lack of recall system and transportation barriers. Education and socioeconomic inequalities emerged as one of the largest themes, as many participants agreed that education is one of the main factors in facilitating a woman’s decision to engage in cancer screening. Participants felt that many Aboriginal women were disadvantaged in formal school education and generalized health literacy. Generational effects and cultural effects, such as language barriers and trauma from residential schools and previous health encounters may deter women from seeking screening.
Nguyen-Truong, Lee-Lin, Leo, Gedaly-Duff, Nail, Wang, Tran, 2012. United States.	Descriptive, community-based survey using purposeful sampling.	211 Vietnamese-American women, at least 21 years of age.	To examine factors potentially influencing Pap testing practices among Vietnamese-American women.	Pap testing continues to fall short in this study population. Only 30% of women in this study knew of cervical cancer screening programs in their community, and only 11% knew where to go to get a low-cost or free Pap test in their area. A recommendation from a friend or healthcare provider was a large predictor of Pap test adherence. English speaking, highly-educated Vietnamese women living in the United States for longer periods of time were more likely to have a Pap test. Additionally, Vietnamese-American women who had access to a regular primary care provider were also more likely to have a Pap test. Women who reported greater perceived common barriers, or a multitude of barriers in combination, were less likely to have ever received a Pap test.
Mills, Chamberlain-Salaun, Christie, Kingston, Gorman, Harvey, 2012. Australia.	Qualitative, exploratory study using purposive sampling and concurrent data collection and analysis of individual interviews.	18 registered nurses working in general practice enrolled in Pap Smear Provider Module.	To examine the process of changing the traditional division of labour related to cervical cancer screening and well women’s health care services in the general practice setting and to develop an approach for practice nurses to incorporate cervical screening into their work.	Participants perceived four key enablers to implementing a model of nursing care that included the provision of cervical cancer screening and well women’s health services: 1. General practitioners being willing to relinquish the role of cervical screener, 2. Practice nurses being willing to expand their role to include cervical screening and well women’s health services, 2. Clients preferring a female practice nurse to meet their cervical screening and well women’s health needs, 3. The presence of a culture that fosters interprofessional teamwork. Participants in this study identified that male general practitioners may have felt uncomfortable providing cervical cancer screening; however, there may be some hesitancy of general practitioners to allow advanced practice nurses to incorporate screening into their practice. An enabler to nurses performing cervical cancer screening is the number of clients who prefer a female clinician. Clients also feel more comfortable with a nurse and are more likely to talk about women’s health needs. Nurses in rural settings may be more consistent providers of care, while general practitioners may change regularly.
Katz, Zimmermann, Moore, Paskett, Reiter, 2017. United States.	Separate focus groups among both healthcare providers and women. Field notes, in-depth interviews.	28 healthcare providers with a mean age of 43. 15 women with a mean age of 45 years.	To gain insight into the perceived acceptability of mailed HPV tests.	Main themes that emerged from the focus groups include 1. Most providers thought that the women understood very little about the association of HPV and cervical cancer and the importance of completing cervical cancer screening within guidelines, 2. Most women voiced lack of understanding about HPV. Barriers to cervical cancer screening emerged as key themes and included embarrassment, emotional stress, physical discomfort, pain, and lack of time and money to complete the test. While women expressed preference for HPV testing at home when compared to a healthcare office or setting, healthcare providers expressed potential flaws of testing including the potential for error; however, many providers viewed the testing as a way to encourage women to return to the healthcare system.
Birkhoff, Krouwel, Nicolai, Bert-Jan de Boer, Beck, Putter, Pelger, Elzevier, 2016. The Netherlands.	Cross-sectional survey. 31-question questionnaire.	357 Dutch general practitioners aged 26–72, 57% female.	To evaluate attitudes of general practitioners about sexual abuse victims, and if specific attention is paid to sexual abuse in advance of performing a cervical smear.	Only three participants “often” asked about sexual abuse to their patients, while 36 participants “regularly” asked. The most agreed upon reason that kept providers from asking about sexual abuse was that there was no motive to ask. In terms of nurse practitioner practice, 34.5% of nurse practitioners “never” asked about sexual abuse while only three percent asked always. The frequency of sexual abuse is underestimated in cervical cancer screening. Most women find it difficult to raise the topic of sexual abuse themselves and would prefer if healthcare professionals initiate the dialogue.
Weston, Page, Jones-Schubart, Akinlotan, 2018. Australia.	Collaborative clinic project evaluated by qualitative survey.	17 nurse practitioner students, unspecified ages. 83 female patients aged 23–66.	To increase access to cancer screening for underserved women while providing collaborative clinical experiences for nurse practitioner students.	Expanding opportunities through student nurse practitioner-led clinics was well received by patients, cost-effective, and improved access to cervical cancer screening.
