Vol.5, No.12, 2162-2168 (2013) Health
Acceptability of self-taken vaginal for early detection
of HPV DNA in women with limited access to health
services: An alternative to increase the coverage in a
state of the Mexican Republic
Terán-Figueroa Yolanda 1, Muñiz-Carreón Patricia1, Gallegos-Arévalo Yolanda Graciela2,
Gaytán-Hernández Darío1, Gutiérrez-Enríquez Sandra Olimpia1*
1Nursing Faculty, Autonomic University of San Luis Potosí, San Luis Potosí, México; *Corresponding Author: sgutierr@uaslp.mx
2Faculty of Nurse and Nutriology, Autonomic University of Chihuahua, Chihuahua, México
Received 5 November 2013; revised 8 December 2013; accepted 21 December 2013
Copyright © 2013 Terán-Figueroa Yolanda et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective: To determine the acceptabilit y of self-
taken vaginal to detect HPV DNA in women liv-
ing in marginalized areas as an alternative to
increase the coverage of health services. Meth-
ods: A cross-sectional study from March 2009 to
April 2011 in 20 municipalities with the highest
marginalization in the Huasteca Region of the
State of San Luis Potosi, México. We applied a
non-probabilistic quota sampling, which was
composed of 608 women aged 25 years and
mo re . Th e re cruitment of women was performed
through loudspeakers, leaflets and community
meetings. A survey consisted of two sections:
socio-demographic data and risk factors, which
was validated by construct. We checked the re-
liability by Cronbach’s Alpha (0.90). Acceptabil-
ity was determined by considering three indi-
cators: perceived comfort, acceptability of the
test and the reasons of acceptability. Results:
41.4% of this woman had 31 - 40 years. 70.5%
were married. 35.3% finished high school and
6.7% had not educat ion experience. 6 7.4% began
their sexual life at 18 years or younger. 85.5%
preferred self-collection and 14.5% Pap. These re-
sults show a clear acceptability of self-making
on the other screening method. Regarding the
reason for the p reference is that 99.4% of women
prefer self-take because they feel more comfort-
able compared to 0.6% who prefer the Papani-
colaou. On the perception of comfort 91% men-
tioned feel very comfortable with self-making
compared with 9% of Pap. There was a statisti-
cally significant correlation between preference
reasons that w omen have to choose the screen-
ing test and the perception of comfort (X2p =
0.000). Conclusions: The self-taken vaginal HPV
DNA detection is a well accepted method in
women who live in marginalized areas; therefore,
it is an alternative that can be considered in the
uterine cancer detection tes ting prog ram.
Keyw ords: Self-Taken Vaginal HPV; Cervical
Cancer; Acceptability of Self-Making
Cervical cancer (CC) remains one of the most frequent
causes of death in women [1] and a public health prob-
lem worldwide especially in underdeveloped countries,
with an annual report of 510,000 cases [2,3], an esti-
mated 274,883 deaths in 2008. In México the disease
ranks second in incidence and is a major cause of cancer
death in women older than 25 years [4]. The cause of
cervical cancer deaths that occur in México each year
mostly affects women living in marginalized areas. For
2007, México recorded that a mortality rate of 14.2 per
100,000 women and specifically in the state of San Luis
Potosi (SLP), which has indigenous settlements, was
between 17 and 17.5 [5]. Prevention efforts worldwide
have focused on the screening of patients at risk using
Pap test (Pap) and treatment of precancerous lesions. In
México the early detection of cervical cancer program
has more than 20 years in operation and avoided less
than 13% of preventable cases [6].
The conventional Pap smear is the most used tech-
Copyright © 2013 SciRes. OPEN ACCESS
T. -F. Yolanda et al. / Health 5 (2013) 2162-2168 2163
nique for early detection of cervical cancer and precan-
cerous lesions. Based on the fact that cells of the cervical
epithelium layers are shed continuously. To remove cells
requires professional or technical staff. For obtaining
cells women must be in the gynecological position, the
speculum of metal or plastic is inserted into the vagina in
order to observe the cervix. Once located proceed to col-
lect the cells by special instruments such as Ayre spatula
and cytobrush. The cellular material extends in a glass
slide, fixed with alcohol and sent to the laboratory for
analysis and interpretation. For this study the woman
must expose their private parts so that the doctor or nur-
sing staff take the sample. In México, one of the main
factors limiting the success of cervical cancer prevention
in addition to those related to the organization of health
systems is the socio-cultural aspect that hinders proper
implementation of preventive measures.
