Stage-Specific Barriers to HPV Follow-Up After Screening in Rural India: A Participatory Qualitative Study
Anju Kane, Devanshi Somaiya, Kiranmayee Muralidhar, Raghavi Karnam, Shivamma N., Poornima Jaykrishna, Purnima MadhivananPURPOSE
Cervical cancer screening coverage in Mysore remains extremely low, with fewer than 3% of women ever screened. Despite expanding HPV-based screening, completion of follow-up after positive results remains a critical gap. Understanding stage-specific barriers across the screening cascade is essential to improving outcomes.
METHODS
We conducted four focus group discussions (FGDs) with women aged 30–65 years from rural Mysore, stratified by screening status including unscreened women (n=16) and screened women awaiting HPV test results (n=11). Participants were recruited from communities engaged in a cervical cancer screening program implemented by the Public Health Research Institute of India (PHRII). FGDs explored psychosocial and structural barriers to follow-up care across stages of the screening cascade, with thematic saturation achieved. Participants prioritized and ranked barriers using a participatory dot voting exercise. Discussions were transcribed and analyzed using inductive thematic analysis.
RESULTS
Participants ranked discomfort with male providers (10 votes) as the highest-priority barrier, followed by long wait times and unwelcoming provider interactions (6 votes each), and financial constraints, the need for family permission, and fear of pelvic examination (5 votes each). Among unscreened women, barriers were concentrated at the decision-making and clinic access stages, driven by provider gender preferences, financial constraints, and family permission. Among screened women, barriers were more heavily concentrated at clinic access and treatment stages, where long wait times, unwelcoming provider interactions, and fear of pelvic examination were most prominent. These barriers help explain observed attrition between result notification and colposcopy attendance in PHRII records, where only 32.2% of HPV-positive women completed colposcopy. These findings suggest that attrition is driven by a shift from social and decision-making constraints before screening to health system barriers after screening.
CONCLUSION
Barriers to HPV follow-up are dynamic and shift across stages of the care cascade. Interventions must be stage-specific to improve follow-up and completion. This study highlights the value of participatory ranking for identifying stage-specific, actionable intervention targets for community-based HPV screening programs in similar settings.