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“I'll Just Pick It Up…”

Women's Acceptability of Self-Sampling Methods for Sexually Transmitted Infection Screening

Griner, Stacey B. PhD, MPH*; Vamos, Cheryl A. PhD, MPH; Puccio, Joseph A. MD, FAAP‡,§; Perrin, Karen M. PhD, MPH; Beckstead, Jason W. PhD; Daley, Ellen M. PhD, MPH

doi: 10.1097/OLQ.0000000000001077
The Real World of STD Prevention
Free

Background Rates of sexually transmitted infection (STI) screening are suboptimal among college women. Self-sampling methods (SSMs) may improve STI screening rates, but critical gaps remain regarding the influential characteristics of SSM to prioritize in intervention development. The purpose of this study was to explore intervention characteristics influencing the decision to adopt SSM among college women.

Methods In-depth interviews (n = 24) were conducted with sexually active college women aged 18–24 years to explore preferred intervention characteristics of SSM. Interviews were stratified by screening status (screened or not screened). The instrument was guided by constructs from the Diffusion of Innovation theory and included characteristics of SSM, such as relative advantage, compatibility, complexity, adaptability, and risk and uncertainty.

Results Overall, women felt that the SSM was not complex and that the instructions were straightforward. Participants discussed their strong preference for receiving their results via text or e-mail rather than via telephone. In addition, women described their concerns about mailing their sample and described their concern about potential contamination and tampering. The most salient advantage to use of SSM was avoiding an interaction with a health care provider.

Conclusions This study contributes to an understanding of the salient intervention characteristics influencing the use of SSM for STI screening, which can be leveraged to improve the health of students and improve rates of screening. Findings can be used to inform the development of a future innovative, theory-based intervention that promotes the use of SSM to improve STI screening rates, and ultimately decrease the burden of STI-related disease.

College women identified mailing issues, contamination and tampering, parental concerns, reducing interactions with health care providers, and cost as factors influencing their adoption of self-sampling methods for chlamydia and gonorrhea screening.

From the *Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center, Fort Worth, TX

College of Public Health, University of South Florida

Division of Adolescent Medicine, University of South Florida Morsani College of Medicine

§University of South Florida Student Health Services, Tampa, FL

Conflict of Interest and Sources of Funding: All authors declare that they have no conflicts of interest. This study was funded in part through the Doug Kirby Adolescent Sexual Health Research Grant from the Rural Center for AIDS/STD Prevention at Indiana University. This study was also funded through the University of South Florida, College of Public Health.

Correspondence: Stacey B. Griner, PhD, MPH, Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center, 3500 Camp Bowie Blvd., Fort Worth, TX 76107. E-mail: Stacey.griner@unthsc.edu.

Received for publication August 13, 2019, and accepted September 13, 2019.

Online date: October 31, 2019

Rates of Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhea) are high in adolescent and young adult populations (15–24 years) and are higher among women in this age group compared with men.1 Because of the asymptomatic nature of these sexually transmitted infections (STIs) and the potential to prevent long-term adverse health outcomes, professional organizations recommend routine annual screening for sexually active women younger than 25 years.2,3 Although screening this population for chlamydia and gonorrhea is an evidence-based recommendation, it is underused in clinical care.4 Screening rates among young adult women range from 40% to 57%5,6 and are lower among at-risk subgroups, including women enrolled in college, with just 20% reporting screening in the past 12 months.7 However, the causes of the lower rates of screening among college women are not clear and may be multifactorial in nature.