One explanation for the low coverage is the limited
use and poor accessibility of women to the Papanicolaou
(PAP) due to cultural and institutional barriers such as:
discomfort with the pelvic exam, their husbands or sex-
ual partners are not allowed to take Pap, previous nega-
tive experiences with service providers, ignorance of the
Pap, perception and the long waiting time for delivery
of results [7]. The limited success of this programs has
been the estimating testing for DNA Human Papillo-
mavirus (HVP). Several studies have evaluated the cli-
nical utility of the Hybrid Capture (CH2) in cervical
cancer screening. The sensitivity was 86% for any type
of HLG (low grade lesions) and 93% for LAG (High
Grade Lesions), compared with 60% and 73% of Pap [8].
Screening of High-Risk HPV has been shown to be a
highly sensitive tool in the early detection, and it has
been successfully used in clinical and epidemiological
studies showing that it is suitable for population pro-
grams obtaining the sample that is much easier, and the
interpretation of the result. Recent large-scale studies in
women, who do not participate in conventional screening
program, have shown that the supply of self-take for
HPV detection, and an effective alternative to attract up
to 30% of these patients [9-12] have increased the cov-
erage. San Luis Potosi in 2010 began to implement HPV
testing [13]. However, the accessibility of the service and
the cultural aspect has not been resolved, like time con-
straints, discomfort, this is how the idea of promoting the
patient’s own take of the sample (self-making) represents
an option that involves social and economic benefits,
which together with other actions would lead to a de-
crease in the incidence of cervical cancer. The objective
of this study was to determine the acceptability of self-
taken vaginal to detect HPV DNA in women living in
marginalized areas as a possible alternative to increase
the coverage of health services.
2.1. Data Source
Cross-sectional study conducted in the period March
2009 to April 2011 in the 20 municipalities with the
highest marginalized rating in the Huasteca region of the
State of San Luis Potosi, México. The level of poverty
data were obtained from CONAPO (National Council of
Population), which considers five units: Very Low, Low,
Medium, High and Very High level of poverty, based on
the indicators: private homes inhabited, percentage of
population 15 years or more without complete primary
illiterate, percentage of occupied private housing inhab-
ited with no toilet and no electricity, percentage of occu-
pied private housing without piped water availability,
average occupants per room in occupied private housing
with floor and have no refrigerator. The universe of
women in municipalities is 79.946. Due to the difficulty
in locating women given the characteristics of the geo-
graphic area we applied a non-probabilistic sampling fee,
which was composed of 608 women aged 25 years and
over, distributed as follows: Aquismón 38, Axtla de Ter-
razas 36, Ciudad Valles 92 Coxcatlán 18, Ébano 45, El
Naranjo 14, Huehuetlán 10, Matlapa 35, San Antonio 5,
San Martin Chalchicuautla 29, San Vicente Tancuayalab
13, Tamasopo 16, Tamazunchale 88, Tampacán 16,
Tampamolón Corona, 15, Tamuín 35, Tancanhuitz 13,
Tanlajás 20, Tanquián of Escobedo 16 and Xilitla 48.
The recruitment of women was carried out through loud-
speakers, leaflets and community meetings. A group of
promoters gave a talk about HPV and vaginal self-take to
build awareness. The women took the samples in the
bathrooms of the health centers. To collect the data, a
survey consisting of two sections: socio-demographic
data and risk factors which was validated by construct,
and the reliability was verified through Cronbach’s Al-
pha (0.90).