Kenison, Silverman, Sustin, Thompson, 2015. United States.	Surveys.	759 breast cancer survivors aged 32 to 95.	To determine if frequency of cancer screening and discussion of healthy lifestyles differed across provider types (nurse practitioner, primary care physicians, surgical and medical oncologists).	No statistically significant differences were found in primary and secondary cancer screening rates among breast cancer survivors between providers. There were significant differences found in relation to discussions of healthy lifestyles, with a higher proportion of patients recalling discussion of physical activity and diet with nurse practitioners.
Hitt, Low, Bird, Ott, 2013. United States.	Telecolposcopy program with pre- and post-project surveys.	1,298 colposcopic exams on female patients aged 14–58.	To provide needed care to an at-risk population and to test the validity of providing care by pairing local examiners with distant expert oversight by telemedicine.	Among the sets of 1,118 biopsies taken, 333 showed precancerous lesions or cancer and were referred for treatment. Results of the survey revealed that 61% of the patients reported that without this program they would have waited at least 12 months or not sought care at all, while 74% percent of patients reported that they would have waited for at least 6 months or not sought care at all. Complications with the telecolposcopic method were rare during the study period.
Choma, McKeever, 2015. United States.	Educational intervention with post-program survey.	78 participants completed the contact hour program with 48 participants competing the post-program survey (93.7% female).	To determine the effectiveness of a web-based continuing education program on advanced practice nurses’ knowledge of current cervical cancer screening guidelines and their application in practice.	Healthcare providers reported great variance in knowledge of cervical cancer and screening guidelines, as well as HPV infection and risk of cervical malignancy. Knowledge gaps exist among advanced practice nurses about cervical cancer screening in adolescents; however, when provided with an educational intervention, knowledge levels increased and self-reported clinical practice behaviours changed in accordance with new cervical cancer screening guidelines.
Peters, 2010. Australia.	Qualitative. Interviews, storytelling. Thematic analysis.	9 healthcare consumers aged 31–65. 6 healthcare professionals, unspecified ages.	To explore stories and perceptions of consumers and healthcare workers with a low uptake of women’s health screening.	Three main themes emerged, including seeking woman-friendly woman-centred services, seeking continuity of care, and seeking safe environments. For many women, simply being able to access a female health practitioner for health screening was essential for having their health attended. Additionally, lack of reminders from providers about screening and ultimately, lack of continuity of care was a major deterrent for screening. Lack of a consistent primary care provider leaves women jumping from clinic to clinic to seek screening and ultimately causes gaps in care and/or inadequate screening.
Thompson, Glavin, Daley, Tatar, Zimet, Rosberger, 2020. United States.	Online survey.	812 women, aged 30 to 65 years.	To assess information, motivation, and behavioural skills associated with willing to receive an HPV test instead of a Pap test among women.	HPV knowledge was significantly associated with a willingness for HPV testing. Motivating factors for testing included: positive attitudes, social norms, perceived benefits, worry about cervical cancer, and worry about abnormal HPV tests. Women were more significantly more willing to get the HPV test if a provider recommended it and currently up to-date on cervical cancer screening guidelines.
Cappiello, Boardman, 2018. United States.	Longitudinal survey.	358 advanced practices nurses in three New England states in 2008, 2012, and 2015.	To explore to what extent advanced practice nurses adopted cervical cancer screening guidelines.	Advanced practice nurses are incorporating guidelines at a high rate. Advanced practice nurses also felt that their patients increasingly are educated and comfortable with guidelines.
Gesink, Filsinger, Mihic, Norwood, Racey, Perez, Antal, Ritvo, Vernich, 2016. Canada.	Multi-phase mixed methods study. Group discussions, online survey, focus groups with healthcare providers. Thematic analysis.	2783 participants included from online survey, 82 percent female, aged 18 years or older. Focus group discussions with healthcare providers then with community members from each underserved population.	To identify and quantify barriers and facilitators for breast, cervical, and colorectal cancer screening for under and never screened residents of Ontario between 2011 and 2013.	In Ontario, cancer screening rates are below targets despite being offered free of charge to all residents eligible for screening. Themes were divided into barriers and facilitators to screening for under- and never-screened patients. Barrier themes included 1. The doctor, 2. The test being too painful, too embarrassing, too scary, too invasive, 3. Fear, 4. History of abuse, 5. Social determinants of health, such as poverty, living in crisis, social norms, low literacy, lack of knowledge/awareness, 6. Lack of health insurance. Facilitators to screening included 1. The doctor, 2. The test, 3. Increasing knowledge and awareness, 4. Symptoms appearing, 5. Family or friends told them to go get screened. The healthcare provider emerged as both a facilitator and a barrier. The doctor could be seen as a barrier if the provider refused to screen patients or was inattentive to specific needs of the patient. The healthcare provider also served as a facilitator of screening if the opposite were true, such as the provider encouraged screening in patients and provided sufficient detail about why screening is required. Patients also appreciated reminders from their healthcare provider about when screening is due. The screening itself proved to be a barrier and a facilitator as well, due to the sensitive and potentially painful nature of the testing. While many patients had preconceived notions about the test being too scary or painful and this served as a barrier, many patients who had undergone testing felt that the test was less painful than anticipated and this served as a facilitator to screening.