Among young adult college women, many barriers to screening exist, including privacy and confidentiality concerns, cost, access, and underutilization of health services in general.8,9 Given these barriers, self-sampling methods (SSMs) used at home may be an innovative solution to improve chlamydia and gonorrhea screening rates among college women. Self-sampling methods are novel approaches to screening where the sample is collected by the patient, typically with a vaginal swab.10 Previous studies have indicated that SSMs are effective, as sensitive as provider-collected samples, and cost-effective.11–13

Although SSMs have proven acceptable among young adult women and adolescents,14–16 there is limited research on SSM acceptability specifically among college women. In previous SSM studies, most college women found it easy to follow the instructions and collect the specimen,17,18 and preferred SSM over traditional provider-collected methods.17 However, 26% of women in one SSM study declined to be screened because they felt uncomfortable with SSM.17 Although these studies provide data as to preferences among those who were willing to use SSM, they did not explore the reasons why women felt uncomfortable using SSM. One study noted that college women who were provided SSM “kits” were more likely to screen themselves than those who had to order the kit from a website.19

Self-sampling method has also been explored as a walk-in service within a college health center.18 After implementation, the main reasons for college women choosing SSM over clinician screening were ease of screening, no appointment needed, confidentiality, and cost ($30).18 In this study, the availability of SSM led to an increase in STI screening.18 Nonetheless, critical gaps remain in the literature regarding the acceptability of SSM for STI screening, which are essential to inform future intervention development. Therefore, the purpose of this study was to explore intervention characteristics influencing the decision to adopt SSM among college women.

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METHODS

In-depth interviews were conducted with sexually active college women aged 18 to 24 years to explore preferred intervention characteristics of SSM. Interviews were stratified by screening status (screened or not screened in the past 12 months). Screened women are women who reported they have received screening for chlamydia or gonorrhea in the past 12 months, whereas nonscreened women are women who reported that they had not received screening for chlamydia or gonorrhea in the past 12 months.

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Subjects and Setting

Participants were recruited via purposive sampling on a large, public university in the southeast via campus e-mail, list-servs, and flyers, and by contacting student organizations and sororities. The inclusion criteria were as follows: (1) identified as a woman, (2) currently enrolled at the university, (3) sexually active in the past 12 months, and (4) 18 to 24 years old.

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Sampling

Interview participants were sampled from those completing an online survey and were willing to participate in an interview. Participants were contacted in the order in which they completed their survey to schedule an interview. Ultimately, 12 screened women were interviewed, and 12 nonscreened women were interviewed. Participants received a $20 gift card for their participation.

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Instrumentation

The instrument was guided by constructs from the Diffusion of Innovation (DOI) theory. The instrument was pilot tested with 3 qualitative methods experts for feedback, refined, and tested with 3 members of the target population. Because of the novelty of SSM, participants were presented with a sample kit with instructions and packaging to familiarize themselves with the process. Characteristics of SSM, such as relative advantage, compatibility, complexity, adaptability, and risk and uncertainty, were included in the interview guide. Interview guide items are presented in Table 1 and aligned with DOI constructs.

TABLE 1

TABLE 1

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Data Analysis

Before the interview, participants were provided with information on chlamydia and gonorrhea and the process of traditional screening. All participants provided verbal informed consent and agreed to audio recording. Interviews averaged approximately 45 minutes. After the interview, the audio files were sent for transcription and the accuracy of the transcripts was verified against the audio files of the interview. The transcripts were then imported into MAXQDA software, where any notes from the debriefing were combined with the matching transcript. A codebook was developed with a priori and structural codes based on the interview guide and DOI innovation characteristics. The interviews were analyzed thematically using the codebook.20 Emergent codes noted were added to the codebook, and previous transcripts were reanalyzed. Interrater reliability with a second coder was calculated by coding one transcript together, resolving any discrepancies, and then independently coding 12.5% of the transcripts (3 interviews) to determine Cohen κ (0.84, indicating high coding agreement20). Matrices were created to view the themes by screening status for comparative thematic analysis.

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RESULTS

The mean age was 19.5 years, and those who were screened were significantly older than those who were not screened. The average (SD) number of partners was 2.7 (2.44) with no significant difference by screening status (Table 2). The salient themes within each construct are discussed hereinafter. A comprehensive list of the themes can be found in Table 3.