2.2. Materials
The samples were obtained as described in the manual
collected vaginal National Institute of Public Health
(INSP) of México [14]. Briefly, the user is prompted: 1)
how to open the collection kit which consists of a cyto-
brush and specimen transport tube, 2) how to get the
brush and 3) how to open and close the tube. Later was
taught how to take the sample taking the following order:
washing hands, naked from the waist down, pull the cy-
tobrush and transport tube case, take the brush with the
dominant hand, raise one leg on the bed, chair or toilet
and non dominant hand to separate the labia (genitals),
insert the brush vagina and once inside, turn three times
to the right and three times to the left, remove and place
immediately in the tube, recharging on the wall of the
tube and close the pressure, deliver to the trainers. At all
Copyright © 2013 SciRes. OPEN ACCESS
T. -F. Yolanda et al. / Health 5 (2013) 2162-2168
times we used appropriate language for understanding
according to the characteristics of the population in each
community. When necessary, they requested support
from translators in order to communicate with women
who only speak a native dialect (Tenek or Nahuatl).
2.3. Sample Processing
Each sample was labeled using a bar code and stored
at 4˚C. The HR-HPV infection was determined by Hy-
brid Capture (Digene Hybrid Capture ® 2). Samples
were processed in the Laboratory of Molecular Biology
Diagnostics on the device INSP Rapid Capture System
Digene DML 2000.
2.4. Map Production
It was used ILWIS 3.3 software which is an acronym
for the integrated management of land and water in a
Geographic Information System (GIS) with image proc-
essing capabilities developed by the International Insti-
tute for Aerospace Survey and Earth Sciences Enschede,
Netherlands, which allows you to view different areas at
one time. To create the map were obtained databases of
geographic coordinates of the locations of the Huasteca,
which were converted to Universal Transverse Marker
(UTM). He placed the Digital Terrain Model (DTM),
and polygon map to identify the boundaries of each mu-
2.5. Data Analysis
We used SPSS (Statistical Program Social Science) v.
15.0. For the interpretation of the data descriptive statis-
tics were used. To verify whether there was a relation-
ship between the variables: “preference reasons” of self-
making as a screening with the “comfort women per-
ceived” to be tested (self-making) was applied Pearson
2.6. Ethical Considerations
All participants gave their consent to participate in the
study. The project was evaluated and accepted by the H.
Research Ethics Committee of the Faculty of Nursing
UASLP, 0028HCEI key.
In México there are 84,769 localities, of which 26.4%
(22,443) are classified as highly marginalized degree,
while 73.5% (62,326) are highly marginalized (National
Institute of Statistics, Geography and Informatics INEGI,
2010). Specifically in the State of San Luis Potosi, 2.2%
of the population (781 seats) has a very high level of
poverty and 32.9% (3001 seats) are highly marginalized
(INEGI, 2010) (Figure 1, panel A and B respectively).
On the other hand, in the region where this study was
done, it appears that women of all municipalities partici-
pants living in high to very high levels of marginalization.
This is an indigenous settlement area (Figure 1, panel
Socio-demographics characteristics were studied.
41.4% were located in the age group of 31 to 40 years,
followed by the group of 41 to 50 years with 31.5%.
Most women are married (70.5%). The highest level of
schooling was to complete high school (35.3%). It is
important to show that 6.7% does not have any study.
Most women (76.8%) are housewives. 67.4% began their
sexual life at 18 years or younger (Table 1).
In relation to Acceptability of self-collected vaginal
test, 85.5% prefer the self-collected and 14.5% Papani-
colaou (Figure 2).
With regard to the reasons for preference of each
method 99.4% prefer self-take because they feel more
comfortable compared to 0.6% who prefer the Pap. The
92.9% reported other reasons for preferring self-taken as
the following “easy”, “simple”, “feel more confident”,
“is faster”, “comfortable”, “do not bother or do not hurt”,
“making it yourself”, “practice”, “safe”, “is more per-
sonal”, “painless”, “no scrape or hurt instruments”, “is
material unique”, “instruments are used only once”, “is
toilet”, “not embarrassed or ashamed”, “the instrument is
personal”, “on-irritating”, “does not open from the va-
gina” With regard to the perception of comfort 91%
mentioned feeling very comfortable with self-taken com-
pared with 9% of Pap. It was considered desirable to
check whether there was a relationship between the rea-
sons for preference for self-collected vaginal test with
the perception of comfort in women who participated in
the study. The result was that the perception of comfort
influencing the choice of technique (X2p = 0.000) (Table
The social substrate determined by poverty, gender
inequity, and poor access to information, among other
factors kept large segments of the female population of
this region under conditions of high vulnerability and
risk of illness and death from cervical cancer. According
to INEGI (2000) in México, 30.6% of all women who
died were illiterate, 21.9% attended less than three years
of elementary school and 13.8% only three to five years
of elementary school, indicating that 66.3% of all deaths
from this cause were illiterate or with incomplete ele-
mentary school. It has been shown that low socioeco-
nomic status is a significant development in the CC risk
factor because of the effect it has on educational and
medical resources. Results of several epidemiological
studies indicate that Hispanic and African-American
women have a higher risk of developing invasive cervi-
Copyright © 2013 SciRes. OPEN ACCESS
T. -F. Yolanda et al. / Health 5 (2013) 2162-2168
Copyright © 2013 SciRes.
