When asked whether they would prefer undergoing a pelvic examination or providing a self-collected vaginal swab in the future to test for infection, most women (60% [314/535]) reported that they would prefer to collect the vaginal swab specimen themselves, 23% (122/535) said they preferred a pelvic examination, and 17% (87/535) said that it did not matter to them (Fig. 2). Many of the women for whom the method did not matter indicated that they would prefer to use whichever of the two methods provides a more accurate medium for detecting infection. Approximately 20 women also commented that they preferred the pelvic examination because the doctor could look for other health problems. Nearly 40 women also expressed preference for the pelvic examination because they were not confident about their ability to perform correctly the self-collection of the swab specimen.
Nineteen percent of participants (103/535) were menstruating at the time of the study. A significantly greater proportion of menstruating versus nonmenstruating women expressed a preference for the noninvasive methods (P < 0.05) (Fig. 3).
We also explored differences between racial and ethnic groups. As with the general study population, we learned that more than half (56%) of the Latinas found no difference between swabbing and urine collection in terms of ease of the method. Latinas did, however, express a slight preference for the latter. There were no significant differences among other races in terms of ease of use or preferences for the future.
Participants’ age influenced preferences. Young participants (aged 18–22 years) were more than twice as likely as all other women to report that self-swabbing was an easier method and to express a preference for using that method rather than urine collection in the future (Fig. 4;P < 0.05). This age group differed only slightly from older women with regard to preferences for pelvic examination or self-collection of swab specimens in the future.
Until recently, optimal screening for bacterial sexually transmitted infections in women required performance of pelvic examination and endocervical specimen collection. With the advent of NAATs, alternative clinical specimens such as voided urine and self-collected swabs perform as well as clinician-obtained specimens for STD diagnosis. They also provide noninvasive options that have been shown in previous studies to be preferred to pelvic examination. 6,12,13 Yet, because most studies exploring preferences and acceptability of noninvasive techniques have generally included adolescent females, this study contributes to our knowledge about adult women's opinions.
Although women in this study could choose to provide a urine specimen, a swab specimen, or both, the fact that 97% of participants agreed to provide both specimens suggests that there was no strong aversion to either method. The results of this study suggest that female federal prisoners would generally favor noninvasive collection methods to invasive collection techniques. Half of the study population expressed no preference for urine or swab collection, finding both to be easy to perform. Inmates did not express aversion to urine collection, despite our concerns that they might suspect drug testing. In fact, a few women said that they preferred urine collection because they are so accustomed to it and they consider it a routine or “normal” procedure.
To our knowledge, whether menstruation influences a woman's preference concerning collection method has not been explored in other studies. We found that menstruating women prefer noninvasive collection to pelvic examination. Latinas were not as comfortable with the self-swabbing as other participants. This is consistent with the findings of focus group studies in which Latinas expressed greater discomfort with the swab self-collection procedure than did their non-Latina counterparts. 17 Young participants (18–22 years old) showed an overall greater preference than in older populations for self-collected swab versus urine specimen collection or pelvic examination. This preference by younger women is consistent with findings in other studies, in which youths expressed a preference for noninvasive techniques, and may reflect a cohort difference in one age group over the other. 12,13
An important limitation of this study is that data were collected from women in only one of the five main federal women's prisons. Therefore, the study results may not be generalizable to the entire women's federal prison population. Another limitation derives from the fact that nearly 80 of the women who gave specimens were required to return to their cells before completing the preferences survey. Fortunately, there were no significant demographic differences between these women and the women included in the study.
This study contributes to our understanding of women's preferences for STD specimen collection, particularly among women incarcerated in long-term facilities. The study found that one in four women preferred the pelvic examination to self-collection techniques. This differs from the findings of studies of adolescent girls in which more than 90% expressed a preference for self-collection techniques over pelvic examination. This difference may be explained by age and experience. Whereas in our study population more than 75% of women reported having had a pelvic examination at least 12 months before incarceration, many young girls (nearly half) have never had a pelvic examination, and fear of the examination may make the noninvasive techniques more appealing. 13,18
In our study, women's concerns about the noninvasive techniques seemed to center around access to a more comprehensive examination and a lack of confidence about self-collection methods. Although women prisoners would not have input on the specimen collection techniques used, knowing that they do not have strong preferences for or aversions to certain collection methods may assist prison health planners to implement changes on the basis of cost and staffing.
Increasing evidence of the effectiveness of these noninvasive methods may result in greater reliance upon them in future testing for a number of sexually transmitted infections. 19–22 If prison health planners consider using noninvasive techniques in the future, findings from this study provide evidence that female prisoners find them acceptable. While these techniques may provide an important opportunity to reduce the heavy demand on highly skilled clinicians, spare women from the discomfort of a pelvic examination, and provide a private, less invasive technique for finding infections, these techniques should not replace or undermine the delivery of quality health care attention by skilled practitioners to female inmates. The benefits of relying on patient-collected specimens must be carefully weighed against the risks of foregoing a pelvic examination in which other treatable conditions might be detected.
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