TABLE 2

TABLE 2

TABLE 3

TABLE 3

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Complexity

Before the questions, participants were given time to review the instructions provided with the kit, and then an overview of the collection and result processes were given by the interviewer. Participants were asked what about the described process was easy and what was difficult in receiving and returning the kit and the behavior of collecting their sample. Participants felt the sample kit would be easy to use and straightforward. Overwhelmingly, participants identified the instructions in the kit as easy to follow and felt that they reduced some of the associated anxiety and fear. Participants described the similarities between SSM and other behaviors, such as using tampons or Diva cups.

“Honestly, I view it as kind of like inserting a tampon except you have a little brush on the end. It's not large at all. It's not threatening in any way.” —Participant S3, screened

Because the process of using the sample kit was presented and included receiving the results online, participants discussed their strong preference for receiving their results online, via text or e-mail, rather than via telephone. Telephone calls were described as inconvenient and not timely. Although screened women and nonscreened women both preferred digital communication of results, the specific reasoning for this differed by screening status. Women who were previously screened were concerned only about lack of convenience associated with receiving their results via telephone but did not describe any associated stigma or privacy concerns. However, nonscreened women were concerned about privacy when receiving their results and felt that talking to someone on the telephone about their results was uncomfortable and more stigmatizing than text. They specified that it would be easier to read their results than have to talk to someone about them.

“I like their online form of like getting it because sometimes the doctor's people will call and that's embarrassing. Then generally they don't say anything over the phone but there's still a chance that they do, like leave a weird voice-mail and it's like, ‘Ugh …’” —Participant NS9, not screened

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Adaptability/Innovation Design

After reviewing the SSM process, participants were asked to consider how it might need to be changed to fit the college setting. One recommendation was to have different pick-up and drop-off options rather than relying on mail to receive and return the kit. Having these options would reduce the burden on students who may have transportation issues or privacy concerns. Overall, participants identified their preference for picking up and dropping off the kit somewhere on campus rather than using the mail system. Although most participants reported that they did not want to return their sample for screening through the mail, the reasoning for this preference differed by screening status. Screened women reported that they did not want to mail the kit because it was inconvenient and difficult to get to a post office or mailbox; however, nonscreened women reported that they did not want to mail the kit because they were unsure of the mailing process or the locations to access to mail the kit. This unfamiliarity was seen as a barrier and would lead participants to favor another approach. Unfamiliarity and concern about mailing the kit were not noted in screened participants.

“Actually, I don't know how to send mail yet, exactly. I know I have to go to the post office on campus, but it's not my mail building.” —Participant NS10, not screened

After discussing pick-up and drop-off locations for the kit, a few students described their preference for picking up the kit, collecting their sample, and dropping off the kit at the same time, in one location such as a bathroom. The bathrooms that were discussed the most were located in the dormitory, library, and student center. However, the preferences for alternative approaches to screening differed by screening status. Nonscreened women described their preference for the entire process to be contained at the student health center. Rather than taking the kit home, they would walk into a restroom at the student health center, collect their sample, and leave it for screening. This eliminated concerns about others tampering with the kit. This preference was not mentioned by screened women.

“I keep thinking the health center, because it should be associated with that. But I think there's a bathroom—so just have it near that, and be like, ‘Hey, go in here and drop that off.’ I think that'd be a good idea.” —Participant NS4, not screened

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Risk and Uncertainty

Participants identified potential issues that could be experienced during their use of SSM including privacy issues. A salient theme was concern about parent's perceptions. Most reported that they would try to keep information about their sexual behaviors from their parents. Some participants who lived at home discussed that their parents might find out if they brought the kit home. Participants also discussed concerns about SSM being billed through their parent's health insurance. They reported concern about their parents learning about their screening or other sexual behaviors.

“I'll just pick it up so I can get it in cash my parents won't even see that there was a transaction. Honestly, I think a lot of the times for college students it's parents and insurance because you know your insurance will contact them and they tell them.” —Participant S9, screened

Participants discussed other concerns with using SSM, such as collecting the sample incorrectly leading to receipt of inconclusive results. Although participants felt that there was little way to collect the sample incorrectly, they described concerns of putting the device in the wrong way. Participants were concerned that if they did collect their sample incorrectly, they would not know until their results came back “inconclusive,” and this would lengthen the time that it took to receive the results. Participants also expressed concerns about receiving results that were not theirs and the potential of others tampering and switching the boxes to take their results as their own.