Source: CONAPO estimations based in INEGI, population and
housing census 2010. Main results by location.
Consejo Nacional de Poblaciόn
Océano Pacífico
0 200 400 600 Km
Golfo de México
El Salvador
Consejo Nacional de Población
0 25 50 75 Km.
uevo León
0 10 20 40 kilometers
Figure 1. Degree of marginalization in which women who participated in all municipalities live. (A) Map of México in which points
light and dark are shown locations with very high and high marginalized respectively (circulated San Luis Potosi region). (B) Map of
San Luis Potosi shown circulated the Huasteca Potosina region. The light and dark spots indicate the various degrees of marginaliza-
tion (Etimations based in INEGI population and housing census 2010). (C) Map of Huasteca Potosina region. Dark areas show very
high and high marginalization locations. Graphics show percentage of marginalization location. Maps were obtained from CONAPO,
cal cancer compared to Caucasians [15]; a decreased risk
of developing this disease is associated with more ad-
vanced education. The increased risk associated with low
socioeconomic status is attributed to the lack of testing, a
failure in the treatment of precancerous conditions, and
lack of knowledge about the prevention of HPV infection
[16]. Women who participated in this study are in this
poverty. Therefore, it is possible that if access to screen-
ing tests such as vaginal self-making, and other measures
of health were improved, the race of the person would
not be proved to be a significant risk factor.
HPV testing has become increasingly important. In
countries that do not have an infrastructure cyto-patho-
logical or have organized health programs, programs are
T. -F. Yolanda et al. / Health 5 (2013) 2162-2168
Table 1. Socio-demographic data and first intercourse of wo-
men who live in the Huasteca region of San Luis Potosi, México.
Variable No. %
Age group
30 or less 101 16.6
31 - 40 252 41.4
41 - 50 192 31.5
51 - 60 55 9.0
61 or over 7 1.1
Not answered 1 0.0
Marital status
Married 429 70.5
Free unión 118 19.4
Single 37 6.0
Widow 14 2.3
Divorced 9 1.4
Not answered 1 0.0
None 41 6.7
Incomplete elementary 92 15.1
Completed elementary 179 29.4
Incomplete secondary 38 6.2
Completed high 215 35.3
Incomplete bachelor 7 1.1
Completed bachelor 31 5.0
Technical career 1 0.1
Unfinished degree 1 0.1
Degree completed 2 0.3
Not answered 1 0.0
Housewives. 467 76.8
Self-employment 69 11.3
Employee 59 9.7
Business 6 0.9
Cooperative member 5 0.8
Laborer 1 0.1
Not answered 1 0.0
Age of first intercourse
18 or less 410 67.4
19 or over 197 32.4
Not answered 1 0.0
n = 608.
14.5 %
85.5 %
Papanicola ou
Self-collected vaginal test
Figure 2. Acceptability of self-collected vaginal test in women
who live in marginalized areas of the Huasteca Potosina region.
considering HPV detection as a surrogate marker of ab-
normal cytology. A study in the USA showed that the
timing of self-sampling does not affect HPV detection
(intercourse menstrual cycle or pre-shot), plus the num-
ber of days since the last sampling does not affect repro-
ducibility of viral detection, which enables the test be
repeated at short intervals (days or weeks), important for
the practical aspects of screening programs for the possi-
bility of loss, as they cannot be processed or have be re-
peated rapidly [17].
