“Those who tested positive should be the ones sensitizing others”: loss to follow-up after door-to-door HPV self-sampling in Cameroon—a socio-ecological thematic analysis

Abstract Background The Cervical Cancer Screening At Home (CASAHO) trial assessed whether home-based HPV self-sampling could improve cervical cancer (CC) screening uptake in Dschang, Cameroon. The CASAHO intervention increased screening coverage by 80% but, was accompanied by a substantial Loss To Follow-Up (LTFU). Therefore, the objective of this study was to explore barriers and facilitators to follow-up care among HPV-positive women to improve women’s health and inform public health recommendations. Methods Exploratory qualitative study using semi-structured individual interviews with women, male partners, community leaders and focus group discussions with health care professionals. Interviews and focus groups were audio-recorded, transcribed verbatim, coded, and analysed thematically, using ATLAS.ti. Barriers and facilitators were categorized according to the Socio-Ecological Model (SEM) covering individual, interpersonal, community, organizational, and policy levels. The study was conducted in the Dschang Health District, Cameroon, between June–August 2024 and July 2025. Ten HPV-positive women, ten male partners and nine community leaders participated in individual interviews. Two focus groups with eight healthcare professionals and nine community health workers engaged in home-based HPV self-sampling. LTFU was defined as missing the scheduled Visual Inspection with Acetic Acid (VIA) and Visual Inspection with Lugol’s Iodine (VILI) appointment within three months of enrolment despite three weekly reminder calls and/or a home visit. Results Barriers were identified at all SEM levels: lack of time and fear of diagnosis (individual); partner influence (interpersonal); stigma and misconceptions (community); poor result communication and distance (organizational); limited infrastructure and policy integration (policy). Facilitators included contextualized health education (individual); partner involvement (interpersonal); community leader engagement (community); HPV-positive women as ambassadors (community/interpersonal); and decentralized screening and treatment services (organizational). Conclusions LTFU among HPV-positive women in Cameroon is influenced by multiple SEM levels. Enhancing health literacy, engaging men, involving HPV positive women as role models, and improving service delivery and policy integration were highlighted as especially important. Thus, multi-level strategies may help reduce LTFU and strengthen cervical cancer prevention in low-resource settings. Trial registration Ethical Cantonal Board of Geneva, Switzerland (CCER, N°202100085), (ClinicalTrials.govID NCT06166420 / 20231204) and the National Ethics Committee for Human Health Research in Cameroon. (N°2023/09/1579/CE/CNERSH/SP).