“I just feel like some people are like weird. I feel like some people would even try to mess with it. I think for the most part; it wouldn't be a problem at all. I would feel a little bit scared if someone switched the boxes and then you got the wrong results.” —Participant S10, screened

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Relative Advantage

There were many advantages discussed when comparing SSM with in-clinic methods including increased comfort, convenience, and privacy. Participants felt that whenever they were in the waiting room at the student health clinic, people assumed they were there to be screened and using SSM would afford them more privacy. However, the most salient theme was the benefit of not interacting with a health care provider. The traditional screening appointment was described as uncomfortable, and the conversations regarding sexual behaviors were described as awkward. Participants voiced that they wanted to have the test done and “move on with their lives.” In addition, visits to a health care provider were viewed as sterile, cold, and clinical, and SSM was viewed as less intimidating.

“You don't have to talk to a doctor, mention anything to them. You don't wanna go to a doctor and be like, ‘I wanna get tested.’ They start asking you questions like, ‘Are you sexually active?’ And sometimes you just don't wanna have to answer those questions, you just want to take the test and be done.” —Participant S7, screened

Participants also described feeling more comfortable with SSM than traditional methods of screening because of their gender identity or sexual orientation. Some were hesitant to discuss their sexual behaviors and health care needs with health care providers because of a fear of judgment and viewed SSM as an alternative.

“For a lot of other people, especially in the LGBT community, it's an awkward topic. Having to speak about that with someone rather than just doing it at home in the comfort, privacy of your own home, and just sending it in and knowing, versus having to go to a doctor in person and talk. Not everyone's comfortable opening up about that.” —Participant NS3, not screened

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Compatibility

When asked about how SSM on campus would fit into their lifestyle, many college women felt that it would be acceptable and compared it with many other health-related resources the university offered, such as free condoms, pads, and tampons. However, many felt that to be compatible with the needs of college women, SSM would need to be covered by insurance or be low cost. Many participants described that the product should be low cost to students, with or without health insurance, as most women do not have money set aside for screening. Some described weighing the privacy concerns versus the financial cost to make their decision.

“I think if it was the same cost to take this versus to go to the doctor, I'll just stay home and take this. But if it's free with insurance at the doctor, I'll bide my time and put in the effort to make that extra phone call, because I have no money.” —Participant NS2, not screened

Participants gave a range of costs they would be willing to pay, from $20 to $30, and also described payment plans to make it more accessible for students. However, participants were very receptive to free opportunities or funding screening through the student health fee (collected through tuition), which was an unprompted response. Participants felt that making SSM available at a low cost was important, but discussed the need for treatment to be inexpensive as well.

“You can just pay—I don't know how much this would cost, but a one-time fee of 15, or 20 or 30 or whatever. That would be less daunting to them. They're like, ‘Okay, I don't have to have insurance to get tested and antibiotics are free at [local store].’” —Participant S9, screened

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DISCUSSION

This study used in-depth interviews, guided by the DOI theory to explore intervention characteristics influencing the decision to adopt SSM among college women. Overall, participants felt that SSM would be easy and straightforward, and increase privacy. Participants felt that the instructions included in the kit made SSM clear and easy to use. In previous studies of SSM, participants had similar perceptions of the directions.21 However, participants did have concerns about receiving their results after screening. Participants overwhelmingly preferred e-mails, texts, or apps, rather than telephone calls for their results, although previous studies have successfully used these methods to provide results.22 Nonscreened women in this study had more specific privacy and stigma concerns regarding telephone calls than did women who were previously screened. Although these concerns may be linked with a lack of knowledge because they have no experience with screening, many described the stigma associated with receiving results and discussing a private, sexually related issue with a stranger, which is common in the literature.8,17,23,24 The participants in this study were recruited from a convenience sample of sexually active college women willing to participate who may have been generally more comfortable discussing STI screening than other young adults. The clear interest in receiving medical information, including STI results via text or e-mail, should be considered a priority in future research and should explore how privacy can be ensured while maximizing patient convenience.

