In this study, sampling continued until ‘data saturation’ was achieved. However, it is important to acknowledge that true data saturation would be something that is very difficult to achieve as every individual will have a slightly different perception relating to HPV self-sampling. Therefore, data saturation in this context refers to the
identification of no new significant or relevant themes of interest to the study
objectives. The type of information that is obtained from qualitative studies is very rich in detail, necessitating relatively small sample sizes so that the data can be analysed in depth (Ritchie et al. 2006). Furthermore, because participants were purposively
recruited based on low intention to self-sample as measured by the survey (Chapter 4), different themes might have been identified if other women had been recruited. The potential for sampling bias is acknowledged as the sample was not representative of the population as a whole. The sample was not representative as it included a high number of highly educated white women and women who had all previously attended
169 a smear test appointment, and many of whom had previously received abnormal smear test results.
The majority of research into attitudes towards HPV self-sampling has been carried out in women who do not attend cervical screening, and is helpful if self-sampling is to be offered as an additional method for cervical screening in non-attenders. However, it was considered important to understand the attitudes of cervical screening attenders if self-sampling is to potentially replace routine cervical smear screening or be used as a method of triage. It was also important to ascertain the self-sampling intentions of women who have had an abnormal smear test result because many of them would eventually be returned to the screening programme and may have to utilise HPV sampling. However, this study investigated women’s attitudes towards HPV self-sampling in a hypothetical scenario where women were asked to predict their intention to self-sample should it become incorporated into the cervical screening programme. Therefore, it may be argued that women’s intentions may be different if they were physically presented with a HPV self-sampling kit for cervical screening.
Although all women interviewed had been classified as less likely to self-sample by the survey, some reported that they would engage in HPV self-sampling. This discrepancy might have been observed because the survey stated that the women were less likely to self-sample as opposed to not intending to self-sample at all. It therefore might have identified women who had more questions about self-sampling and were more
apprehensive about this screening method. Furthermore, the survey utilised quantitative methods to ascertain women’s intentions to self-sample, whilst the interviews provided further insight and depth on how intentions were formed. The high level of self-sampling intention observed is contrary to that observed in some other studies (Bais et al. 2007; Sanner et al. 2009a; Gok et al. 2010), where only around a third of women reported that they would be likely to self-sample. It is important to note that the majority of these studies involved women who were cervical screening non-responders and were therefore a difficult group of women to engage in screening.
170 In contrast, all of the participants in the current study had attended a cervical smear screen and were already engaged in the cervical screening programme, which might explain the high intention rate. The qualitative approach was able to provide more insight and depth in understanding the way in which intentions to self-sample were formed by acknowledging the world view of the participants (Ritchie and Spencer 2002). Interviews were an appropriate data collection method as they facilitated the in-depth exploration of interactions between factors previously identified (Chapter 4) as being associated with intentions to self-sample (Smith 1995). The semi-structured interview schedule consisted of open ended questions, probes and follow up
questions, ensuring that the topics covered in each interview were standardised. This ensured that all participants responded to the same questions, representing a range of views (Bourgeault et al. 2010). However, due to the flexible and reflexive nature of interviews, deviations from the interview schedule were often observed, and therefore interviews allowed new themes to emerge (Green and Thorogood 2011).
Verbatim transcription was conducted and was a useful method in bringing the researcher closer to the data than selective transcription (Halcomb and Davidson 2006). Verbatim transcription was beneficial for facilitating the development of the conceptual framework by enabling the researcher to check the relevant primary data.
It also provided an audit trail (Halcomb and Davidson 2006) for the data analysis and framework modification process. Nevertheless, the process of transcription is prone to human error and interpretation of phrases might have been altered if the intonation of words transcribed were also noted. To minimise this risk, the researcher listened to all the interview recordings before the transcript analysis and was familiar with the tone of the interview.
