Feasibility of HPV self-sampling pathway in Kathmandu Valley, Nepal using a human-centred design approach

Figures & data

Figure 1. Stages of IDIs

Table 1. Demographic and socioeconomic characteristics of healthy women participants

Categories	Healthy participants (n = 30)
	n	%
Age group
25–30	9	30.0
31–35	9	30.0
36–40	3	10.0
41–45	8	26.6
46–50	1	3.4
Total	30	100
Highest education level
No formal education	8	26.7
10th grade	4	13.3
12th grade	4	13.3
Graduate	9	30.0
Postgraduate	5	16.7
Total	30	100
Socioeconomic status
Upper	6	20.0
Middle	17	56.6
Lower	7	23.4
Total	30	100

Figure 2. Proposed user journey presented to the participants in stage 2 and 3*

*Between stage 2 and 3, the format of information provided in the prototypes was adapted following potential user feedback

Table 2. Findings on the proposed user journey as per the healthy participants’ feedback

Stage in proposed user journey	Key findings indentified during in-depth interviews
Hear/ know about HPV testing online	− All literate participants engaged with concept − Limited literacy participants had passive interaction with social media content − Participants with limited literacy would be able to engage in the concept if it had more audio visual component
Finding out more about importance if an HPV test via chat /video	– All participants were familiar with some form of social media with varying degrees of engagements – All interviewees were familiar with Facebook Messenger (FBM) – Many factors influenced the choice to engage in a chat with a healthcare provider: ○ if symptoms were present ○ if the chat was free of cost ○ if they stumbled into the information when they were not engaged in work
Ordering an HPV test online	− There was an overall low experience & trust in online purchasing − Varied perception of cost from 100 to 10,000 NRs − Only 7 of the 30 participants (23.3%) had used digital payment methods
Receive the test package via a delivery person	− Online parcel delivery was possible to local landmarks as well as home address − There was a general preference to buy from a pharmacy − There were some concerns about the identity of driver and privacy
Self-sampling	− Mixed response to self-sampling. (56.7% (n = 17/30) of interviewees willing to self sample and 43.3% (n = 13/30) said they were hesitant and would like some professional aid to do the self-sampling.) − There were some concerns of breaking the swab or doing the process incorrectly (and getting a false negative result) − Although useful, the imaged based instructions were not easy to understand at times, perhaps because of the language barrier − Women suggested that a video-based instruction would be useful to both raise awareness and understand the instructions
Returning the sample to the lab	− Low confidence in having the sample collected by a pick up person − There were some trust issues in the driver returning the sample safely − There was a positive feedback on dropping the sample at a suitable location e.g. clinic, hospital
Obtaining results of the test + signposting and referral	− There was mixed response to receiving results via chat channel − There were concerns over privacy, literacy and understanding the results − Participants who preferred getting message wanted it in a downloadable format to use the results with their doctors

Table 3. Quotes from the healthy participants

On SRH issues:
“I think many Nepali people are negligent about their SRH. For instance, people don't even change their undergarments every day, people don't follow proper hygiene habits after using public toilets, and people don't pay attention to what chemicals they are using near their private parts, or to wash them.” “I don't think I am well informed regarding the SRH. When I was growing up, sex was always a taboo subject, nobody would talk about it freely. I never put forward any questions regarding it and nobody in the family came forward to educate me about it … . Till now I am not really open about talking about the SRH issues with anyone, it's via movies that I know a little and there is the internet which provides a bulk of the information.”
On STIs and cervical cancer:
“I thought cancer of the uterus and cancer of the mouth of the uterus were the same.” “I have heard of cervical cancer in the news sometimes but I don't know anything in detail of the tests that can be done.” “I think I would not be too uncomfortable [to discuss about STIs] because I have a kid, and I think women with children or who are married will have less hesitation to talk about it than women who are unmarried. Unmarried women may have problems talking about it for the fear of what people would say about how she got this disease even before getting married.”
On use of internet & apps:
“I don't know how to put up posts, so I just look at what others put up as posts. I know how to like and share the posts, that is all. Mostly I pay attention to the photos and videos put up there, but I am limited to the post that comes in my feed. I don't know how to navigate the app properly.” “I use the internet only when I have the time. But having said that I do use the internet to play music in the background when I am working. But I use Facebook to see what others have posted, if someone has posted some health related information, I do read them if I have the time.”
On online purchasing and transactions:
“I do tend to do online shopping quite a bit. I used to engage in it before as well, but obviously, now it's become more frequent in many people's lives due to COVID. From small groceries to other non-essentials, I get them from ‘Daraz’ [online shopping store]” “I think online shopping is for people who are very busy and don't have time to go in person to buy things. But since we are free at home, I think it's better that we go out and get things ourselves. Also because we are housewives, it's important that we try and use the money earned by our husbands in the best possible economic way by searching for places where things can be bought in the cheapest price.”
Reaction to the kit:
“I would use it [the swab in the kit], put it back in the packet and the box. And because of the medical literacy that we have all built because of COVID, everybody sort of knows that this is like a swab instrument. It's not alien medical equipment to us anymore.” “I would not want to do it on my own because I would worry whether I did the test correctly or not, and how painful the insertion might be. I would worry if the cervical brush might break inside and get stuck there, what would I do in such a situation? Owing to all these fears, I would want to go to the doctor themselves” “I think a video would help. By video I mean animation. If all the steps written here are shown there in an animated version, perhaps it can be more informative. Here just the pictures are shown, I don't know in which position I am supposed to be when I insert this, a video could make it clearer.”
On online availability/ delivery of the kit:
“I think online [availability of the kit] would be better. Even if you put the kit in pharmacies, even to this day, women get embarrassed in buying birth control pills and other contraceptives from the pharmacies. So I think online is best.” “I think pharmacies can be a better alternative for our context. That can make it more accessible for many people” “Yes, I think so too [buying it online] because many times women may be busy with their chores and may not get the time to go out to buy things”
On sending the sample:
“I am concerned about sending the sample. I am concerned what if the delivery person doesn't take the sample with the level of care that the sample needs to be transported with? What if someone actually has some sort of infection and if the delivery person does not take proper care during the transport, what if the infection [infectious organisms] increases in the kit? So the report may show increased infection in comparison to what one actually may have.” “In case the lab is far away, I would probably use the delivery personnel provided by the lab or organization. For eg: after I do the self sample, if I have the option of dropping it off at my local pharmacy or nearby hospital, I can do it myself. But if I would need to travel to a hospital to a distance like that of Bir Hospital, then I might feel lethargic and just not do the test itself.”
On obtaining the results:
“They could call. If they sent messages, since I can't read that well, it would be difficult for me.” “Email because it is instantly accessible. I don't have to go collect results, so it's practical. Another key factor is that it's accessible, but at the same time, unlike the SMS service [mobile messaging service], it doesn't randomly pop up on your phone, when you're hanging out with friends or family.” “But if the result is positive then I should get the opportunity to meet Dr. Rina Kumari, and consult with her. If the test is negative, messaging like this is fine.” “If the result is told to the women via phone, one only gets to hear it, one will not be able to see the report. So I prefer to get the result via email so that I could print it and show that to the doctor next time I visit the doctor.”