Ensuring a Successful Transition From Cytology to Human Papillomavirus–Based Primary Cervical Cancer Screening in Canada by Investigating the Psychosocial Correlates of Women’s Intentions: Protocol for an Observational Study

Background The human papillomavirus (HPV) test has emerged as a significant improvement over cytology for primary cervical cancer screening. In Canada, provinces and territories are moving toward implementing HPV testing in cervical cancer screening programs. Although an abundance of research exists on the benefits of HPV-based screening, there is a dearth of research examining women’s understanding of HPV testing. In other countries, failure to adequately address women’s concerns about changes has disrupted the implementation of HPV-based screening. Objective The aims of the multipart study described in this paper are to develop psychometrically valid measures of cervical cancer screening–related knowledge, attitudes, and beliefs; to examine the feasibility of a questionnaire examining psychosocial factors related to HPV-based screening; and to investigate psychosocial correlates of women’s intentions to participate in HPV-based screening. Methods We conducted a web-based survey (study 1) of Canadian women to assess the acceptability and feasibility of a questionnaire, including the validation of scales examining cervical cancer knowledge, HPV testing knowledge, HPV testing attitudes and beliefs, and HPV test self-sampling attitudes and beliefs. Preferences for cervical cancer screening were assessed using the best-worst scaling methodology. A second web-based survey (study 2) will be administered to a national sample of Canadian women between June 2022 and July 2022 using the validated scales. Differences in the knowledge, attitudes, beliefs, and preferences of women who are currently either underscreened or adequately screened for cervical cancer will be examined through bivariate analyses. Multinomial logistic regression will be used to estimate the associations between psychosocial and sociodemographic factors and intentions to undergo HPV-based screening. Results Between October 2021 and November 2021, a total of 1230 participants completed the questionnaire in study 1, and 1027 (83.49%) responses were retained after data cleaning methods were applied. Feasibility was comparable with similar population-based surveys in terms of survey length, participant attrition, and the number of participants excluded after data cleaning. As of May 2022, analysis of study 1 is ongoing, and results are expected to be published in the summer of 2022. Data collection is expected to begin for study 2 in the summer of 2022. Results are expected to be published between late 2022 and early 2023. Conclusions Findings will provide direction for Canadian public health authorities to align guidelines to address women’s concerns and optimize the acceptability and uptake of HPV-based primary screening. Validated scales can be used by other researchers to improve and standardize the measurement of psychosocial factors affecting HPV test acceptability. Study results will be disseminated through peer-reviewed journal articles; conference presentations; and direct communication with researchers, clinicians, policy makers, media, and specialty organizations. International Registered Report Identifier (IRRID) DERR1-10.2196/38917


Strengths and Weaknesses/Forces et faiblesses:
The researchers make a very strong case for the timeliness of this research. The change in practice will occur but uptake problems could be prevented if the beliefs of women are taken into account. They also argue that there is no Canadian data available (based on a systematic review they conducted).
The theoretical basis for the study is well thought out and the measures are appropriately based on theory.
The research is based on previous work by the team that includes a systematic review outlining some of the issues in the area. The team itself is strong with relevant expertise and the inclusion of knowledge users.
The researchers argue that women who do not have English or French as their first language are less likely to be screened, but this is not addressed in the research design. They include a comment in the limitations about this and that the results will inform research with marginalized groups, including Indigenous groups. If the research is needed now, how will these groups be helped? The researchers made a strong case for the need for research with underrepresented groups at the start, and for the timeliness of the research, but it appears that these issues will not be addressed by the currently proposed research. This is the fourth time this research was submitted. In reading the application (before reading the response to reviewers) I had the concern that vulnerable groups were not included. Unfortunately, the response to reviewers does not increase my confidence. How will the market survey company ensure women who do not speak English or French will complete a survey only offered in those two languages? I think it is best to just acknowledge this is a limitation.
I'm not sure what is meant by "intelligent programming of the survey" -is this from the market survey company?
The researchers will ask women the date of their last gynecological exam because they are concerned they will not remember when their last pap test was, but will women be able to remember their last gynecological exam any better than when their last pap was? I see this research as an important first step, but it is unclear how the results will actually be used to mitigate potential concerns among Canadian women. The researchers propose a one day workshop to present findings to policy makers and media, but how those people disseminate the findings to the public is not within the scope of this research.
I suggest the informative statements be simplified, particularly if they want to get adequate data from lower SES or immigrant groups.

Review Type / Type d'évaluation:
Reviewer   Rosberger and colleagues note that the cervical cancer prevention landscape is shifting in Canada. Current guidelines focus on identification of cervical neoplasia using Pap methods at relatively short intervals; however, there is increasing acceptance by expert guidance bodies of screening practices with wider intervals, later age of onset, and (increasingly) HPV testing (with self-sampling). As they note, such major changes in practice must be informed by information on knowledge, beliefs, preferences and practices of Canadian women, and such knowledge does not currently exist in Canada.
They propose to perform a web-based survey in partnership with Leger, which will compare knowledge, attitudes and practices around cervical cancer screening in adequately screened and underscreened women. There is a particular emphasis on attitudes and knowledge related to HPV testing, which is key, given impending changes in cervical cancer screening.

Strengths and Weaknesses/Forces et faiblesses:
This is a strong proposal which has been extensively and repeatedly revised to meet the concerns of reviewers. The approach is reasonable, and the work is important.
The background is well written; the team are expert in areas of cervical cancer prevention and survey research, including work related to cervical cancer prevention. The work is very timely.
Measurements are to be made using validated available instruments and approaches. I do not see mention of survey weights in the proposal itself but provision of appropriate weights is noted in the materials provided by Leger.
There are sensible approaches to oversampling, and to dealing with careless responses and non-completion. The sample size description is reassuring. Again, as above, these investigators have knowledge and experience in this area.
The obvious criticism here is that women who are disenfranchised enough to be non-participants in existing cervical cancer screening programs are likely to be underrepresented among women with internet access. This is a limitation but I don't have any suggestion as to how this could be reasonably overcome, and the work remains of substantial importance even with this limitation.