Acceptability of self-sampling for high-risk HPV DNA testing for primary cervical cancer screening among women in Thyolo, Malawi: A qualitative study

Despite the roll-out of cervical cancer screening within routine health facilities, uptake of cervical cancer screening in Malawi remains low due to factors such as privacy concerns, stigma, and distance to health facility. Self-sampling for human papillomavirus (HPV) testing offers a viable alternative to provider-delivered sampling, resolving issues with accessibility and privacy related barriers. However, there is limited understanding of the acceptability of self-sampling among women in low-income settings. We aimed to assess women's perceptions, experiences, and acceptability of self-sampling for HPV testing for primary cervical cancer screening. We conducted a qualitative phenomenological study among ten purposively sampled women screening for cervical cancer at a rural hospital in Malawi. Data collection instruments and the thematic analytical approach were guided by the Theoretical Framework of Acceptability. Key constructs that were central to this analysis included affective attitude, burden, self-efficacy, intervention coherence, and perceived effectiveness. Self-sampling emerged as a culturally and socially acceptable diagnostic practice by the women, mediated by emic values of privacy, bodily autonomy, and convenience. Women valued the ability to autonomously collect samples, which allowed them to circumvent discomfort and perceived invasiveness linked to speculum use, especially by male clinicians. Sociocultural barriers such as limited literacy levels, poor access to transport, and a lack of spousal approval restricted broader acceptability. Facilitators of acceptability included comprehension of the intervention, confidence in the self-sampling process, and the potential of the intervention to increase screening uptake, reduce cervical cancer screening-related stigma and reduce healthcare worker burden. Self-sampling for cervical cancer screening is an acceptable and promising alternative for improving the uptake of screening among women in Malawi and similar low-income countries. Scale-up of this approach will require addressing socio-cultural barriers through optimising instructional materials, engaging male partners, and leveraging community health workers for scaled community implementation via task-sharing.