The acceptability of self-making depends largely on
cultural factors. The results of this research in women
living in marginalized regions of the Huasteca region
indicate that the perception of comfort is related to the
acceptability of the test and that the reasons are related to
the preferred screening method, so that you can evidence
that the comfort of the test is what leads to their accep-
tance as well. Women do not feel embarrassed and feel
more confident in the result. A study by Torres-Poveda
in 2008 mentions that in programs for indigenous people
whose cultural barriers can be an obstacle to the accep-
tance of common gynecological, procedures and access
of women to them obtaining samples for their own fea-
tures suitable for use in the HPV DNA test can be a sat-
isfying and culturally acceptable procedure [18]. Heide-
man in 2012 mentioned that the women report preferring
self-takes to the sample by a professional. The reasons
women gave are very similar to those presented in this
study as follows: the point of sampling, privacy and the
simplification of the technique compared to the Pap that
causes pain and shame [19]. Given this preference is not
surprising that the supply of self-taken for HPV DNA
detection attracts up to 30% of women not participating
or unwilling to make use of regular screening program
[20]. This is encouraging to be implemented in our envi-
ronment, thereby increasing the coverage and thus achiev-
ing the goal of reducing mortality rates in México.
Papers published in US and European populations in-
dicate that acceptance of self-making is almost univer-
sal and this technique is preferred to annual review spec-
ula. The authors emphatically mention that it is important
to perform studies to determine the acceptability of self-
take between the target populations before embarking on
larger projects [21]. In the cluster randomized controlled
trial done in rural India by Sankaranarayanan, found that
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T. -F. Yolanda et al. / Health 5 (2013) 2162-2168
Copyright © 2013 SciRes.
Table 2. Reason of preference and perception of comfort with self-taken vaginal and Pap.
Self-colleted Pap test
Criterion Frequency % Frequency % Frequency %
Prefera b ly reason
Another 118 92.9 9 7.1 127 100.0
Feel more confident 75 50.7 73 49.3 148 100.0
Se siente más cómoda 324 99.4 2 0.6 326 100.0
Felt ashamed 2 40.0 3 60.0 5 100.0
Not answered 1 50.0 1 50.0 2 100.0
Overall 520 85.5 88 14.5 608 100.0
Comfort perception
Nothing comfortable 0 0.0 1 100.0 1 100.0
Shortly comfortable 29 46.0 34 54.0 63 100.0
Comfortable 298 89.8 34 10.2 332 100.0
Very comfortable 193 91.0 19 9.0 212 100.0
Overall 520 85.5 88 14.5 608 100.0
a single round of screening with HPV testing substan-
tially reduced the risk of death from cervical cancer in a
follow-up of eight years compared to women who were
not offered the test, indicating that the former were half
as likely to develop or die from this disease [22]. Women
with DNA positive for high risk HPV in samples ob-
tained by self-making, currently were advised to do the
Pap with a significant risk of loss to follow-up. In the
future, this step can probably be avoided by direct appli-
cation of molecular markers. It is therefore considered
that the time has come to introduce self-sampling as an
alternative screening by testing for viral DNA [17].
gram for early detection of cervical cancer, even in de-
veloped countries. For those who have not achieved
100% coverage, for example in the Netherlands, the pro-
gram has been since the 70s, and has a participation rate
of 67% and together with opportunistic smears and di-
agnostic coverage of 75% [9], therefore, implement self-
making is an opportunity for decision makers, mainly in
countries where the magnitude of this problem is still
very large.
These results are important for the management of
public services. The health programs should have special
characteristics according to the population it is intended.
In this particular case of indigenous communities, health
personnel should be trained on the new technologies for
cervical cancer screening in order to offer to clients and a
safe and reliable screening, guidance on the importance
of self-care, because the poorer women are those that
generally require treatment for advanced forms of CC,
due to the fact that they are those who have had limited
access to early detection services likely cultural reasons.
This situation of inequality in health in sexual and re-
productive health of the indigenous population is socio-
logically determined and in different cultural contexts is
difficult to interpret the epidemiological risk for devel-
oping cervical cancer. Increase coverage has been a con-
cern of all countries that implement a public health pro-
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