Although many SSM project designs have included mail, mailing the kit was not acceptable to this population for a variety of reasons. Women in this study generally described mailing as inconvenient and preferred dropping their sample off at a campus location. However, nonscreened women specifically felt that they lacked knowledge of the postal system to return their sample through the mail, although the sample kit indicated that returning the kit was postage paid. Nonscreened women were younger overall and may be less familiar with behaviors that are becoming uncommon among their age group. Generation Z, those born in years 1995 to 2010, are very familiar with online shopping and having items mailed to them,25 but not comfortable with interacting the postal system. Although little literature has focused on Generation Z's perceptions of mail, one study of college interns found that many would not send in their absentee voting ballots because they do not know where to purchase stamps.26 Generation Z are digital natives27 and therefore may desire interacting in this manner, and therefore, future studies should explore alternative methods to STI screening without involving the postal system to eliminate a potential barrier. However, because of the small sample size (n = 24), these themes are not generalizable to college women across the United States.

While exploring pick-up and drop-off locations for SSM kits, many women described potential alternative methods. Some women felt comfortable placing the entire process within a restroom, but also expressed concerns about contamination or tampering in those settings. In previous studies, worries of contamination and tampering during STI screening were common and also included the potential for others to use their sample for drug testing.28 Although contamination during sample collection has occurred in the past, the rates are very low.29 Considering this, many nonscreened women felt safer to have the process placed entirely within the student health center, which is similar to the process described in previous studies evaluating alternative sites for STI screening.18 The study used a walk-in, SSM approach, which reduced the scheduling barriers and increased rates of screening.18 This alternative approach is aligned with 2 themes participants described: the desire to have the process located in a private, safe area, and the desire to avoid speaking with a health care provider. Also, provider interaction was a concern among LGBT students, which is consistent with previous literature,30 and exploring preferences for alternative approaches to screening among LGBT populations may be insightful. Although other studies have noted that SSM would be comfortable and convenient for college women,17–19 it may be important to evaluate other programs and interventions that may increase screening rates, such as Get Yourself Tested, in addition to SSM.

A salient concern noted in this study linked parental perceptions with cost. Participants described not using their health insurance because they felt that their privacy would be compromised through insurance documentation. These concerns are similar to what is noted with traditional methods of screening.8 Because of the desire to avoid their parents gaining knowledge of their screening behaviors, many participants felt that it was essential that SSM was low cost so that the process could be completed without using insurance. Given this, future studies may focus on determining an acceptable price point for SSM. One study found that $30 for SSM was an acceptable cost for students18; however, a second study offered self-sampling kits at no cost, and many of the kits were not used.17 Given these findings, exploring alternative options and cost-effective solutions to traditional screening methods as a whole may be beneficial.

Future research could focus on translation of these results into practice through the development of interventions and programs by exploring another DOI construct, trialability. Few studies have evaluated the perceptions of SSM among college women after they have used SSM themselves,17–19 and providing women with the opportunity to try the method may impact their perceptions. Future research should explore how these intervention characteristics may differ by demographic and psychosocial determinants, including perceived STI risk, STI knowledge, and race/ethnicity. Although this formative research identified salient theory-based characteristics, next steps should further explore the application of the innovation-decision process and how development of interventions prioritizing these constructs might impact the adoption process and future dissemination and implementation. In addition, future research could generalize these results with larger, more diverse populations, and include transgender populations and men. This study contributes to an understanding of the influence of the salient intervention characteristics on use of SSM for STI screening. This study also contributes to advancing the field of public health by identifying theory-based concepts that can be leveraged to improve the health of students and improve rates of screening. Findings can be used to inform the development of a future innovative, theory-based, patient-centered intervention that promotes the use of SSM to improve STI screening rates, and ultimately decrease the burden of STI-related disease.

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