Discussion
CERVICAL CANCER
In our assessment of barriers to clinic-based screening during the COVID-19 pandemic, we found that discomfort with the test and with male providers, as well as embarrassment, are important and prevalent barriers to screening among under-screened safety net health system patients. These barriers were more prevalent among Hispanic women and those who completed the survey in Spanish. Our results suggest that barriers experienced by under-screened women within a safety net healthcare system may differ from those experienced by patients in other healthcare systems who have difficulty accessing care due to financial reasons and other barriers (The motivators for using an at-home HPV self-sampling kit appear to address key barriers to cervical cancer screening found in our survey participants. Most who used the kit found it to be less stressful, embarrassing, and more convenient than clinic-based screening. Significantly more Spanish-speaking women and women with lower education completion found the at-home kits to be less embarrassing than clinic-based screening, a barrier reported significantly more among those groups of participants. Our findings suggest that self-sampling kits may address or circumvent some of the key barriers reported by survey participants within a safety net health system, especially those reported by Spanish-speaking women, and may help to address disparities in cervical cancer screening adherence. Our findings are consistent with other studies in showing that self-sampling can address barriers to clinic-based screening in various countries and health system settings (Our results show that COVID-19 was a motivating factor for most respondents to participate in the at-home self-sampling HPV trial and that many patients experienced additional barriers to care since the beginning of the pandemic. The most common barriers included difficulty making appointments, fear of getting COVID, and a broad response that screening was easier at home. While the survey did not probe about this last response, many participants mentioned it in the context of competing priorities amid the pandemic, such as childcare. These responses align with research indicating that the burden of childcare and elder care has fallen disproportionately on women during the pandemic (This study had certain limitations that should be considered when interpreting the results. Because the study was conducted among women in a safety net system that cares for un- and under-insured individuals, results may not be generalizable to women served by other types of health systems. Similarly, the main analysis, while relevant to the safety net system in which the study was conducted, may not apply to other healthcare systems, or to international audiences. Women in the community and other healthcare settings often face significant structural barriers related to access to care due to lack of insurance and/or cost. The prevalent barriers in our study most certainly reflect that financial and insurance barriers are largely removed due to participants’ enrollment in the health system. Additionally, as mentioned, the closed-ended survey format did not allow us to probe into some of the responses, particularly how the COVID-19 pandemic influenced the use of the kit. Nonetheless, this study is unique in that it gives in-depth insight into the particular barriers experienced by safety net patients during the COVID-19 pandemic. To our knowledge, this is the first analysis of cervical cancer screening barriers among under-screened women in a safety net healthcare system in the COVID-19 era.In conclusion, mailed at-home HPV self-sampling kits present an opportunity to reduce important barriers to cervical cancer screening among women in a safety net healthcare system. Furthermore, during the COVID-19 pandemic, these barriers may have been exacerbated by the economic, physical, and mental effects of the pandemic. Further research is needed to understand additional barriers experienced by women during the COVID-19 pandemic and how these might be addressed with new screening tools such as at-home HPV testing using self-sampling. Implementation of new screening programs should address the specific barriers to clinic-based screening and motivators to self-sampling experienced by their patient populations.