Framework analysis was particularly suitable for the present study, because findings will be used to inform the content of a behavioural intervention and to help inform policy and practice (Green and Thorogood 2011). A detailed framework analysis was conducted which was highly time consuming but was able to provide a rich, clear and
171 structured representation of women’s attitudes towards HPV self-sampling. Although the framework originally started deductively from pre-set categories relating to the HBM and findings from the survey, it was modified extensively throughout the analytical process which became more thematic and therefore became a highly
complex multi-level framework. The structured nature of the framework facilitated the viewing and assessment of the data analysis process by people other than the primary analyst (Pope et al. 2000).
5.6.2 Conclusion
The present chapter facilitated a rich understanding of potential facilitators and barriers to primary HPV self-sampling. This is the first study to highlight the potentially important influence of system factors on intentions to self-sample. To encourage uptake of HPV self-sampling, an intervention is needed that aims to increase women’s HPV knowledge, confidence in their ability to carry out HPV self-sampling and
confidence in the set-up of a potential self-sampling programme.
The following chapter will describe how factors identified in this PhD research were synthesised to form the content of a theoretically-based intervention designed to increase engagement with HPV self-sampling.
172 Chapter 6
Intervention development and user testing 6.1 Chapter Overview
This chapter will present the development, preliminary user testing and subsequent modification of an intervention to enhance uptake of HPV self-sampling.
6.2 Introduction
Findings from the previous phases of work were used to develop a draft intervention to enhance uptake of HPV self-sampling. Barriers and enablers to HPV self-sampling identified in Chapters 4 and 6 were synthesised in the draft intervention, which was designed to increase women’s HPV related knowledge, address identified barriers, highlight benefits of self-sampling and to increase self-efficacy. Self-efficacy refers to the users’ confidence in their ability to carry out self-sampling correctly. Increasing self-efficacy beliefs was highly important because self-efficacy was shown to be the strongest predictor of intention to self-sample (Chapter 4) and influenced women’s confidence in HPV self-sampling results.
Interventions to promote health protective behaviour can be developed at an
individual level, community level and organizational level or societal level (Westmaas et al. 2007). Interventions designed to promote healthy behaviour can be targeted directly at the individual, by attempting to alter attitudes and beliefs through an intervention directly distributed to the individual such as a leaflet. Interventions that attempt to alter societal or community attitudes attempt to influence whole
communities. Such interventions can include media campaigns such as posters and social organisations to promote healthy behaviours. The population based
interventions are wide spread interventions designed to portray simple messages and include laws such as wearing seat belts whilst in cars and the prohibition of smoking in social spaces. The Behaviour Change Wheel (BCW) (Michie et al. 2011) can be used to
173 design interventions that capture different sources of behaviour, such as individual perceptions regarding capability, motivation and opportunity, as well policy
considerations. Therefore, the BCW could have been used to develop an intervention designed to address both individual, as well as social and policy level considerations associated with HPV self-sampling intention. However, as a HPV self-sampling programme is currently not available, policy considerations are still to be debated.
Therefore, it was decided that although the BCW would be a useful model for intervention development that can account for individual, societal and policy considerations, an intervention that focused on the individual level would be
preferable in this context. It was decided that the intervention would be based on the extended Health Belief Model (Rosenstock, 1988), which focused the investigation and exploration of women’s intentions to HPV self-sample throughout this research.
Therefore, the intervention was developed to address the identified barriers and facilitators to HPV self-sampling and was structured around the HBM constructs.
Guidance for developing quality health-related information (Charnock 1998) was also used to structure the draft intervention. In line with MRC guidance for developing complex interventions, key empirical findings and theoretical concepts were linked to each section of the draft tool. The DISCERN handbook (Charnock 1998) was used to guide intervention development. DISCERN determines the quality criteria for consumer health information on treatment choices. Although the HPV self-sampling intervention does not provide information about treatment choices, the principles of the DISCERN handbook were transferrable in terms of helping to ensure the clear presentation of information. A small sample of potential intervention users and providers were
recruited to explore the usability of the draft intervention to help ensure that it is user-friendly and reflective of a potential future HPV self-sampling system.
This chapter aims to (1) describe the creation of the first draft HPV self-sampling intervention, (2) outline usability and acceptability testing of the draft intervention during a small pilot study, and (3) present modifications to the intervention based on the findings of preliminary user testing.
174 6.3 Development of the HPV self-sampling intervention